The Modified – Modified Schober Test for range of motion assessment of lumbar flexion in patients with low back pain: A study of criterion validity, intra- and inter-rater reliability and minimum metrically detectable change

PURPOSE

The objective was to estimate the psychometric properties of the Modified-Modified Schober Test (MMST).

DESIGN

This study compared range of motion measurements of lumbar flexion in low back pain (LBP) patients using the MMST with measurements calculated on X-rays as the gold standard, and compared the measurements taken by two independent examiners.

METHOD

This study was conducted at the main hospital in the Outaouais area, Quebéc, Canada. Thirty-one subjects with LBP from private and public clinics participated in the study. After a warm-up session, measurements with the MMST were taken in neutral position and an X-ray technician took an exposure in the same position.

RESULTS

Pearson's correlation test (r) between measurements made with the MMST and the gold standard, intra-class correlation coefficient (ICC), minimum metrically detectable change (MMDC) and confidence interval (CI) were used to analyze the data. The MMST demonstrated moderate validity (r=0.67; 95%CI 0.44-0.84), excellent reliability (intra: ICC=0.95; 95%CI 0.89-0.97; inter: ICC=0.91; 95%CI 0.83-0.96) and a MMDC of 1 cm.

CONCLUSIONS

In our sample of LBP patients, the MMST showed moderate validity but excellent reliability and MMDC.

[Evaluation of thymopoiesis: clinical applications]

In the precedent article, we have described how T-cell generation in the thymus (thymopoiesis) may be currently evaluated through quantification by PCR of T-cell receptor excision circles (TREC) generated by intrathymic random recombination of the gene segments coding for variable parts of T-cell receptor for antigen (TCR). In hematology, TREC methodology helps in a better understanding of immune reconstitution after graft of hematopoietic stem cells: first there is a proliferation of mature T cells present in the graft, then a differentiation of naive T cells. In geriatrics, the homeostasis of the peripheral T-cell repertoire is maintained through proliferation of peripheral memory T cells rather than through thymic generation of naive T cells. In addition, TREC quantification constitutes a novel major tool for deciphering the tight control of thymopoiesis by the neuroendocrine system.

[Clinical evaluation of thymic function]

The essential role of the thymus is to install an extremely diverse repertoire of T lymphocytes that are self-tolerant and competent against non-self, as well as to generate self-antigen specific regulatory T cells (Treg) able to inactivate in periphery self-reactive T cells having escaped the thymic censorship. Although indirect, techniques of medical imaging and phenotyping of peripheral T cells may help in the investigation of thymic function. Nowadays however, thymopoiesis is better evaluated through quantification by PCR of T-cell receptor excision circles (TREC) generated by intrathymic random recombination of the gene segments coding for the variable parts of the T-cell receptor for antigen (TCR). The TREC methodology is very valuable in the circumstances not associated with intense proliferation or apoptosis of peripheral T lymphocytes.

Pharmacokinetics of meropenem determined by microdialysis in the peritoneal fluid of patients with severe peritonitis associated with septic shock

Our objective was to describe the pharmacokinetics of meropenem in the peritoneal fluid (PF) of six patients with severe peritonitis and septic shock and to relate measured concentrations to the minimum inhibitory concentration of bacteria. Microdialysis catheters were placed into the peritoneal space during surgery. Meropenem concentrations in plasma and in PF were analyzed using compartmental modeling. Meropenem areas under the concentration-time curve were lower in PF than in plasma (average ratio, 73.8+/-15%) because of degradation confirmed ex vivo. Compartment modeling with elimination from a peripheral compartment described the data adequately, and was used to simulate steady-state concentration profiles in plasma and PF during various dosing regimens. At the currently recommended dosing regimen of 1 g infused over 20 min every 8 h, PF concentrations of meropenem in patients with severe peritonitis associated with septic shock reach values sufficient for antibacterial effects against susceptible, but not always against intermediately susceptible, bacteria.

