Drug-resistant epilepsy is a common complaint in dogs and affects up to 30% of dogs with idiopathic epilepsy. Experimental data suggest that targeting cyclooxygenase-2 (COX-2) mediated signaling might limit excessive excitability and prevent ictogenesis. Moreover, the role of COX-2 signaling in the seizure-associated induction of P-glycoprotein has been described. Thus, targeting this pathway may improve seizure control based on disease-modifying effects as well as enhancement of brain access and efficacy of the co-administered antiseizure medication. The present open-label non-controlled pilot study investigated the efficacy and tolerability of a COX-2 inhibitor (firocoxib) add-on therapy in a translational natural occurring chronic epilepsy animal model (client-owned dogs with phenobarbital-resistant idiopathic epilepsy). The study cohort was characterized by frequent tonic-clonic seizures and cluster seizures despite adequate phenobarbital treatment. Enrolled dogs (n = 17) received a firocoxib add-on therapy for 6 months. Tonic-clonic seizure and cluster seizure frequencies were analyzed at baseline (6 months) months during the study (6 months). The responders were defined by a substantial reduction of tonic-clonic seizure and cluster seizure frequency (≥50%). In total, eleven dogs completed the study and were considered for the statistical analysis. Two dogs (18%, 2/11) were classified as responders based on their change in seizure frequency. Interestingly, those two dogs had the highest baseline seizure frequency. The overall tolerability was good. However, given the low percentage of responders, the present data do not support an overall considerable efficacy of COX-2 inhibitor add-on therapy to overcome naturally occurring phenobarbital-resistant epilepsy in dogs. Further translational evaluation should only be considered in the canine patients with a very high baseline seizure density.

Patients with complex regional pain syndrome suffer from chronic neuropathic pain and also show a decrease in sensorimotor performance associated with characteristic central and peripheral neural system parameters. In the brain imaging domain, these comprise altered functional sensorimotor representation for the affected hand side. With regard to neurophysiology, a decrease in intracortical inhibition for the sensorimotor cortex contralateral to the affected hand has been repetitively verified, which might be related to increased primary somatosensory cortex functional activation for the affected limb. Rare longitudinal intervention studies in randomized controlled trials have demonstrated that a decrease in primary somatosensory cortex functional MRI activation coincided with pain relief and recovery in sensorimotor performance. By applying a randomized wait-list control crossover study design, we tested possible associations of clinical, imaging and neurophysiology parameters in 21 patients with complex regional pain syndrome in the chronic stage (>6 months). In more detail, we applied graded motor imagery over 6 weeks to relieve movement pain of the affected upper limb. First, baseline parameters were tested between the affected and the non-affected upper limb side and age-matched healthy controls. Second, longitudinal changes in clinical and testing parameters were associated with neurophysiological and imaging parameters. During baseline short intracortical inhibition, as assessed with transcranial magnetic stimulation, was decreased only for hand muscles of the affected hand side. During movement of the affected limb, primary somatosensory cortex functional MRI activation was increased. Hand representation area size for somatosensory stimulation in functional MRI was smaller on the affected side with longer disease duration. Graded motor imagery intervention but not waiting, resulted in a decrease of movement pain. An increase of somatosensory hand representation size over graded motor imagery intervention was related to movement pain relief. Over graded motor imagery intervention, pathological parameters like the increased primary somatosensory cortex activation during fist movement or decreased short intracortical inhibition were modified in the same way as movement pain and hand performance improved. No such changes were observed during the waiting period. Overall, we demonstrated characteristic changes in clinical, behaviour and neuropathology parameters applying graded motor imagery in patients with upper limb complex regional pain syndrome, which casts light on the effects of graded motor imagery intervention on biomarkers for chronic neuropathic pain.

UNASSIGNED: Advances in statistical methods and computing power have led to a renewed interest in addressing the statistical analysis challenges posed by Small-N Designs (SND). Linear mixed-effects modeling (LMEM) is a multiple regression technique that is flexible and suitable for SND and can provide standardized effect sizes and measures of statistical significance.
UNASSIGNED: Our primary goals are to: 1) explain LMEM at the conceptual level, situating it in the context of treatment studies, and 2) provide practical guidance for implementing LMEM in repeated measures SND.
UNASSIGNED: We illustrate an LMEM analysis, presenting data from a longitudinal training study of five individuals with acquired dysgraphia, analyzing both binomial (accuracy) and continuous (reaction time) repeated measurements.
UNASSIGNED: The LMEM analysis reveals that both spelling accuracy and reaction time improved and, for accuracy, improved significantly more quickly under a training schedule with distributed, compared to clustered, practice. We present guidance on obtaining and interpreting various effect sizes and measures of statistical significance from LMEM, and include a simulation study comparing two p-value methods for generalized LMEM.
UNASSIGNED: We provide a strong case for the application of LMEM to the analysis of training studies as a preferable alternative to visual analysis or other statistical techniques. When applied to a treatment dataset, the evidence supports that the approach holds up under the extreme conditions of small numbers of individuals, with repeated measures training data for both continuous (reaction time) and binomially distributed (accuracy) dependent measures. The approach provides standardized measures of effect sizes that are obtained through readily available and well-supported statistical packages, and provides statistically rigorous estimates of the expected average effect size of training effects, taking into account variability across both items and individuals.

