Liang Q. Liu

Diffuse endothelial dysfunction is common to ANCA associated systemic vasculitis and polyarteritis nodosa

Background: Excess cardiovascular mortality complicates systemic rheumatic disease, suggesting an accelerated atheromatous process, which it has been proposed relates to the vascular inflammation common in such diseases. Impaired endothelium dependent vasodilatation is an early marker of atheromatous disease. It has previously been shown that such endothelial cell dysfunction (ECD) occurring in the brachial artery can complicate primary systemic necrotising vasculitis (SNV). Objective: To determine if ECD occurs in a wider spectrum of primary SNV, if it is restricted to the major arteries, and whether vasculitis subgroup, ANCA status, or renal involvement influenced the endothelial responses. Methods: Fifty four patients attending the Birmingham vasculitis clinic, including patients with a range of ANCA and non-ANCA associated primary vasculitides, and a group of age matched controls were recruited. The length of patient follow up and disease activity was variable. Disease activity, damage scores, and cardiovascular risk factors were recorded before assessment of flow mediated brachial artery vasodilatation by high resolution ultrasound. Dermal microvascular responses to acetylcholine were also measured in 32 patients and 21 controls by laser Doppler flowmetry. Results: ECD was demonstrated in all primary SNV subgroups of patients with ANCA associated vasculitis and in polyarteritis nodosa, compared with controls. Significant impairment occurred in both vascular beds, regardless of vessel size targeted in the inflammatory vasculitis, ANCA association and titre, or renal involvement. Conclusions: Diffuse endothelial dysfunction, a predictor of atherosclerotic disease, is found extensively in primary systemic vasculitis. Involvement of different vascular beds is independent of target vessel size or ANCA association, and is unrelated to local disease expression. It is suggested that this results from a systemic response that may be a consequence of primary vasculitis, but is distinct from the local inflammatory vasculitic process.

Do wound complications or lymphoceles occur more often in solid organ transplant recipients on mTOR inhibitors? A systematic review of randomized controlled trials.

mTOR inhibitors have been associated with wound complications and lymphoceles. We systematically reviewed randomized controlled trials (RCTs) to compare these outcomes for solid organ transplant recipients. Relevant medical databases were searched to identify RCTs in solid organ transplantation comparing mTOR inhibitors with an alternative therapy reporting on wound complications and/or lymphoceles. Methodological quality of RCTs was assessed. Pooled analyses were performed to calculate odds ratios (OR) and 95% confidence intervals (CI). Thirty‐seven RCTs in kidney, heart, simultaneous pancreas‐kidney and liver transplantation were included. Pooled analyses showed a higher incidence of wound complications (OR 1.77, CI 1.31–2.37) and lymphoceles (OR 2.07, CI 1.62–2.65) for kidney transplant recipients on mTOR inhibitors together with calcineurin inhibitors (CNIs). There was also a higher incidence of wound complications (OR 3.00, CI 1.61–5.59) and lymphoceles (OR 2.13, CI 1.57–2.90) for kidney transplant recipients on mTOR inhibitors together with antimetabolites. Heart transplant patients receiving mTOR inhibitors together with CNIs also reported more wound complications (OR 1.82, CI 1.15–2.87). We found a higher incidence of wound complications and lymphoceles after kidney transplantation and a higher incidence of wound complications after heart transplantation for immunosuppressive regimens that included mTOR inhibitors from the time of transplantation.

Pressure changes under the ischial tuberosities of seated individuals during sacral nerve root stimulation

Neuromuscular stimulation via the sacral nerve roots is proposed for prevention of ischial pressure ulcers following a spinal cord injury (SCI). Acute effects of sacral functional magnetic stimulation (FMS) on seat interface pressure changes were investigated in five nondisabled volunteers. Similar effects were demonstrated with functional electrical stimulation in people with SCI who used a sacral anterior root stimulator implant. The results indicated that sacral nerve root stimulation, either by FMS or implanted electrical stimulation, induced gluteus maximus contraction and mild pelvic tilt sufficient for clinically significant reductions in ischial pressures during sitting.

Functional outcomes in children with osteonecrosis secondary to treatment of developmental dysplasia of the hip.