Sex differences in opioid-mediated pain inhibitory mechanisms during the interphase in the formalin test

Many chronic pain conditions are more prevalent in women than men and both fundamental and clinical research supports the implication of endogenous pain inhibitory mechanisms. The goal of this study was to verify if sex differences on endogenous pain inhibitory mechanisms during the formalin test are opioidergic and modulated by sex hormones. Formalin tests were performed with naloxone hydrochloride, a non-selective opioid antagonist in intact and gonadectomized Sprague-Dawley rats of both sexes. Considering the sexual dimorphisms we found, where naloxone preferentially blocked the interphase in female rats, injections of all the possible combinations of mu- (naltrexone hydrochloride), delta- (naltrindole hydrochloride) and kappa-selective antagonists (norbinaltorphimine dihydrochloride) were given to evaluate the contribution of these opioid-receptor subtypes to the inhibitory mechanism during the interphase in intact females. Finally, the systemic administration of naloxone methiodide and intrathecal administration of naloxone hydrochloride in intact females allowed us to verify if the action of endogenous opioids that are liberated during the interphase takes place at the periphery or spinally, respectively. The results show that the interphase was almost completely inhibited by naloxone in females while it produced only a slight blockade in males. These results permitted us to conclude that opioids play a major role in the pain inhibitory mechanism of the interphase in females while a non-opioid mechanism seems to be responsible for this inhibitory pathway in males. Using gonadectomized animals of both sexes, we demonstrated the modulation of the opioidergic system of the interphase by sex hormones. The administration of different combinations of selective antagonists for mu-, kappa- and delta-opioid receptors in intact females permitted us to conclude that only the combination of kappa- and delta-selective antagonists significantly blocked the interphase. The same result was obtained with the combination of the three antagonists, confirming the results with systemic naloxone hydrochloride. Finally, intrathecal administration permitted us to support that the action of naloxone is primarily at the spinal level, even if a supraspinal action cannot be ruled out. These results are of particular interest in showing sexual dimorphisms in endogenous pain modulation mechanisms during the interphase of the formalin test. A clearer understanding of the difference between male and female endogenous pain inhibitory pathways should lead to a better understanding of the role of endogenous pain modulation deficits in certain chronic pain conditions.

Feelings of warmth correlate with neural activity in right anterior insular cortex

The neural coding of perception can differ from that for the physical attributes of a stimulus. Recent studies suggest that activity in right anterior insular cortex may underlie thermal perception, particularly that of cold. We now examine whether this region is also important for the perception of warmth. We applied cutaneous warm stimuli on the left leg (warmth) in normal subjects (n = 7) during functional magnetic resonance imaging (fMRI). After each stimulus, subjects rated their subjective intensity of the stimulus using a visual analogue scale (VAS), and correlations were determined between the fMRI signal and the VAS ratings. We found that intensity ratings of warmth correlated with the fMRI signal in the right (contralateral to stimulation) anterior insular cortex. These results, in conjunction with previous reports, suggest that the right anterior insular cortex is important for different types of thermal perception.

Spread of Stenotrophomonas maltophilia colonization in a pediatric intensive care unit detected by monitoring tracheal bacterial carriage and molecular typing

In our pediatric intensive care unit in Tours (France), intubated and ventilated inpatients are systematically monitored for tracheal bacterial colonization twice a week. This led us to detect five patients colonized with Stenotrophomonas maltophilia over a 4-month period. Molecular typing of the isolates using random amplified polymorphism DNA (RAPD) and pulsed-field gel electrophoresis (PFGE) confirmed that four of the five isolates were genetically related. The strict isolation of carriers and improvements in hygiene measures stopped the spread. This systematic strategy prevented pulmonary nosocomial infections or allowed their early detection. Moreover, it has made it possible to assess the efficiency of care practices continuously.

Flow control versus antisiphon valves: late results concerning slit ventricles and slit-ventricle syndrome

INTRODUCTION

The aims of the study were firstly to investigate the time course of development of slit ventricles (SV) and slit-ventricle syndrome (SVsyndrome) in hydrocephalic patients shunted as infants and secondly to assess the difference in incidence of SV and SVsyndrome in 2 groups of patients - group A with a conventional valve and group B with an anti-siphon valve.

