Journal articles on the topic 'Oxford Grading Scale'

ABSTRACT Objectives The objectives of the study are to: (i) Assess the perineal muscle strength of postnatal mothers after vaginal delivery in the experimental and control groups before and after the intervention. (ii) Evaluate the effectiveness of Kegel's exercise on perineal laxity in the experimental group compared to control group. Methods This single blinded randomized controlled trial at a 1000 bedded tertiary care teaching hospital in India, enrolled 290 postnatal mothers between 20 and 40 years who had vaginal delivery with < 2 on modified Oxford grading scale as measured by per vaginal digital examination. The subjects were randomized into experimental and control groups. The experimental group received instructions to perform Kegel's exercises along with routine postnatal care while the control group received advice on routine postnatal care. Two follow-up assessments were done at 6 and 10 weeks. The primary outcome measure was increase in Oxford grading score. Results Major findings of the study were: The mean perineal muscle strength assessment scores noted before the intervention and during first and second postintervention assessments were 1.5 ± 0.52, 3.58 ± 0.51 and 4.28 ± 0.57 respectively for the experimental group and 1.56 ± 0.55, 2.41 ± 0.52 and 3 ± 0.51 respectively for the control group. Comparison of these scores between the groups by unpaired t-test yielded p-value of < 0.0001 suggesting high significant difference in favor of the experimental group. However, no additional benefit was observed after Kegel's exercise in the mothers who had episiotomy during vaginal delivery. Conclusion The Kegel's exercise is effective to reduce perineal laxity and hence should be included as a part of routine postnatal care.

Summary Introduction: Digital palpation and manometry are methods that can provide information regarding maximum voluntary contraction (MVC) and endurance of the pelvic floor muscles (PFM), and a strong correlation between these variables can be expected. Objective: To investigate the correlation between MVC and endurance, measured by digital palpation and manometry. Method: Forty-two women, with mean age of 58.1 years (±10.2), and predominant symptoms of stress urinary incontinence (SUI), were included. Examination was firstly conducted by digital palpation and subsequently using a Peritron manometer. MVC was measured using a 0-5 score, based on the Oxford Grading Scale. Endurance was assessed based on the PERFECT scheme. Results: We found a significant positive correlation between the MVC measured by digital palpation and the peak manometric pressure (r=0.579, p<0.001), and between the measurements of the endurance by Peritron manometer and the PERFECT assessment scheme (r=0.559, P<0.001). Conclusion: Our results revealed a positive and significant correlation between the capacity and maintenance of PFM contraction using digital and manometer evaluations in women with predominant symptoms of SUI.

Background: Knee Osteoarthritis is the most common joint disorder and one of the leading causes of disability. The main symptoms associated with osteoarthritis are pain, discomfort, limitation of activity and reduced participation. Physiotherapy management is evidence-based treatment approach that have short-term and long-term effect on reducing pain, improve muscle strength and function. Aim: The aim of this study was to find out evidence-based physiotherapy in patient with knee osteoarthritis through three tract reasoning on reducing pain, improve muscle strength and function. Method: A case-based study was conducted. The three tract reasoning: procedural, interactive and conditional were used during diagnosis and in management of knee osteoarthritis. Results: The patient respond well in physiotherapy treatment. The swelling was 100% reduced, reduced pain in VAS from 8/10 to 1/10, improved muscle strength by oxford muscle grading scale by grade V, weight bearing is more (90%) and only 25% remain limitation in functionally from 69%. Conclusion: Knee osteoarthritis is frequent musculoskeletal condition that affect person’s activities and restricted the participation. Using clinical reasoning physiotherapist diagnosed and managed the symptoms. After receiving physiotherapy treatment improved the patient’s status of health.

Purpose This study aimed to analyze the association of tear matrix metalloproteinase 9 (MMP-9) immunoassay with the severity of dry eye (DE) signs and symptoms through qualitative, semiquantitative, and quantitative evaluations of immunoassay band. Materials and methods This cross-sectional study enrolled 320 eyes of 320 patients. The clinical signs of DE were assessed using the Ocular Surface Disorder Index (OSDI) score, visual analogue scale (VAS), tear breakup time (tBUT), tear volume evaluation by tear meniscometry, and staining scores of the cornea and conjunctiva by the Oxford grading scheme. The tear MMP-9 immunoassay results were interpreted using qualitative (positive or negative), semi-quantitative (reagent band density on a four-point scale: 0 = negative; 1 = weakly positive; 2 = moderately positive; 3 = strongly positive), and quantitative (ratio of reagent band density to control band density) indicators. Results Positive MMP-9 immunoassay results were significantly related to shorter tBUT, tBUT ≤3 seconds, higher corneal staining score, corneal staining score ≥2, and conjunctival staining score ≥2. The semi-quantitative results of the MMP-9 immunoassay were positively correlated with higher corneal staining score (r = 0.122, p = 0.029) and negatively correlated with tBUT (r = -0.125, p = 0.025). However, in the quantitative analysis, none of the DE signs or symptoms were correlated to the band density of the MMP-9 immunoassay. Conclusions The positive MMP-9 immunoassay results were related to the severity of ocular signs of DE. However, using quantitative measures of the MMP-9 immunoassay to assess the clinical severity of DE requires further investigation.

