Aspirus

Spinal surgeries have become common procedures due to greater life expectancy and the increasing elderly population. Failed fusion, or nonunion, may be influenced by patient risk factors and can lead to a myriad of complications. Pulsed electromagnetic field (PEMF) stimulation is a noninvasive post-operative adjunct therapy that has been shown to influence underlying cellular processes that may improve osteogenesis to promote successful fusion following spinal surgery. The aim of the study was to evaluate the effect of PEMF on lumbar fusion in patients with risk factors for nonunion. The current study employed a prospective, multicenter study to investigate PEMF as an adjunct therapy following lumbar spinal fusion procedures in subjects with risk factors for failed fusion. A retrospective control arm was used as a comparator. Subjects were enrolled with at least one of the following risk factors: prior failed fusion, multi-level fusion, nicotine use, osteoporosis, advanced age (>65 years), body mass index >30 kg/m2, and diabetes. PEMF was delivered for 6-months following surgery. Overall fusion status and influence of risk factors were assessed. Successful fusion was determined by radiographic imaging. Fusion status was compared at a 12-month follow-up in subjects treated with PEMF (n=142) vs. control (n=47). Successful fusion was observed in 88.0% (n=125/142) of PEMF subjects and 68.1% (n=32/47) of control subjects. PEMF therapy resulted in statistically improved fusion rates in subjects with prior failed fusion (P=0.04), multi-level fusion surgery (P<0.001), and advanced age (P<0.001) when compared to control. PEMF therapy resulted in statistically improved fusion rates in subjects who had at least one risk factor (P=0.002), ≥2 risk factors (P<0.001), and ≥3 risk factors (P=0.003) compared to control. Linear regression analyses showed a significant treatment effect of PEMF across all risk factors and presentations (P=0.003). A favorable safety profile was observed with PEMF therapy. PEMF therapy improved fusion success in subjects following lumbar spinal surgery and represents a beneficial adjunct treatment resulting in significant improvements in subjects having risk factors for nonunion.

Purpose: The study determines how accessible tourism (tourism for individuals with disabilities) is marketed in the Kingdom of Saudi Arabia and how respondents' responses varied based on their gender, kind of disability, and geographic location. Methods: The descriptive survey method was employed to fulfill the study's objective. After confirming the indicators of its validity and stability in the Saudi context, the researchers designed the study instrument "electronic questionnaire" that consisted of (18) items divided throughout three domains: (tourism planning, tourist sales and goods, and tourism services). The instrument was used on a sample of (142) male and female participants with impairments (physically challenged, visually impaired, and hearing impaired) who were chosen by the stratified random technique from three locations in the south of the Kingdom of Saudi Arabia (Najran, Jazan, and Asir). Results: The results indicated that accessible tourism (travel for people with disabilities) marketing reality in the Kingdom of Saudi Arabia is at a low level. In addition, it was discovered that the variables of gender, type of disability, and region have no statistically significant impact on the reality of tourism marketing for accessible tourism (tourism for people with disabilities) in the Kingdom of Saudi Arabia. The study recommended that broad steps and measures be taken by the Saudi government and the Tourism and Leisure Authority toward developing tourism marketing for accessible tourism. Therefore, these measures should meet the needs of people with disabilities, attracting them and placing accessible tourism on the local and international tourism map. Implications and values: Broad steps and measures must be taken from the Saudi government and the Tourism and Entertainment Authority towards developing tourism marketing for accessible tourism to suit the requirements and needs of people with disabilities, attract them, and place accessible tourism on the map of local and global tourism.