PATIENTS AND METHODS

27 infant patients with hydrocephalus received a ventriculoperitoneal shunt and were followed prospectively with annual clinic visits and at least two CT or MRI scans postoperatively. The scans were assessed for SV, and ventricular and parenchymal surface and cortical mantle thickness were measured. Revisions for shunt malfunction were recorded.

RESULTS

SV were more frequent than SVsyndrome and developed within 6.5 months postoperatively in 21 % of patients and 48 % after 6 years. No significant difference in incidence of SV or in the surface and cortical mantle thickness were found between the two groups. Two patients (40 %) with early development of SV developed SVsyndrome, and the relative risk for shunt revision was significantly higher in patients who developed SV early. 48 % of patients did not need emergency shunt revision during the first 9 years.

CONCLUSIONS

SV develop over years. The majority of patients with SV remain asymptomatic. No significant difference between the two groups was found concerning SV and SVsyndrome. If SV develop early in the postoperative period, complications are more frequent in the long-term, so elective valve adjustment should be considered.

Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, inflammatory, system disease. It commonly affects the small peripheral joints (such as fingers and wrist). The main goals of intervention for RA are preventing joint deformity, preserving joint function, and reducing inflammation and pain. Transelectrical nerve stimulation (TENS) is a form of electrotherapy and is thought to produce analgesia according to the gate control theory.

OBJECTIVES

To determine the efficacy and safety of TENS in the treatment of RA of the hand. The primary outcomes of interest were relief of grip pain and resting pain intensity, relief of joint tenderness, number of tender joints and patient assessment of disease. The secondary objective was to determine the most effective mode of TENS application in pain control.

SEARCH STRATEGY

We searched for relevant studies, in English, in the Cochrane field of physical and related therapies, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, HEALTHSTAR, Sports Discus, CINAHL, Current Contents, and the PEDro database, up to October 2002.

SELECTION CRITERIA

Two independent reviewers selected the trials that met predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

Study results were extracted by two independent reviewers. Continuous outcomes were analyzed by weighted mean difference (WMD) using a fixed effects model.

MAIN RESULTS

Three RCTs, involving 78 people, were included in this review. AL-TENS and C-TENS were compared to placebo and to each other. Administration of 15 minutes of AL-TENS a week, for 3 weeks, resulted in a significant decrease in rest pain (67% relative benefit, 45 points absolute benefit on 100 mm VAS scale) but not in grip pain compared to placebo. AL-TENS did result in a clinical beneficial improvement in muscle power scores with a relative difference of 55%, and an absolute benefit of 0.98, compared to placebo. No significant difference was found between one 20-minute treatment duration of C-TENS versus AL-TENS, or C-TENS versus placebo on decrease in mean scores for rest pain or grip pain, or on the number of tender joints. Results showed a statistically significant reduction in joint tenderness, but no clinical benefit from C-TENS over placebo in relief of joint tenderness. No statistically significant difference was shown between 15 days of treatment with C-TENS or AL-TENS in relief of joint pain, although there was a clinically important benefit of C-TENS over AL-TENS on patient assessment of change in disease (risk difference 21%, NNT 5).

REVIEWER'S CONCLUSIONS

There are conflicting effects of TENS on pain outcomes in patients with RA. AL-TENS is beneficial for reducing pain intensity and improving muscle power scores over placebo while, conversely, C-TENS resulted in no clinical benefit on pain intensity compared with placebo. However C-TENS resulted in a clinical benefit on patient assessment of change in disease over AL-TENS. More well designed studies with a standardized protocol and adequate number of subjects are needed to fully conclude the effect of C-TENS and AL-TENS in the treatment of RA of the hand.

Thermotherapy for treatment of osteoarthritis

BACKGROUND

Osteoarthritis is a degenerative joint disease that affects mostly the weight-bearing joints in the knees and hips. As the affected joint degenerates pain and restriction of movement often occur. Inflammation can also occur sometimes resulting in edema of the joint with OA. Treatment focuses on decreasing pain and improving movement.