Now a day’s abnormal uterine bleeding in premenopausal women is the most common indication of hysterectomy which usually results from myomas and adenomyosis. In this case study, a 38-year-old female, with a complaint of abnormally heavy bleeding with menstrual cycle irregularity and discomfort for 15 days each month with dysmenorrhoea. She was diagnosed for large fibroid deposition at the posterior wall of the uterus and extroverted in the position. So, she was prescribed for vaginal Hysterectomy by a gynecologist further investigation, she underwent a vaginal hysterectomy, post-operatively patient was complaining about lower abdominal pain and difficulty in bed mobility activities. There was weakness in pelvic floor muscles after the surgery, due to which she had worried about overweight, physical health, and her quality of life. So she approached the physiotherapist, where she had trained for pelvic floor muscle training two-three sessions per day for two weeks with abdominal, back, and hip strengthening exercises with a home exercise program. VAS scale, Oxford grading system, PFIQ, QOL questionnaire was taken as outcome measure prior and after the intervention. The present case report emphasizes the effect of the combination of different exercises for pelvic floor muscles encasing the comprehensive rehabilitation plan including a home exercise regimen allowing the patient to recover early and return to daily activities.

Introduction: Frequent and regular exercises in the first six months of stroke may cause return of a significant portion of sensory and motor function of patients. This study aimed to examine the effects of passive range of motion exercise in the acute phase after stroke on motor function of the patients. Methods: A randomized controlled trial study was conducted. The patients with first ischemic stroke were randomly allocated to either experimental (n=33) or control (n=19) group. Passive range of motion exercises was performed in the experimental group during the first 48 hours of admission as 6 to 8 times of 30 minute exercise. Before intervention, and one and three months after intervention, motor function were measured by muscle strength grading scale (Oxford scale) and compared. SPSS version 13.0 for Windows was used for statistical analysis. Frequency distribution was used to describe the data. For comparisons, paired t-test, independent t-test was used, and repeated measures test was used. Results: In acute phase, the intervention in the experimental group led to significant improvement of motor function between the first and third month in both the upper and lower extremities. In control group, improvement was observed only in the muscle strength of upper extremity in the first and third month compared to pre-intervention measurement. The greatest improvement was observed in the interval from base to one month in the upper extremity, and base to the first month and the first to the third month in the lower extremity. Conclusion: It is recommended to use early passive range of motion exercise as part of care for people with stroke during the acute phase of the disease.

Background: Various techniques have been described for surgical treatment of recalcitrant medial epicondylitis (ME). No single technique has yet to be proven the most effective. Purpose: To evaluate the clinical outcomes of a double-row repair for ME. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed on 31 consecutive patients (33 elbows) treated surgically for ME with a minimum clinical follow-up of 2 years. All patients were initially managed nonoperatively with anti-inflammatories, steroid injections, topical creams, and physical therapy. Outcome measures at final follow-up included visual analog scale (VAS) scores (scale, 0-10), time to completely pain-free state, time to full range of motion (FROM), Mayo Elbow Performance Scores (MEPS), and Oxford Elbow Scores (OES). Patients were contacted by telephone to determine current functional outcomes, pain, activity, functional limitations, and MEPS/OES. Successful and unsuccessful outcomes were determined by the Nirschl grading system. Results: The mean clinical and telephone follow-up periods were 2.3 and 3.6 years, respectively, and 31 of 33 (94%) elbows were found to have a successful outcome. The mean VAS improvement was 4.9 points, from 5.8 preoperatively to 0.9 postoperatively ( P < .001). The mean MEPS and OES at final follow-up were 95.1 and 45.3, respectively. The mean time to pain-free state and time to FROM were 87.4 and 96 days, respectively. Unlike prior studies, no difference in outcome was found between those with and without ulnar neuritis preoperatively ( P = .67). Conclusion: A double-row repair is effective in decreasing pain and improving the overall function for recalcitrant ME. Uniquely, the presence of preoperative ulnar neuritis was associated with higher patient-reported preoperative pain scores but not with poor outcomes using this protocol.

Background: The prognostic factors for patients with full-thickness rotator cuff tears (RCTs) include tear size, muscle atrophy and fatty infiltration. However, the influence of early coexisting degenerative changes on RCT outcomes is unappreciated. The purpose of this study was to calculate the impact that pre-existing partial glenohumeral cartilaginous changes have on patients undergoing arthroscopic RCT repair.Methods: A study of 54 patients undergoing arthroscopic RCT repair was undertaken. The presence of co-existing patches of glenohumeral degenerative cartilaginous changes and RCT size was recorded at surgery. Pre- and postoperative outcomes were assessed using traditional (Oxford Shoulder Score [OSS], 5-level EuroQol-5D [EQ-5D-5L] questionnaire and EuroQol visual analog scale [EQ-VAS]) and patient-centric re-formatted prisms. Outcomes were assessed as an entire dataset, and sub-group analysis was performed according to the grade of co-existing arthritis and tear size.Results: Significant improvements (p<0.05) in clinical outcomes were recognized when assessed using either the traditional or reformatted prisms (average % improvements in OSS, EQ-5D-5L and EQ-VAS were 47%, 33% and 43%, respectively; average improvements in pain, function, and psychological well-being were 48%, 33% and, 29%, respectively). Positive gain was noted in all sub-groups of arthritic grading and tear size.Conclusions: Good clinical outcomes can be achieved following RCT repair even in the presence of local partial degenerative cartilage changes and advancing tear size. These benefits are patient-centered but require RCT repairability.