BACKGROUND Osteonecrosis of the femoral head is a major potential complication following the treatment of developmental dysplasia of the hip. It remains unclear if the radiographic changes associated with osteonecrosis are clinically relevant. METHODS In the present cross-sectional study, we determined the relationship between morphological changes on radiographs (classified with use of the Bucholz-Ogden system) and health-related quality of life (assessed with the Health Utilities Index Mark 3 [HUI3]; maximum score, 1), physical function (assessed with the Activities Scale for Kids [ASK]; maximum score, 100), and hip function (assessed with the Childrens Hospital Oakland Hip Evaluation Scale [CHOHES]; maximum score, 100). The study group included seventy-two children (mean age, 14 ± 2.5 years) with a diagnosis of osteonecrosis of the hip secondary to the treatment of developmental dysplasia of the hip. Patient assessments were standardized (intraclass correlation coefficient, ≥0.93). Radiographs were graded by three experts according to consensus. Analyses were adjusted for the number of previous surgical procedures on the hip and for the severity of residual hip dysplasia. RESULTS The median ASK score was 97 (interquartile range, 93 to 100), the median CHOHES score was 86 (interquartile range, 77 to 96), and the median HUI3 score was 1 (interquartile range, 0.9 to 1). The ASK summary scores were nearly equal (median, >90) across all radiographic grades. Adjusted mean scores showed a downward shift with worse radiographic grades. The ASK scores (p = 0.004) and CHOHES scores (p = 0.006) differed across radiographic grades, with Bucholz-Ogden grade-I and II hips demonstrating significantly better scores than grade-III and IV hips. DISCUSSION Osteonecrosis secondary to the treatment of developmental dysplasia of the hip is a relatively benign condition in children and teenagers. While it was associated with limited hip function, it was not associated with physical disability. However, we speculate that this function will decline with increasing age. With regard to clinical outcome, Bucholz-Ogden grade-I hips are similar to grade-II hips and grade-III hips are similar to grade-IV hips.

Compliance to the CONSORT statement of randomized controlled trials in solid organ transplantation: a 3-year overview

The Consolidated Standards of Reporting Trials (CONSORT) statement was developed to improve the reporting quality of randomized controlled trials (RCTs). Our primary aim was to assess to what extent reports of RCTs in solid organ transplantation adhere to the 2010 CONSORT statement. Secondly, we investigated the relationship between CONSORT adherence, methodological quality and some other factors. We included 290 RCTs that were published between 2007 and 2009. We examined to what extent trial reports complied with 30 items of the CONSORT statement. Methodological quality was evaluated using the Jadad scale plus allocation concealment and whether data analysis was by randomized group (intention to treat). On average, trial reports addressed 47% of the CONSORT items. Forty‐three per cent of RCTs was considered to be of good quality according to Jadad scale, and the items allocation concealment and data analysis were satisfied in approximately one‐third of trials. Good quality RCTs reported on more CONSORT items than poor quality trials. The methodological quality and adherence to the CONSORT statement of RCTs published in journals that endorse the CONSORT statement was superior to those in journals without CONSORT endorsement. Overall compliance with the CONSORT statement and the methodological quality of RCTs in organ transplantation remains unsatisfactory.

A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries

Abstract Context Electrical stimulation (ES) can confer benefit to pressure ulcer (PU) prevention and treatment in spinal cord injuries (SCIs). However, clinical guidelines regarding the use of ES for PU management in SCI remain limited. Objectives To critically appraise and synthesize the research evidence on ES for PU prevention and treatment in SCI. Method Review was limited to peer-reviewed studies published in English from 1970 to July 2013. Studies included randomized controlled trials (RCTs), non-RCTs, prospective cohort studies, case series, case control, and case report studies. Target population included adults with SCI. Interventions of any type of ES were accepted. Any outcome measuring effectiveness of PU prevention and treatment was included. Methodological quality was evaluated using established instruments. Results Twenty-seven studies were included, 9 of 27 studies were RCTs. Six RCTs were therapeutic trials. ES enhanced PU healing in all 11 therapeutic studies. Two types of ES modalities were identified in therapeutic studies (surface electrodes, anal probe), four types of modalities in preventive studies (surface electrodes, ES shorts, sacral anterior nerve root implant, neuromuscular ES implant). Conclusion The methodological quality of the studies was poor, in particular for prevention studies. A significant effect of ES on enhancement of PU healing is shown in limited Grade I evidence. The great variability in ES parameters, stimulating locations, and outcome measure leads to an inability to advocate any one standard approach for PU therapy or prevention. Future research is suggested to improve the design of ES devices, standardize ES parameters, and conduct more rigorous trials.

Pressure Changes Under the Ischial Tuberosities During Gluteal Neuromuscular Stimulation in Spinal Cord Injury: A Comparison of Sacral Nerve Root Stimulation With Surface Functional Electrical Stimulation

