Spasticity is a velocity-dependent increase in muscle tone and uncontrolled, repetitive, involuntary contractions of skeletal muscles. Spasticity presents as upper motor neuron symptoms in patients with central nervous system pathology such as stroke, spinal cord injury, brain injury, or multiple sclerosis. As a result, a patient can have significant pain and limited mobility, which can lead to decreased quality of life and difficulty maintaining personal care. In this article we discuss mechanisms, indications, efficacy, and side effects of the most accepted current treatments. Currently available treatment options include oral medications and interventional procedures. Oral medications comprise centrally acting agents, such as baclofen, clonidine, and tizanidine, as well as anticonvulsants such as benzodiazepines and gabapentin and peripherally acting dantrolene. Interventional procedures include focal injections of botulinum toxin, phenol or alcohol, and an intrathecal baclofen pump. Surgical treatments include selective dorsal rhizotomy and neurectomy. We found that there are several treatments available with data to support their use, but many still need further research to prove their efficacy and develop optimal utilization.

In developed countries, coronary artery disease (CAD) continues to be a major cause of death and disability. Over the past two decades, positron emission tomography (PET) imaging has become more widely accessible for the management of ischemic heart disease. Positron emission tomography has also emerged as an important alternative perfusion imaging modality in the context of recent shortages of molybdenum-99/technetium-99m ((99m)Tc). The clinical application of PET in ischaemic heart disease falls into two main categories: first, it is a well-established modality for evaluation of myocardial blood flow (MBF); second, it enables assessment of myocardial metabolism and viability in patients with ischaemic left ventricular dysfunction. The combined study of MBF and metabolism by PET has led to a better understanding of the pathophysiology of ischaemic heart disease. While there are potential future applications of PET for plaque and molecular imaging, as well as some clinical use in inflammatory conditions, this article provides an overview of the physical and biological principles behind PET imaging and its main clinical applications in cardiology, namely the assessment of MBF and metabolism.

Multiparametric cardiac PET evaluation including quantification of MBF provides improved detection and gradation of CAV severity over standard myocardial perfusion assessment and is predictive of major adverse events.

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Current classification criteria for axial spondyloarthritis (axSpA) provide for the inclusion of patients with a wide range of presentations and manifestations. While not considered a formal subclassification, patients are often divided into radiographic or nonradiographic axSpA based on the presence or absence of radiographic sacroiliitis. This review will focus on nonradiographic axSpA and will discuss clinical manifestations of disease that distinguish, or in many cases do not distinguish, this entity from other individuals with axSpA. This review will also cover treatment paradigms for nonradiographic axSpA, particularly the use of biologic therapies, where current data suggest that nonradiographic disease should be managed largely the same as radiographic disease, or classical ankylosing spondylitis.

Background:Ultrasound has become an increasingly utilized tool for the imaging of the musculoskeletal system, especially for imaging the components of the knee. Even though MRI is touted as being the golden standard for identifying knee pathologies, the use of ultrasound has gained popularity in this field given its ability for rapid diagnosis. This study aims to investigate the efficacy of point-of-care ultrasound (POCUS) to diagnose injuries to the medial knee compartment when compared to magnetic resonance imaging (MRI).Methods:This was a prospective, observational study conducted at an orthopedic outpatient clinic. Prospective patients with medial knee pain scheduled for an MRI of the knee were evaluated by POCUS prior to the MRI. Sonographic findings were then compared to MRI results to assess correlation.Results:Nine patients were enrolled in the study. Median age was 53 years and eight were male (89%). POCUS demonstrated 100% sensitivity and 50% specificity for medial meniscus tear and 67% sensitivity and 83% specificity for medial collateral ligament (MCL) tear.Conclusion:Ultrasound may have a role as the initial rapid imaging modality in patients with suspected medial meniscus or MCL tears as it is highly sensitive, and it may serve as an effective screening tool for patients with both acute and chronic knee pain.

Purpose Medical training has traditionally focused on the proximate determinants of disease, with little focus on how social conditions influence health. The authors conducted a scoping review of existing curricula to understand the current programs designed to teach primary care residents about the social determinants of health (SDH). Method In January and March 2017, the authors searched seven databases. Eligible articles focused on primary care residents, described a curriculum related to SDH, were published between January 2007 and January 2017, and were based in the United States. Results Of the initial 5,523 articles identified, 43 met study eligibility criteria. Most programs (29; 67%) were in internal medicine. Sixteen studies (37%) described the curriculum development process. Overall, 20 programs (47%) were short or one-time sessions, and 15 (35%) were longitudinal programs lasting at least 6 months. Thirty-two programs (74%) reported teaching SDH content using didactics, 22 (51%) incorporated experiential learning, and many programs (n = 38; 88%) employed both. Most studies reported satisfaction and/or self-perceived changes in knowledge or attitudes. Conclusions The authors identified wide variation in curriculum development, implementation, and evaluation. They highlight curricula that considered community and resident needs, used conceptual frameworks or engaged multiple stakeholders to select content, used multiple delivery methods, and focused evaluation on changes in skills or behaviors. This review highlights the need not only for systematic, standardized approaches to developing and delivering SDH curricula but also for developing rigorous evaluation of the curricula, particularly effects on resident behavior.

Laser extraction of device leads offers an attractive alternative to countertraction and electrosurgical dissection sheath, potentially increasing efficacy and reducing complications. Wider adoption of this technology depends on relative ease of use. We report the experience of a new center to define the "learning curve." We performed 76 laser lead extractions in 75 patients (age 63 +/- 17 years, 59 male) from July 2001 to January 2004. Two experienced device implanters who were novice extractors underwent a 2-day site visit to a high volume extraction center for training. Lead extractions were performed in the operating room with immediate surgical backup. The indication for extraction was infection in 39 (systemic in 15), erosion or pain in 11, and lead related or debulking in 25. Complete removal was achieved in 139 of 145 leads (14 ICD, 131 pacemaker). Partial removal (<4 cm retained) was achieved in five leads (4%), and one lead could not be extracted. Complete success was 95% in the first third of patients, 94% in the second third, and 100% in the latter third. Fluoroscopy time fell from 19 +/- 22 minute in the first third of patients to 11 +/- 8 minute in the second third to 8 +/- 4 minute in the latter third (ANOVA P = 0.02). No major complications occurred. Local bleeding required minor left subclavian vein repair in two individuals. Symptomatic venous thrombosis occurred in 3 of the first 11 cases 1-21 days after extraction, but did not occur in the next 64 consecutive patients who received a 1-month anticoagulation regimen (27% vs 0%, P < 0.001). One patient developed venous thrombosis 3 weeks following cessation of warfarin therapy. Practice guidelines reasonably recommend appropriate training prior to independent performance of lead extraction. The current study suggests that experienced device implanters with appropriate operative backup taking a limited, but intensive training program can be safe and effective at lead extraction in a short time, in part a reflection of the improved technology.