Introduction: Alzheimer’s disease (AD) is a degenerative disease and dementia is a neurological condition which is significantly caused by AD. Sometimes it is found at early to middle age which is associated with cognitive and functional impairment. There is no significant curative treatment till now but only symptomatic treatment in available. Aim of this study is to describe evidence-based physiotherapy management for fall prevention associated with Alzheimer’s disease. Case Report: This is a case-based study which features an elderly man who has just fallen for the few times and has early Alzheimer’s disease (AD). In literature, exercise therapy is proven to be effective for fall management. Exercise was demonstrated by the physiotherapist and follow-up was done on a regular basis. The fall prevention exercise included core muscle strength training, cue gait training, fall prevention strategy, and task-based functional activity practice focused on Alzheimer’s symptoms. The patient was assessed with the Tinetti Patient Oriented Mobility Assessment (POMA) and Berg Balance Scale score (BBS). The initial score was 8/28 for POMA and 19/56 for BBS, and after 8 weeks it was recorded as 19/28 and 21/56. Oxford muscle grading system was used for measuring strength. Conclusion: Final outcomes suggested minor improvements in balance, strength of lower limbs, functional activities. This case study focuses on the importance of physical exercise to improve balance and prevent consequences of fall.

Abstract Purpose To evaluate the effect of IPL (intense pulsed light) treatment in patients with meibomian gland dysfunction (MGD). Methods Clinical data of 25 patients with MGD who underwent IPL treatment at the department of ophthalmology of Ludwig-Maximilians-University between 2016 and 2018 were analyzed. Demographics, clinical history, examination findings (eyelid vascularization, meibomian gland findings, conjunctival redness, tear film break-up time [TFBUT], corneal staining (Oxford grading scale [OGS]), and subjective patientsʼ findings (including ocular surface disease index [OSDI]) were collected from each visit (D1, D15, D45, D75). Results All included patients underwent three sessions of IPL treatment in both eyes (D1, D15, D45). There was a significant improvement after IPL treatment (D75) in TFBUT (p < 0.001), corneal staining (OGS) (p < 0.001), conjunctival redness (p < 0.001), lid margin edema (p < 0.001) and redness (p < 0.001), meibum quality (p < 0.001), lid margin telangiectasia (p = 0.005), meibomian gland obstruction (p = 0.001), and OSDI score (p = 0.004). Even after the first IPL session, significant improvements in TFBUT (p < 0.001), corneal staining (OGS p < 0.001), conjunctival redness (p < 0.022), lid margin edema (p < 0.001) and redness (p < 0.016), meibum quality (p = 0.014), and OSDI score (p < 0.013) were noted. There were no relevant negative side effects. Subgroup analysis for age, sex, duration or severity of disease, and associated diagnosis of rosacea showed no significant difference in effectiveness. Conclusion IPL is an effective and safe treatment for patients with MGD, which can be used as a supportive therapeutic option.

AimsTo describe clinical and in vivo confocal microscopy (IVCM) features of neuropathic corneal pain (NCP) without clinically visible signs.MethodsProspective, observational study of 27 eyes of 14 patients who had continuous severe ocular pain for one or more years, with minimal or no ocular surface signs and were non-responsive to topical lubricants, steroids and/or ciclosporin. All patients were evaluated using Ocular Surface Disease Index, Oxford grading scale, Schirmer test 1, Cochet Bonnet esthesiometry and response to topical anaesthesia. Central and paracentral regions of the cornea of patients and seven healthy controls were studied by IVCM. Corneal epithelial thickness and sub-basal nerve density were measured in patients and controls.ResultsFour patients responded to topical anaesthesia (responsive group (RG)), indicating peripheral NCP while 10 patients did not show any improvement (non-responsive group (NRG)), indicating central NCP. Schirmer-1 test was within normal limits in the RG but significantly greater in the NRG (p<0.001). None of the other clinical parameters nor corneal epithelial thickness were statistically significantly different. The sub-basal nerve density was significantly reduced (p<0.008) in patients compared with controls. Stroma of all patients demonstrated activated keratocytes and spindle, lateral and stump microneuromas. There was a statistically significant greater number of microneuromas (p<0.0001) and activated keratocytes in RG compared with NRG.ConclusionNCP without visible clinical signs does not represent typical dry eye disease. Distinct signs demonstrated on IVCM suggest that peripheral NCP, which responds to topical anaesthesia, and central NCP, which does not, are separate entities.