Atrial fibrillation (AF) is common in patients undergoing transcatheter aortic valve replacement (TAVR) and is associated with increased risk of bleeding and stroke. While left atrial appendage occlusion (LAAO) is approved as an alternative to anticoagulants for stroke prevention in patients with AF, placement of these devices in patients with severe aortic stenosis, or when performed at the same time as TAVR, has not been extensively studied. WATCH-TAVR (WATCHMAN for Patients with AF Undergoing TAVR) was a multicenter, randomized trial evaluating the safety and effectiveness of concomitant TAVR and LAAO with WATCHMAN in AF patients. Patients were randomized 1:1 to TAVR + LAAO or TAVR + medical therapy. WATCHMAN patients received anticoagulation for 45 days followed by dual antiplatelet therapy until 6 months. Anticoagulation was per treating physician preference for patients randomized to TAVR + medical therapy. The primary noninferiority end point was all-cause mortality, stroke, and major bleeding at 2 years between the 2 strategies. The study enrolled 349 patients (177 TAVR + LAAO and 172 TAVR + medical therapy) between December 2017 and November 2020 at 34 US centers. The mean age of patients was 81 years, and the mean scores for CHA2DS2-VASc and HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly) were 4.9 and 3.0, respectively. At baseline, 85.4% of patients were taking anticoagulants and 71.3% patients were on antiplatelet therapy. The cohorts were well-balanced for baseline characteristics. The incremental LAAO procedure time was 38 minutes, and the median contrast volume used for combined procedures was 119 mL versus 70 mL with TAVR alone. At the 24-month follow-up, 82.5% compared with 50.8% of patients were on any antiplatelet therapy, and 13.9% compared with 66.7% of patients were on any anticoagulation therapy in TAVR + LAAO compared with TAVR + medical therapy group, respectively. For the composite primary end point, TAVR + LAAO was noninferior to TAVR + medical therapy (22.7 versus 27.3 events per 100 patient-years for TAVR + LAAO and TAVR + medical therapy, respectively; hazard ratio, 0.86 [95% CI, 0.60-1.22]; Pnoninferiority<0.001). Concomitant WATCHMAN LAAO and TAVR is noninferior to TAVR with medical therapy in severe aortic stenosis patients with AF. The increased complexity and risks of the combined procedure should be considered when concomitant LAAO is viewed as an alternative to medical therapy for patients with AF undergoing TAVR. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03173534.

Increasing awareness of precipitating factors and associated complications of TTS has led to a broader understanding of the presentation, clinical course, and pathophysiology of this syndrome. Here we present two cases of TTS; One representing an uncommon complication and another with a unique mechanism of emotional stress.

Quadriceps atrophy and weakness can persist for years after anterior cruciate ligament reconstruction (ACLR). We evaluated the effectiveness of a home-based blood flow restriction (BFR) exercise program to increase quadriceps size and strength several years after ACLR. Nine adults with ACLR (5±2 yrs post-surgery, ≤90% symmetry in quadriceps size and strength) and nine uninjured controls volunteered. ACLR participants exercised at home for 25 min, 5×/wk for 4 wks (single-leg knee extension, bodyweight half-squats, walking). Blood flow in only the involved leg was restricted using a thigh cuff inflated to 50% of limb occlusion pressure. Rectus femoris and vastus lateralis thickness and knee extensor strength were measured before and after training. Baseline and post-training symmetry (involved leg/uninvolved leg) indices were compared to uninjured controls. Rectus femoris and vastus lateralis thickness and knee extensor strength in the involved leg increased by 11±5%, 10±6%, and 20±14%, respectively (all P<0.01). Compared to baseline, post-training knee extensor strength symmetry increased from 88±4 to 99±5% (P<0.01) and did not differ from uninjured controls (99±5%, P=0.95). Implementation of BFR exercise at home was feasible, safe and effective. Results extend upon early post-operative application of BFR exercise for ACLR recovery and demonstrate that BFR can improve quadriceps function long after ACLR.

Laparoscopic and robotic-assisted laparoscopic diaphragm plication is a safe, effective, and minimally invasive surgical alternative to transthoracic approaches. Theoretic advantages of the laparoscopic approach are operative space and potentially less pain, but access to the posterior diaphragm in obese patients is more challenging than via a transthoracic approach. Midterm results with standardized quality of life questionnaires and imaging have shown excellent symptomatic improvement and radiologic confirmation of a persistent diaphragm position. In summary, robotic-assisted laparoscopic diaphragm plication is a good therapeutic alternative to transthoracic approaches.

Abstract Löwdin's correlation potential formalism has been used to define a modified bielectronic potential, allowing one to calculate the exact electronic energy, given the Hartree–Fock wave function. This modified potential is in principle peculiar to each electronic system, and is defined by a correlation factor depending on the interelectronic distance r2. The explicit calculation of the correlation factor has been performed for some two‐electron atoms, in the 11S and 23S states, and for the beryllium atom. Examination of the results so obtained leads us to conclude in favor of the nonexistence of a universal modified bielectronic potential.

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