OBJECTIVE To compare the magnitude of interface pressure changes during gluteal maximus contraction by stimulating sacral nerve roots with surface electrical stimulations in patients with spinal cord injuries (SCIs). DESIGN Pilot interventional study. SETTING Spinal injury research laboratory. PARTICIPANTS Adults (N=18) with suprasacral complete SCI. INTERVENTIONS Sacral nerve root stimulation (SNRS) via a functional magnetic stimulator (FMS) or a sacral anterior root stimulator (SARS) implant; and surface functional electrical stimulation (FES). MAIN OUTCOME MEASURES Interface pressure under the ischial tuberosity (IT) defined as peak pressure, gradient at peak pressure, and average pressure. RESULTS With optimal FMS, a 29% average reduction of IT peak pressure was achieved during FMS (mean ± SD: 160.1±24.3mmHg at rest vs 114.7±18.0mmHg during FMS, t5=6.3, P=.002). A 30% average reduction of peak pressure during stimulation via an SARS implant (143.2±31.7mmHg at rest vs 98.5±21.5mmHg during SARS, t5=4.4, P=.007) and a 22% average decrease of IT peak pressure during FES stimulation (153.7±34.8mmHg at rest vs 120.5±26.1mmHg during FES, t5=5.3, P=.003) were obtained. In 4 participants who completed both the FMS and FES studies, the percentage of peak pressure reduction with FMS was slightly greater than with FES (mean difference, 7.8%; 95% confidence interval, 1.6%-14.0; P=.04). CONCLUSIONS SNRS or surface FES can induce sufficient gluteus maximus contraction and significantly reduce ischial pressure. SNRS via an SARS implant may be more convenient and efficient for frequently activating the gluteus maximus.

The extent, variability, and attitudes towards volunteering among undergraduate nursing students: Implications for pedagogy in nurse education

In the aftermath of the Francis Report nurses are being called to account for an apparent lack of care and compassion, leading to debate around pedagogy in nurse education. Absent from this debate is a consideration of student volunteering within undergraduate nursing programmes and its potential to promote student nurses self-esteem and to enhance the development of critical thinking skills. The aim of this study was therefore to understand the extent of and attitudes towards volunteering among nursing students. A mixed methods approach using a specifically developed questionnaire, followed by in-depth interviews to ascertain extent, variability, and attitudes towards volunteering revealed low levels of volunteering among nursing students. Limited time, limited access, and lack of academic support were cited as reasons. Nevertheless, students displayed positive attitudes towards volunteering. While volunteering has been shown to impact upon students abilities to think critically, to develop personal values and respond to the needs of others, volunteering within the UK undergraduate nursing programme considered here is neither structured nor formalized. Nurse educators should pay attention to the positive benefits of volunteering for nursing students and consider ways in which volunteering might be incorporated into the curriculum.

Blood perfusion changes during sacral nerve root stimulation versus surface gluteus electrical stimulation on in seated spinal cord injury

ABSTRACT The objective of this article is to examine dynamic changes of ischial blood perfusion during sacral nerve root stimulation against surface functional electrical stimulation (FES). Fourteen adults with suprasacral spinal cord injury (SCI) were recruited. The gluteal maximus was activated by surface FES or stimulating sacral nerve roots by functional magnetic stimulation (FMS) or a sacral anterior root stimulator implant (SARS). Ischial skin index of hemoglobin (IHB) and oxygenation (IOX) was measured.Skin blood perfusion was significantly higher during FMS than the baseline (IHB 1.05 ± 0.21 before vs.1.08 ± 0.02 during stimulation, p = 0.03; IOX 0.18 ± 0.21 before vs. 0.46 ± 0.30, p = 0.01 during stimulation). Similarly, when using the SARS implant, we also observed blood perfusion significantly increased (IHB 1.01 ± 0.02 before vs.1.07 ± 0.02 during stimulation, p = 0.003; IOX 0.79 ± 0.81 before vs. 2.2 ± 1.21 during stimulation, p = 0.036). Among four participants who completed both the FMS and FES studies, the magnitude of increase in both parameters was significantly higher during FMS. This study demonstrates sacral nerve root stimulation confer better benefit on blood perfusion than applying traditional FES in SCI population.

Non-invasive technologies of tissue viability measurement for pressure ulcer prevention in spinal cord injury

Developing Pressure Ulcer (PU) is one of the most common devastating complications following Spinal Cord Injury (SCI). Following SCI, loss of sensation and mobility alongside changes in circulation leads to elevated risk of developing PU. Once a PU is formed, it significantly increases the burden on the individual with SCI individual and/or the caregivers and has substantial detrimental impact on the quality of life, independence, and dignity of a patient. Apart from personal consequences, PU also represents a significant cost burden for health and social care systems. Therefore, preventing PU formation is vitally important in SCI. Thus far, numerous prevention methods have been implemented, such as using various expensive specified cushions, patients regularly repositioning together with health professionals investigating significant time on monitoring patients using various subjective risk assessment tools. In spite of tremendous efforts, incidence of PU remains unacceptably high in people living with SCI. Without robust objective assessment tools to detect or monitor early sign of PU has been long considered as main challenges for clinicians and health professionals. This article reviews current non-invasive technologies for measuring risk of PU formation in SCI, and provides an insight in topics for further application and exploration.