BackgroundThe femoral nerve block (FNB) may be used for analgesia in hip fracture surgery. The pericapsular nerve group (PENG) block is a novel regional technique and may provide better pain reduction while preserving motor function, but these blocks have not been directly compared.MethodsIn a single-center double-blinded randomized comparative trial, patients presenting for hip fracture surgery received analgesia with either FNB or PENG block. The primary outcome measure was pain scores (Numeric Rating Scale (NRS) 0 to 10). Secondary outcomes were postoperative quadriceps strength, opiate use, complications, length of hospital stay, and patient-reported outcomes.ResultsSixty patients were randomized and equally allocated between groups. Baseline demographics were similar. Postoperatively in recovery (day 0), the PENG group experienced less pain compared with the FNB group. (In the PENG group, 63% experienced no pain, 27% mild pain, and 10% moderate to severe pain. In comparison, 30% of the FNB group reported no pain, 27% mild pain, and 36% moderate to severe pain; p=0.04). This was assessed using an 11-point Likert NRS. Quadriceps strength was better preserved in the PENG group in the recovery unit (assessed using Oxford muscle strength grading, 60% intact in the PENG group vs none intact in the FNB group; p<0.001) and on day 1 (90% intact vs 50%, respectively; p=0.004). There was no difference in other outcomes.ConclusionsPatients receiving a PENG block for intraoperative and postoperative analgesia during hip fracture surgery experience less postoperative pain in the recovery room with no difference detected by postoperative day 1. Quadriceps strength was better preserved with the PENG block. Despite the short-term analgesic benefit and improved quadriceps strength, there were no differences detected in the quality of recovery.

Objective: This study aimed to evaluate effectiveness of pelvic floor muscles training on females’ sexual function throughout pregnancy and postpartum.Methods: A quasi experimental research design was applied at the antenatal clinic of Mansoura University hospital, Egypt. A purposive sample of 72 nulliparous singleton pregnant client free from any connotation affect sexual practice was studied. The subjects were allocated into two groups; control group received conventional antenatal and postnatal care, while the intervention group received the same care besides performing pelvic floor muscle exercise at 20 weeks pregnancy until 10-12 weeks postpartum. Female sexual function, sexual quality of life, and strength of the pelvic floor muscle contraction were evaluated at baseline, at 28-30 weeks gestation, and at 10-12 weeks postpartum, by using the female sexual function index scale, sexual quality of life-female, and the Oxford grading scale.Results: The total female sexual quality of life index scores in the intervention group were higher than those of the control group at the pregnancy and postpartum follow ups (22.3 ± 6.9 vs. 15.9 ± 6.8 & 26.0 ± 6.7 vs. 13.5 ± 6.3 respectively; p < .001). The sexual quality of life-female scores were significantly higher in the intervention group than in the control group at the pregnancy follow up evaluation (54.2 ± 15.9 vs. 36.9 ± 9.7 respectively, p < .001) and at the postpartum follow up evaluation (59.8 ± 13.5 vs. 30.3 ± 7.0 respectively, p < .001). The pelvic floor muscles strength was significantly better in the intervention group than in the control group at the pregnancy follow up evaluation and at the postpartum follow up evaluation.Conclusions: Pelvic floor muscle training during early gestation weeks was an effective tool for improvement of the female sexual function, sexual quality of life-female, and pelvic floor muscles strength during pregnancy and postpartum. Thus, it should be encouraged for pregnant mothers at early weeks and continued till postpartum.

Aims This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes. Methods Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiological, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire, and EuroQol five-dimension five-level score) were collected preoperatively, at six months, one year, and two years. The Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system was used to stratify deformity. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts, and/or subsidence. Results In all, 500 patients reached six-month follow-up, 420 reached one-year follow-up, and 188 reached two-year follow-up. The mean age was 67.8 years (23.9 to 88.5). A total of 38 patients (7.5%) presented with inflammatory arthritis. A total of 101 (20.0%) of implantations used patient-specific instrumentation; 167 patients (33.1%) underwent an additional procedure at the time of surgery. A total of seven patients died of unrelated causes, two withdrew, and one was lost to follow-up. The mean follow-up was 16.2 months (6 to 36). There was a significant improvement from baseline across all functional outcome scores at six months, one, and two years. There was no significant difference in outcomes with the use of patient-specific instrumentation, type of arthritis, or COFAS type. Five (1.0%) implants were revised. The overall complication rate was 8.8%. The non-revision reoperation rate was 1.4%. The 30-day readmission rate was 1.2% and the one-year mortality 0.74%. Conclusion The early experience and complications reported in this study support the current use of the INFINITY TAA as a safe and effective implant in the treatment of end-stage ankle arthritis. Cite this article: Bone Joint J 2021;103-B(7):1270–1276.

Category Ankle Arthritis; Ankle Introduction/Purpose: This is the first report from the UK INFINITY study. This is a multicentre, non-inventor, prospective observational study of 504 INFINITY fixed bearing total ankle arthroplasties. We report our early experience, complications, radiographic and functional outcomes of this prosthesis. Methods: Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiographic, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire and Euroquol 5D-5L) were collected preoperatively, at 6 months (454 patients), 1 year (328 patients) and 2 years (104 patients). The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.9 (18.9 to 48.0). The COFAS grading system was used to stratify deformity. There were 259 (51.4%) COFAS Type 1, 122 (24.2%) COFAS Type 2, 32 (6.3%) COFAS 3 and 87 (17.3%) COFAS type 4. 38 patients (7.54%) presented with inflammatory arthritis. 101 (20.0%) of implantations utilised patient specific instrumentation (Prophecy). 169 (33.5%) of patients underwent an additional procedure at the time of surgery. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results: There was a significant (p<0.01) improvement across all functional outcome scores at 6 months, which was sustained at one and two years. There was no significant difference with the use of patient specific instrumentation. 167 (33.1%) underwent additional procedures at index surgery. At the latest follow up 3 implants (0.6%) have been revised. One patient at 6 weeks for deep infection, one patient at 6 months for subsidence and one patient at 18 months for loosening. There were an additional 13 reoperations (2.6%) at the latest follow up. Conclusion: The UK INFINITY study is the largest reported multicentre study of a Total Ankle Arthroplasty to date. This study has shown a low early revision rate and high functional outcomes of the INFINITY prosthesis.