OBJECTIVES

To determine the effectiveness of thermotherapy in the treatment of OA of the knee. The outcomes of interest were relief of pain, reduction of edema, and improvement of flexion or range of motion (ROM) and function.

SEARCH STRATEGY

Two independent reviewers selected randomized and controlled clinical trials with participants with clinical and/or radiological confirmation of OA of the knee; and interventions using heat or cold therapy compared with standard treatment and/or placebo. Trials comparing head to head therapies, such as two different types of diathermy, were excluded.

SELECTION CRITERIA

Randomized and controlled clinical trials including participants with clinical or radiographical confirmation of OA of the knee; and interventions using heat or cold compared to standard treatment or placebo were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Study results were extracted by two independent reviewers. Outcomes were continuous in nature (pain, strength, improvement) and were analyzed by weighted mean difference using a fixed effects model. Graphical data were used when table data were not available.

MAIN RESULTS

Three randomized controlled trials, involving 179 patients, were included in this review. The included trials varied in terms of design, outcomes measured, cryotherapy or thermotherapy treatments and overall methodological quality. In one trial, administration of 20 minutes of ice massage, 5 days per week, for 3 weeks, compared to control demonstrated a clinically important benefit for knee OA on increasing quadriceps strength (29% relative difference). There was also a statistically significant improvement, but no clinical benefit in improving knee flexion ROM (8% relative difference) and functional status (11% relative difference). Another trial showed that cold packs decreased knee edema.

REVIEWER'S CONCLUSIONS

Ice massage compared to control had a statistically beneficial effect on ROM, function and knee strength. Cold packs decreased swelling. Hot packs had no beneficial effect on edema compared with placebo or cold application. Ice packs did not effect pain significantly compared to control in patients with OA. More well designed studies with a standardized protocol and adequate number of subjects are needed to evaluate the effect of thermotherapy in the treatment of OA of the knee.

Convulsant and subconvulsant doses of norfloxacin in the presence and absence of biphenylacetic acid alter extracellular hippocampal glutamate but not gamma-aminobutyric acid levels in conscious rats

Fluoroquinolones are antibiotics with central excitatory side effects. These adverse effects presumably result from inhibition of gamma-aminobutyric acid (GABA) binding to GABA(A) receptors. This GABA antagonistic effect is greatly potentiated by the active metabolite of fenbufen, biphenylacetic acid (BPAA). Nevertheless, it remains questionable whether GABA receptor antagonism alone can explain the convulsant activity potentials of these antimicrobial agents. The present study was undertaken to investigate the possible effects of norfloxacin, both in the absence and in the presence of BPAA, on the extracellular hippocampal levels of GABA and glutamate, the main central inhibitory and excitatory amino acid neurotransmitters, respectively. This in vivo microdialysis approach with conscious rats allows monitoring of behavioral alterations and concomitant transmitter modulation in the hippocampus. Peroral administration of 100 mg of BPAA per kg of body weight had no effect on behavior and did not significantly alter extracellular GABA or glutamate concentrations. Intravenous perfusion of 300 mg of norfloxacin per kg did not change the rat's behavior or the concomitant neurotransmitter levels in about half of the experiments, while the remaining animals exhibited severe seizures. These norfloxacin-induced convulsions did not affect extracellular hippocampal GABA levels but were accompanied by enhanced glutamate concentrations. Half of the rats receiving both 100 mg of BPAA per kg and 50 mg of norfloxacin per kg displayed lethal seizures, while the remaining animals showed no seizure-related behavior. In the latter subgroup, again no significant alterations in extracellular GABA levels were observed, but glutamate overflow remained significantly elevated for at least 3 h. In conclusion, norfloxacin exerts convulsant activity in rats, accompanied by elevations of extracellular hippocampal glutamate levels but not GABA levels, even in the presence of BPAA.