OBJECTIVE: Hoarding disorder (HD) was recognized as a psychiatric disorder in 2013. Existing literature suggests room for improvement in its treatment. The current pilot study aimed to provide an initial evaluation on the potential of compassion-focused therapy (CFT) as an intervention for HD, with the primary aim being assessing its feasibility and acceptability, and the secondary being evaluating its effects.
METHODS: Both CFT and a second round of the current standard of treatment and cognitive behavioural therapy (CBT) were investigated in the current study as follow-up treatment options for individuals who had completed CBT but were still significantly symptomatic.
METHODS: Forty eligible individuals were enrolled (20 in each treatment). Treatment feasibility and acceptability were assessed by quantitative and qualitative measures. To explore treatment effects, HD symptom severity, HD-related dysfunctions, and their underlying mechanisms were assessed pre-treatment and post-treatment.
RESULTS: Retention rates were 72% for CFT and 37% for CBT. All participants and 79% of the participants rated CFT and CBT, respectively, as good or excellent. After receiving CFT as a follow-up treatment, HD symptom severity dropped below the cut-off point for clinically significant HD for 77% of the treatment completers, and 62% achieved clinically significant reduction in symptom severity. In contrast, after completing a second course of CBT, 23% had HD symptom severity dropped below the cut-off threshold, and 29% achieved clinically significant symptom reduction.
CONCLUSIONS: The current study showed satisfactory feasibility and acceptability of CFT. Moreover, it also found promising effects of CFT in addressing hoarding-related mechanisms that may not have been sufficiently addressed by CBT. The results suggest promising potential of CFT as a treatment for HD. Further investigation on this intervention is needed.
UNASSIGNED: CFT may be a promising treatment option, particularly for those who do not respond well to CBT. Improving emotion regulation and negative self-perception by applying CFT interventions may help relieve hoarding symptoms. Generalization of the findings should be applied with caution given the small convenience sample of the current study. Statistical comparison on treatment effect measures between CFT and CBT as follow-up treatments was not available due to small sample size. Therefore, the comparative conclusions based on this pilot study should be made with caution.

The purpose of this study was to compare clinical outcomes and retear rate between arthroscopic double row (DR) and suture bridge (SB) repair for rotator cuff tears. Postoperative Constant score and MRI findings were compared between 52 patients underwent DR repair and 63 patients underwent SB repair with medium tear of the supraspinatus. There was no significant difference in Constant score between the two groups. Postoperative MRI revealed that retear rate of SB group was significantly lower than DR group. This study suggests that SB repair can provide better clinical and structural outcomes compared with DR repair.

BACKGROUND: Bilateral reverse shoulder arthroplasty (RSA) is controversial because of potential rotational deficits impairing daily living activities. We assessed achievement of insufficient internal rotation (IR) and associated factors in bilateral RSA patients.
METHODS: Fifty-seven staged bilateral RSA patients with a minimum of 1 year of follow-up after the second intervention were identified from our local monocentric register. Shoulder range of motion (including IR using the Apley scratch test), strength, and Constant and Shoulder Pain and Disability Index scores were assessed preoperatively and 6, 12, and 24 months postoperatively.
RESULTS: Before surgery, both shoulders were similar regarding imaging parameters, but first operated shoulders tended to have poorer function. One year after the first RSA, 21% of patients had insufficient IR (not reaching the lumbosacral junction) compared with 33% after the second intervention (P = .180). At 2 years, 5% of patients had insufficient IR on both sides. Patients with insufficient IR on the second side at baseline (relative risk [RR], 1.8 [1.0-3.2]) and patients with insufficient IR 1 year after the first RSA (RR, 3.0 [1.6-5.6]) were more likely to have insufficient IR 1 year after the second RSA. Constant and Shoulder Pain and Disability Index scores and abduction of the second side were significantly worse 1 year after the second RSA (P ≤ .047); at 2 years, there were no differences in functional outcome between shoulders.
CONCLUSIONS: A minority of bilateral RSA patients did not achieve sufficient IR on at least 1 side. Staged surgery is justified, particularly when the outcome of the initial operation is satisfactory.