Purpose. To explore the relationship between serum prolactin, testosterone level, and tear film parameters. The potential impact of these hormones on the health of the ocular surface in pregnant women was evaluated. Methods. This was a hospital-based cross-sectional study in which ocular symptoms (Ocular Surface Disease Index (OSDI)), tear function (fluorescein tear breakup time, Schirmer’s test 1), corneal and conjunctival staining, meibomian gland (MG) expressibility, and quality of secretion were measured. Lid margin findings including lid notching, thickness, and lid margin telangiectasia were also recorded. Venous blood was collected and the serum concentrations of prolactin and testosterone were determined using ELISA kits. Correlation and multiple linear regression analyses were used to examine predictors of dry eye symptoms and signs. Results. A total of 160 pregnant women participated in the study and their mean age was 30.1 ± 4.6 years (range 18–42 years). The correlation analysis indicated that testosterone concentration did not significantly correlate with any of the clinical parameters hence it was not included in the linear regression analysis. However, prolactin serum concentration correlated significantly with Schirmer’s test 1. Multiple linear regression was done to predict participants’ Schirmer’s test 1 score based upon their ocular surface staining score (oxford grading scale), meibomian gland expressibility, meibomian secretion quality, and serum concentration of prolactin. Only predictors that significantly correlated with Schirmer’s test 1 in the correlation analysis were included in the linear regression analysis. A significant regression equation was obtained (F (2, 157) = 5.119, p=0.007) with an R square of 0.05. Multiple linear regression analysis revealed that concentration of prolactin (ß coefficient = 0.032, p=0.044) and meibomian gland expressibility scores (ß coefficient = 2.14, p=0.016) were associated with Schirmer’s test 1 scores when adjusted for duration of pregnancy. Conclusion. The study showed that increased serum prolactin levels have a weak but positive impact on Schirmer’s test 1 scores whilst serum testosterone level has no association with the clinical parameters of dry eye in pregnant women.

Background: There is a risk of pelvic floor dysfunction (PFD) from baby delivery. Many clinical guidelines recommend pelvic floor muscle training (PFMT) as the conservative treatment for PFD because pelvic floor muscles (PFMs) play a crucial role in development of PFD. However, there is disagreement about the method and intensity of PFM training and the relevant measurements. To pilot the study in PFM training, we designed a Pelvic Floor Workout (PEFLOW) for women to train their pelvic through entire body exercises, and we planned a trial to evaluate its effectiveness through comparing the outcomes from a group of postpartum women who perform PELFLOW at home under professional guidance online with the control group. Methods/design: The randomized controlled trial was projected to be conducted from November 2021 to March 2023. A total of 260 postpartum women would be recruited from the obstetrics departments of the study hospital and women would be eligible for participation randomized into experimental or control groups (EG/CG) if their PFM strength are scaled by less than Modified Oxford grading Scale (MOS) to be less than grade 3. Women in EG would perform a 12-week PEFLOW online under the supervision and guidance of a physiotherapist, while women in CG would have no interventions. Assessments would be conducted at enrollment, post intervention (for EG) or 18th to 24th week postpartum (for CG), and 1 year postpartum. Assessment would be performed in terms of pelvic floor symptoms, including MOS, cough stress test, urinary leakage symptoms, pelvic organ prolapse quantitation (POP-Q), and vaginal relaxation, clinic examinations including Pelvic floor electrophysiological test, Pelvic floor ultrasound and Spine X-ray, overall body test including trunk endurance test, handgrip test, body composition test, and questionnaires including International Physical Activity Questionnaire Score-Short Form(IPAQ-SF), Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the 6-item Female Sexual Function Index (FSFI-6), and the Pittsburgh Sleep Quality Index (PSQI). Primary analysis will be performed to test our main hypothesis that PEFLOW is effective with respect to strengthen PFM strength. Discussion: This trial will demonstrate that pelvic floor-care is accessible to most women and clinical practice on PFD may change relevantly should this study find that Online PEFLOW approach is effective to improve PFMs. Trial registration: ClinicalTrials.gov, NCT05218239.

