Characteristics of Patients With Complex Limb Pain Evaluated Through an Interdisciplinary Approach Utilizing Magnetic Resonance Neurography

Patients with persistent complex limb pain represent a substantial diagnostic challenge. Physical exam, and tests such as nerve conduction, are often normal even though the patient suffers from severe pain. In 2015, we initiated a team-based approach to evaluate such patients. The approach included physicians from several specialties (Anesthesiology/Pain Medicine, Radiology, Plastic Surgery, Neurosurgery) combined with the use of advanced imaging with Magnetic Resonance Neurography (MRN). This preliminary case series discusses MRN findings identified in patients with previously difficult-to-diagnose peripheral limb pain and describes how this combination of approaches influenced our diagnosis and treatment plans. We extracted demographics, patient characteristics, presenting features, diagnostic tests performed, treatments provided, referral diagnosis and the diagnosis after interdisciplinary team evaluation from patient charts. We evaluated MRN and electrodiagnostic studies (EDX) ability to identify injured nerves. We compared abnormal findings from these diagnostics to patient reported outcome after ultrasound-guided nerve block. A total of 58 patients, 17 males and 41 females, were identified. The majority of patients presented with lower extremity pain (75%) and had prior surgery (43%). The most commonly identified abnormality on MRN was nerve signal alteration on fluid sensitive sequences, followed by caliber change and impingement. Comparing the outcome of diagnostic nerve blocks with abnormal nerve findings on MRN or EDX, we found that MRN had a sensitivity of 67% and specificity of 100% while for EDX it was 45 and 0%, respectively. After interdisciplinary discussion and imaging review, a more specific diagnosis was produced in 78% of evaluated cases opening up additional treatment pathways such as nerve-targeted surgery, which was performed in 36% cases. This descriptive case series demonstrates that a majority of patients evaluated by our team for complex limb pain were women with lower extremity pain resulting from surgery. In addition, an interdisciplinary team evaluation and the use of the moderately sensitive but highly specific MRN imaging modality resulted in a change in diagnosis for a majority of patients with complex limb pain. Future studies investigating patient outcomes after diagnosis change are currently underway based on the findings of this preliminary study.

Clinical Evaluation of Children with Arthrogryposis Multiplex Congenital in Pakistani Population

Background: Arthrogryposis multiplex congenita (AMC) is a rare syndrome with multiple joint contractures. The number of studies which have been previously done on Pakistani population to investigate patients with arthrogryposis is limited. Aim: This study presents our experience with evaluation and management of children with AMC at The Children Hospital & the Institute of Child Health, Lahore. Method: During the period from January 2018 to December 2018, we evaluated 25 children with AMC. The mean age at the time of evaluation was 20.56 months (range, 5 days to 9 years). All of the included patients were evaluated in terms of their clinical state according to selected subjective and objective criteria. Result: Our results indicate that shoulders were internally rotated (20%), the elbows were extended (36%), and the wrists (76%) and digits (56%) were flexed. Thumb was adducted (36%), hands were clawed (52%) and palmar crease was absent (28%). Hips were found to be dislocated (16%) and adducted (16%). Knees having extension contracture (32%); feet were in equinocavovarus (72%). Calf muscles were atrophic (56%). Conclusion: Our experience shows that the clinical findings are highly variable between families and also within families with AMC. Joint manipulation and casting during the first few months of life may produce considerable improvement. Orthotics may help. Surgery may be needed later, but mobility is rarely enhanced. Muscle transfers may improve function. Many children do remarkably well; two thirds are ambulatory after treatment. A multidisciplinary team evaluation of the child with AMC is recommended for specific diagnosis and planning of treatment. Keywords: Arthrogryposis multiplex congenita (AMC), clinical evaluation

Student & Faculty as Pedagogical Co-designers: An experience of partnership between a graduate student and a faculty member

• Students as Partners (SaP) is a pedagogical approach that challenges the traditional learner roles in higher education by promoting collaboration between students and faculty to enhance teaching and learning [1]• This work consists of the partnership between a new faculty member and graduate student partner (GSP) (not the course TA) to design assessment materials for a year 3 core Mech. Eng. course with ~40 students• Deliverables from the collaboration include adaptation of course rubrics (see below) and the implementation of the CATME rubric [2] for team evaluation• Rubric adaptation was in part guided from Brookhart’s book [3]

Sensory and chemical evaluation of tea brews prepared with the assistance of ultrasound

ABSTRACT: The aim of the study was to evaluate sensory and phytochemical (polyphenols, flavonoids and caffeine) estimation of black and green tea brews obtained in an alternative way through brewing with the assistance of ultrasound. Brews produced with the application of sonication for 2 minutes and 1 minute were the most preferred by the sensory evaluation team. Evaluation of the brews in terms of component descriptors, i.e. fragrance, flavour and colour, was varied and depended on the kinds of tea and on the applied experimental factors. It was demonstrated that ultrasound have a significant effect on the extraction of active substances, i.e. polyphenols, flavonoids and caffeine, from black and green tea. The application of sonication caused a significant increase in the concentration of flavonoids (by ca. 29% and 73%), polyphenols (by ca. 34% and 41%) and caffeine (by ca. 51% and 60%) in the tea brews.

Multi-dimensional approach to end-of-life care: The Welfare Model

Appropriate and balanced decision-making is sentinel to goal setting and the provision of appropriate clinical care that are attuned to preserving the best interests of the patient. Current family-led decision-making in family-centric societies such as those in Singapore and other countries in East Asia are believed to compromise these objectives in favor of protecting familial interests. Redressing these skewed clinical practices employing autonomy-based patient-centric approaches however have been found wanting in their failure to contend with wider sociocultural considerations that impact care determinations. Evaluation of a number of alternative decision-making frameworks set out to address the shortcomings of prevailing atomistic and family-centric decision-making models within the confines of end-of-life care prove these alternative frameworks to be little better at protecting the best interests of vulnerable patients. As a result, we propose the Welfare Model that we believe is attentive to the relevant socio-culturally significant considerations of a particular case and better meets the needs of end-of-life care goals of preserving the welfare of patients. Employing a multi-professional team evaluation guided by regnant psychosocial, legal, and clinical standards and the prevailing practical and clinical realities of the particular patient’s setting the Welfare Model provides a clinically relevant, culturally sensitive, transparent, and evidence-based approach to care determinations.