BACKGROUND: Surgical management of extra-articular distal humerus fractures results in predictable fracture alignment. Open reduction and internal fixation also decrease the soft tissue complications and frequent follow-up required with functional bracing. A triceps-reflecting posterior approach provides excellent exposure to the humerus and minimizes trauma to the triceps. An anatomically precontoured plate on the posterolateral surface of the humerus provides stable fixation of these injuries and is placed directly through the interval developed by the triceps-reflecting approach.
METHODS: We retrospectively reviewed the trauma databases at 2 level I academic trauma institutions during a 5-year period for all patients with an extra-articular distal humerus fracture treated with a triceps-reflecting approach and an anatomically precontoured posterolateral distal humerus plate. Patient and fracture characteristics were recorded, as were QuickDASH functional scores and visual analog scale scores for pain, function, and quality of life.
RESULTS: Forty patients were eligible for our study. Average follow-up was 88 weeks. Thirty-eight (95%) patients went on to union. Seven (20%) patients required a secondary procedure. The average QuickDASH score was 17.5 (range, 2.6-56.8). The average visual analog scale scores were 1.9 (range, 0-7) for pain, 2.3 (range, 0-8) for function, and 1.6 (range, 0-5) for quality of life. Thirty-five (87.5%) patients reported satisfaction with the outcome of their surgery.
CONCLUSIONS: Surgical fixation of extra-articular distal humerus fractures through a triceps-reflecting approach with an anatomically precontoured posterolateral distal humerus plate results in predictable osseous union and overall excellent functional results for patients with this injury.

BACKGROUND: This article presents the experience at the Rizzoli Orthopaedic Institute in the treatment of intracapsular osteoid osteoma (OO) of the elbow by computed tomography-guided percutaneous radiofrequency thermal ablation (RFA).
METHODS: Our team performed more than 800 RFA procedures to treat OO up to 2010. In 27 cases, the lesion site was the articular area of the elbow (humerus in 13 cases, ulna in 13, and radius in 1). These patients were reviewed and assessed for eradication rate, incidence of complications, and functional results measured by the Mayo Elbow Performance Score. The outcome was evaluated after a mean follow-up period of 67.4 ± 35.3 months (range, 24-128 months).
RESULTS: The mean duration of symptoms at the time of diagnosis was 31.0 ± 19.8 months (range, 5-72 months). All patients complained about pain, and in 24 of 27 cases (88.8%), the joint function was significantly impaired by the presence of OO (pretreatment score, 54.8). After RFA, the Mayo Elbow Performance Score improved by a mean of 37.7 ± 14.8 points, with 25 of 27 patients (92.5%) scoring 90 to 100 points at final follow-up. OO recurred in only 1 patient (3.7%), 5 months after the procedure. However, this was successfully retreated by RFA. No adverse effects were observed, and all patients were free of disease at the final follow-up.
CONCLUSIONS: The RFA procedure can be technically challenging in difficult sites such as the elbow joint. The low invasiveness of RFA compared with traditional surgery allows excellent functional recovery. RFA of elbow OO is effective and safe, and it should be considered the first-choice treatment for this disease.

BACKGROUND: The posterior elbow is prone to soft tissue loss that may require reconstructive methods for wound healing to be achieved. The flexor carpi ulnaris (FCU) muscle has been described for coverage in case reports and small series. Previous studies give conflicting anatomic findings about the dominant vascular pedicle for the FCU.
METHODS: Twenty-five cadaveric specimens were dissected. Pedicle location, number, and distance from the medial epicondyle were recorded along with the extent of posterior elbow coverage. Chart review was conducted during a 4-year period. Eight patients who underwent FCU rotational flap coverage were identified. Those flaps relied entirely on a single proximal pedicle.
RESULTS: The vascular pedicles from the ulnar artery or recurrent ulnar artery were identified in 24 of 25 specimens. The average distance from the tip of the medial epicondyle to the first pedicle was 5.7 cm (range, 3 to 10 cm). The length of muscle coverage proximal to the olecranon tip averaged 9.3 cm. The clinical follow-up of 7 patients requiring FCU rotational flaps for coverage of the posterior elbow showed that all flaps survived and provided adequate coverage for the defect.
CONCLUSIONS: The FCU rotational pedicle flap provides predictable coverage of small to medium-sized defects about the posterior elbow. Although it is relatively consistent, the proximal vascular pedicle does demonstrate some variability, which should be considered in planning surgery. The consistent distal extent of the FCU muscle belly provides wider proximal coverage of defects.

BACKGROUND: Aseptic implant loosening is one of the most common complications leading to revision surgery in total elbow arthroplasty. Different humeral stem lengths are available with varying designs. In general, the decision of which stem length to use depends on the surgical diagnosis or simply the surgeon preference. Often, the longer stem is used for post-traumatic or revision cases while for rheumatoid patients the shorter stem is preferred. There are no data in the literature to favor one humeral stem size over the other according to the diagnosis.
METHODS: We analyzed the total elbow joint database of the Coonrad-Morrey design at our institution for aseptic loosening leading to revision and compared the revision rate and the survival of the 4- and 6-inch humeral stems.
RESULTS: Overall, revision for aseptic humeral loosening is infrequent and occurred in only 16 of 711 total elbow arthroplasties during a mean follow-up of 88 months. There was no significant difference in the revision rate between the 2 stem lengths (1.9% for the 4-inch stems and 2.6% for the 6-inch stem).
CONCLUSIONS: Revision rate was correlated to the surgical diagnosis and was significantly higher for post-traumatic patients than for rheumatoid patients (5.1% vs 0.66%, P < .001). Of interest, and possibly not surprising, the mean time to revision was shorter for the 4-inch stems than it was for the 6-inch stems (37 vs 95 months, P = .034).