Purpose To evaluate the relationship of symptoms of dry eye with closed chamber infrared thermometry and humidity measurements. Methods The authors studied 54 patients (108 eyes) with dry eye disorders of different grades of clinical severity (mean age 35.75±14.37 years), 31 cases (62 eyes) with normal eyes (mean age 33.68±14.42 years), and 10 cases (20 eyes) with epidemic conjunctivitis (mean age 33.68±14.42 years). The symptoms and the clinical tests (Schirmer-1 test, fluorescein tear break up time, Lissamine green stain; closed chamber infrared thermometry and humidity) were used to establish the diagnosis of dry eyes. The closed chamber humidity difference was used to classify the groups of dry eye. Results The authors noted no temperature difference from closed to open eye position in dry eyes as compared to 0.10±0.00 °C difference in normal eyes and epidemic conjunctivitis. Four groups of cases were identified by difference in values of humidity: Group 1 = <0.9 relative humidity (RH)% to 1 RH%; Group 2 = >1 RH% to 1.5 RH%; Group 3 = >1.5 RH% to 2 RH %; and Group 4 = >2 RH%. The symptomatology was measured in the eyes using Oxford scale (0–4) and correlated with the humidity groups. The grading of symptoms with the humidity showed a statistically significant relationship (p<0.0001) in each group. The severity of the symptoms showed an increase in frequency and severity from Group 1 to Group 4, which was statistically significant (p<0.0001). The mean sum total of global symptomatology score was statistically significant (p<0.0001): 3.43±0.31 in Group 1, 4.65±0.42 in Group 2, 8.56±0.78 in Group 3, and 13.35±1.21 in Group 4. However, total symptomatology score in epidemic conjunctivitis did not show a statistically significant value (p=0.20). Conclusions The closed chamber humidity and thermometry measurements showed statistical correlation in all four groups of dry eyes to total mean symptomatology score (p<0.001) and showed an increase in value with increasing severity of symptoms. However, all individual symptoms fail to show any conclusive relationship.

BackgroundRheumatoid arthritis (RA) is a chronic inflammatory disorder initiated from local synovium inflammation and consequently bone/cartilage destruction. Active disease status brings persistent inflammation, which stimulates the activation of osteoclasts, accelerating systemic bone loss and decreasing bone mineral density (BMD)(1). Ultrasound (US), a powerful tool for clinical practice, was reported to be beneficial for the prediction of new bone erosion and disease activity (2, 3), based on the synovitis grading recommendation by the European League against rheumatism- Outcome Measures in Rheumatology Clinical Trial (EULAR-OMERACT) Taskforce. The severity of RA synovitis is associated with local bone destruction; however, the impact on systemic bone loss is still unknown.ObjectivesThis pilot study aims to investigate if the US-detected synovitis change is associated with systemic bone loss.MethodsA registry was conducted in Chang Gung Memorial Hospital, Kaohsiung, from September 2014 till April 2021 to monitor BMD changes in patients with rheumatic diseases. In RA patients, we regularly assessed synovium change of bilateral wrist by ultrasound at enrollment and one year later, based on EULAR-OMERACT system(4), which is a semiquantitative grading tool incorporating both gray-scale synovial hypertrophy (SH) and power Doppler (PD) signal. These ultrasound scans were performed by an independent and well-trained rheumatologist, using MyLab 70 system (Esaote, Firenze, Italy) and B-mode frequency at 12–18 MHz. We performed a longitudinal scan of volar and dorsal wrists, observing GS and PD signals. All participants who underwent standard care for RA were followed at least three years to monitor BMD change, and those who underwent anti-osteoporosis therapy at index day were excluded. We defined improvement of US-detected synovitis (US+) as a change from high to low grade by EULAR-OMERACT score. Conversely, patients who failed improvement were recorded as “US- “, defined as change from low to high grade. Patients who improved one or more grades, such as from Grade 3 to 2 (or from Grade 2 to 0), were registered as US+1 (or US+2) and vice versa. If there is no change of synovitis grade, we registered as US+0.ResultsA total of 212 participants were enrolled in the current study, with a mean age of 56.0 ± 10.1 years and a mean RA disease duration of 13.6 ±9.1 years. In patients with US+, the mean change of hip BMD [defined as (final BMD-baseline BMD)/baseline BMD, in percentage] was 0.73 ±6.8%, while US- was -2.2 ±7.7% and US+0 -1.9 ±6.6% (p=0.047). in post-hoc analysis, US+ demonstrated borderline significance compared to US-(p=0.059) and US+0 (p=0.087) by Bonferroni method. Subsequent analysis (Figure 1 A) revealed that patients with US+2 presented preservation of hip bone mass (3.1 ±6.8%), followed by US+1 (0.1 ±6.8%) and then US+0. US-1 and US-2 showed rapid bone loss on the hip (-2.1 ±7.9% and -2.3 ±6.7%, respectively).Figure 1.ConclusionPersistent synovitis is associated with total hip bone loss, and detection of synovitis change by ultrasound with EULAR-OMERACT scoring system is helpful to predict hip BMD change.References[1]Tanaka Y. Managing Osteoporosis and Joint Damage in Patients with Rheumatoid Arthritis: An Overview. J Clin Med. 2021;10(6).[2]Moller B, Aletaha D, Andor M, Atkinson A, Aubry-Rozier B, Brulhart L, et al. Synovitis in rheumatoid arthritis detected by grey scale ultrasound predicts the development of erosions over the next three years. Rheumatology (Oxford). 2020;59(7):1556-65.[3]Mandl P, Balint PV, Brault Y, Backhaus M, D’Agostino MA, Grassi W, et al. Clinical and ultrasound-based composite disease activity indices in rheumatoid arthritis: results from a multicenter, randomized study. Arthritis Care Res (Hoboken). 2013;65(6):879-87.[4]D’Agostino MA, Terslev L, Aegerter P, Backhaus M, Balint P, Bruyn GA, et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 1: definition and development of a standardised, consensus-based scoring system. RMD Open. 2017;3(1):e000428.Disclosure of InterestsNone declared