A pharmacokinetic/pharmacodynamic approach to show that not all fluoroquinolones exhibit similar sensitivity toward the proconvulsant effect of biphenyl acetic acid in rats

The proconvulsant effect of biphenyl acetic acid (BPAA) on several fluoroquinolones (FQs) was investigated in vivo, by measuring drug concentrations in the biophase at the onset of convulsions. Male Sprague-Dawley rats (n = 134) were given BPAA orally, at various doses 1 h before starting FQ infusion, which was maintained until the onset of maximal seizures, when cerebrospinal fluid (CSF) and plasma samples were collected for drug concentration determination. The FQ-BPAA interactions in the biophase (CSF) were adequately described on most occasions by an inhibitory Emax effect model with a baseline effect parameter. The efficacy of the proconvulsant effect was characterized by the ratio of the CSF concentrations of FQs at the onset of convulsant activity when BPAA was absent (CCSF0, FQs) and as BPAA CSF concentrations tended toward infinity (CCSFbase, FQs). This ratio varied from 15 for enoxacin to 1.9 for sparfloxacin. The potency of the proconvulsant effect was characterized by the CSF concentration of BPAA corresponding to a proconvulsant effect half of its maximum. This parameter varied between 0.18 +/- 0.06 micromol/L with enoxacin and 15.0 +/- 12.1 micromol/L with sparfloxacin. The CSF diffusion of all FQs was apparently non-linear, as well as the plasma protein binding of BPAA, complicating interpretation of plasma data. The important variability in the proconvulsant effect of BPAA demonstrated in this study between various FQs suggests that in vitro gamma-aminobutyric acid (GABA) binding experiments conducted in the presence of BPAA are unlikely to be good predictors of FQ convulsant risk in clinical practice.

Ventricular and parenchymal surface before and after shunting--do they have prognostic value for outcome?

PATIENTS AND METHODS

26 consecutive patients with early hydrocephalus (median age at shunting 2.5 months) were followed up to the age of 3 years, prospectively. The work-up included: regular evaluation of psychomotor development and CT/MRI prior and 6 months following surgery. The latter with measurement of the area of the ventricles (degree of hydrocephalus) and the area of the hemispheres in cm(2) (area of hemispheres minus area of ventricles = parenchymal area and degree of brain mass) at the level of the slice with the largest area of the ventricles.

RESULTS

16 (62 %) had normal development (= Group A) and 10 (38 %) moderate or severe retardation (= Group B). The mean ventricular surface was 25.4 cm(2) in Group A and 31.2 cm(2) in Group B prior to surgery (p = 0.1) and 8.9 versus 14.1 cm(2) postsurgery (p = 0.2). The percentage decrease postoperatively was 59.9, versus 57.1 % (p = 0.4). The percentage of ventricular surface in relation to the hemispheres prior to surgery was 42.2 versus 51.4 % (p = 0.1) and post-surgery 12.8 versus 22.4 % (p = 0.1). The mean parenchymal surface was 34.9 cm(2) in Group A and 29.0 cm(2) in Group B prior to surgery (p = 0.3) and 60.9 versus 48.1 cm(2) post surgery (p = 0.07). Percentage increase was 87.3 % versus 77.3 % (p = 0.9). The absolute increase was 26.0 versus 19.0 cm(2) postoperatively (p = 0.2). In contrast to these mean values and their distribution with no significant differences in Group A and B there was some correlation between development and percentage of ventricular surface in relation to the hemispheres prior to surgery: more than 40 % is a critical value, because most of the later retarded children belonged to this radiological subgroup and only half of the later normal patients. After surgery, there was a distinct correlation between developmental outcome and parenchymal surface and its absolute increase in cm(2): most of those who had a normal outcome had a parenchymal surface of more than 40 cm(2) in the third trimenon and an increase of 20 cm(2) and more within six months post surgery, whereas this was the case in only 40 - 50 % of the retarded patients.

CONCLUSIONS

In most young infants with hydrocephalus there is more brain mass than the ventricular enlargement suggests. The prognostic value of quantitative evaluation of neuroimaging should not be overestimated. Nevertheless, some prognostication in this age group is possible prior to surgery by measurement of ventricular area in relation to the hemispheres and after surgery by measurement of the parenchymal area and its increase in cm(2).