BackgroundNo clear-cut guidelines exist about the use of imaging procedures for the diagnosis of idiopathic inflammatory myopathies (IIM). Similarly, conflicting, and scanty data exist about Power Doppler Ultrasonography (PDUS) in this subset of patients. In this regard, we recently proposed (1) a 0-3 grey scale (GS) and Power Doppler (PD) score in a cohort of patients affected by IIM, evidencing a positive, statistically significant, correlation for PD and oedema and disease activity.ObjectivesThe aim of this study was to assess the diagnostic accuracy of our score in IIM patients compared to a control group.MethodsWe prospectively collected, since July 2020 to December 2021, all patients evaluated in Vasculitis and Myositis clinic, Rheumatology Unit, University of Siena, with a recent diagnosis of IIM, as well as patients with a previous, definite diagnosis of IIM and evaluated during follow-up or referred from other centres for a second opinion. As control group, we collected all patients affected by amyopathic dermatomyositis (DM) or who underwent myositis immunoblot or muscle biopsy for proximal limbs weakness but eventually received a diagnosis other than IIM. All patients underwent US examination of both thighs in axial and longitudinal scans.ResultsForty-five IIM patients (11 anti-synthetase syndrome, 20 DM, 12 PM, 2 scleromyositis) and twenty-six controls were included. During the observational period, 7, 8, 1 and 1 patients underwent PDUS twice, three, four and five times, respectivelyAssessing area under the receiver operating characteristic (AUROC) curve analysis, IIM patients and control group were distinguished according to PD sum, Oedema sum, atrophy sum and CRP values (Figure 1a). The best cut-off value for PD sum values was 0.5 (70.2% SE and 83.3% SP), for Oedema sum 1.5 (74.5% SE and 79.2% SP), atrophy sum 0.5 (63.4% SE and 65.4% SP) and CRP was 0.22 mg/dL (61.5% SE and 75% SP).Figure 1.Stratifying IIM population into two groups according to disease activity (PhGA≥2), AUROC curve analysis allow to distinguish these groups according to PD and oedema sum and CRP values (Figure 1b) and the best cut-off values was 1.5 (69.6% SE and 76.9% SP), 2.5 (52.2% SE and 92.3% SP) and 0.55 mg/dL (66.7% SE and 88.9% SP), respectively.Testing the IIM group versus control as dependent variable by logistic regression, with PD sum, oedema sum, atrophy sum, CRP, CPK and myoglobin as independent variables, the AUROC was 0.976. From the probability associated with the Chi-square tests, the Type II analysis showed the variable that most influences the IIM diagnosis was PD sum and oedema sum (p=0.017 and p=0.013, respectively) (Figure 1c).ConclusionGS and PDUS have proven an overall good diagnostic accuracy in distinguishing between IIM and myositis mimicker. In particular, even low values of PD (sum 1.5) display a good sensitivity and specificity and, together with oedema, elevated CRP values and myositis-specific and associated antibodies, may be considered a reliable tool for a definite diagnosis of IIM.References[1]Conticini E, Falsetti P, Al Khayyat SG et al. A novel grey scale and Power Doppler ultrasonographic score for idiopathic inflammatory myopathies: Siena Myositis Ultrasound Grading Scale. Rheumatology (Oxford). 2021 Dec 24;61(1):185-194.Disclosure of InterestsNone declared

IntroductionImplementing non-pharmaceutical interventions (NPIs) protect the public from COVID-19. However, the impact of NPIs has been inconsistent and remains unclear. This study, therefore, aims to measure the impact of major NPIs (social distancing, social isolation and quarantine) on reducing COVID-19 transmission.Methods and analysisWe will conduct a systematic review and meta-analysis research of both randomised and non-randomised controlled trials. We will undertake a systematic search of: MEDLINE, Embase, Allied & Complementary Medicine, COVID-19 Research, WHO database on COVID-19, ClinicalTrails.Gov for clinical trials on COVID-19, Cochrane Resources on Coronavirus (COVID-19), Oxford COVID-19 Evidence Service and Google Scholar for published and unpublished literatures on COVID-19 including preprint engines such as medRxiv, bioRxiv, Litcovid and SSRN for unpublished studies on COVID-19 and will be reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Outcomes of interest for impact analysis will include the reduction of COVID-19 transmission, avoiding crowds and restricting movement, isolating ill and psychological impacts. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist has been used for this protocol. For quality of included studies, we will use the Cochrane Collaboration’s tool for assessing risk of bias for randomised controlled trials and the Newcastle-Ottawa Scale for observational studies. The Grading of Recommendations Assessment, Development and Evaluation approach will grade the certainty of the evidence for all outcome measures across studies. Random-effects model for meta-analysis will measure the effect size of NPIs or the strengths of relationships. For quantitative data, risk ratio or OR, absolute risk difference (for dichotomous outcome data), or mean difference or standardised mean difference (for continuous data) and their 95% CIs will be calculated. Where statistical pooling is not possible, a narrative synthesis will be conducted for the included studies. To assess the heterogeneity of effects, I2 together with the observed effects will be evaluated to provide the true effects in the analysis.Ethics and disseminationFormal ethical approval from an institutional review board or research ethics committee is not required as primary data will not be collected. The final results of this study will be published in an open-access peer-reviewed journal, and abstract will be presented at suitable national/international conferences or workshops. We will also share important information with public health authorities as well as with the WHO. In addition, we may post the submitted manuscript under review to medRxiv, or other relevant preprint servers.Trial registration numberCRD42020207338.

Background:Several chronic inflammatory diseases are associated with a higher risk of cancer.[1] Whether, this is the case in Polymyalgia Rheumatica (PMR) and Giant Cell Arteritis (GCA) is still a matter of debate.Objectives:To identify the prevalence of newly diagnosed cancers in patients with PMR and GCA by means of 18F-FDG PET/CT. Moreover, to compare the characteristics of the patients with and without cancer.Methods:Eighty consecutive patients with newly diagnosed PMR/GCA were studied. Diagnosis of PMR/GCA was confirmed by a 40-weeks follow up. A unilateral temporal artery biopsy (TAB) was also performed at the time of diagnosis. All included patients underwent an 18F-FDG PET/CT before, or in case of GCA, within 3 days of initiation of high dose oral glucocorticoid (40-75mg). All cancer-suspicious 18F-FDG-PET/CT findings were assessed thoroughly and malignant diseases were confirmed by histology. Total PMR and GCA scores were defined as the sum of a 4-point visual grading scale in each articular/periarticular site as well as arterial segment.Results:Of the 80 patients, 64 (83.1%) were diagnosed with pure PMR, 10 (13.0%) with concomitant GCA with PMR and 3 (3.9%) with pure GCA. Three patients were diagnosed with rheumatoid arthritis during follow up and excluded from the study. Five types of cancer in 4 (5.2%;95% CI:1.4-12.8%) patients were found. Two patients had breast cancer, one patient had adenocarcinoma of colon and one patient had adenocarcinoma of colon together with skin cancer. Besides, 4 (5.2%;95% CI:1.4-12.8%) patients had Monoclonal Gammopathy of Unknown Significance (MGUS). Age and C-reactive protein were significantly higher among those with solid cancers (p:0.049) and MGUS (p:0.017), respectively (Table1).Table 1.Characteristics of the patients with and without solid cancer ae well as MGUSVariablesCancer –,n=73Cancer +,n=4P-valueMGUS -, n =73MGUS +,n =4P-valueAge, mean±SD71.4±7.879.7±7.50.04971.9±8.070.2±9.20.79Gender, n(%)Female46(59.7%)3(3.9%)0.9947(61.0%)2(2.6%)0.62Constitutional symptoms, n(%)70(90.9%)4(5.2%)0.9970(90.9%)4(5.2%)0.99Shoulder girdle symptoms, n(%)68(88.3%)4(5.2%)0.9968(88.3%)4(5.2%)0.99Hip girdle symptoms, n(%)65(84.4%)3(3.9%)0.4064(83.1%)4(5.2%)0.99Cranial symptoms, n(%)19(24.7%)0(0%)0.5717(22.1%)2(2.6%)0.25Patients pain VAS75(50-85)62.5(50-75)0.5372.5(50 -80)87.5(77.5-95)0.07Patients global VAS80(60-90)62.5(50-75)0.3780(60-90)89.5(79.5-95)0.23Physician global VAS30(25-40)24.5(20-29)0.1530(22.5-40)37.5(32.5-45)0.17Erythrocyte sedimentation rate, mm[2-20]54(38-79)62.5(37.5-76)0.9354(38-77.5)57.5(39 -73.5)0.94C-reactive protein, mg/L[<6.0]37(17-64)34(17.0-76)0.8033(17-60)98(68 -115)0.017TAB positive7(9.1%)0(0%)0.997(9.1%)0(0%)0.99Total PMR score14(10-17)12(5-15)0.3914(10-17)13(6-15.5)0.64Total GCA score0(0-0)0(0-0.5)0.890(0-0)0(0-0)0.34Clinical diagnosis, n(%)0.990.53 Pure PMR60(77.9%)4(5.2%)61(79.2%)3(3.9%) Pure GCA3(3.9%)0(0%)3(3.9%)0(0%) Concomitant PMR and GCA10(13.0%)0(0%)9(11.7%)1(1.3%)VAS: Visual analogue scaleConclusion:The prevalence of cancers in this cohort was higher, compared to the 1-year prevalence of all cancer sites of 1.2% among age-, gender- and region-matched background population in 2016. Occult malignancies are important and relatively prevalent findings in newly diagnosed PMR/GCA patients.References:[1]Hemminki K, et al. Cancer risk in hospitalized rheumatoid arthritis patients. Rheumatology (Oxford) 2008;47:698-701.Disclosure of Interests:None declared

Background:Loss of articular cartilage is one of the major signs of osteoarthritis (OA). Aggrecan, the main proteoglycan component of the extracellular matrix of articular cartilage is cleaved by ADAMTS-5 (A Disintegrin And Metalloproteinase with ThromboSpondin-motif-5).1GLPG1972/S201086, a potent and highly selective inhibitor of ADAMTS-5, is an oral Disease-Modifying OsteoArthritis Drug (DMOAD) candidate. In a pooled Phase 1 safety analysis involving 171 participants GLPG1972/S201086 was shown to be well tolerated.Objectives:To present the study design of ROCCELLA, a large Phase 2 clinical trial in knee OA (KOA) patients, evaluating the efficacy and safety of GLPG1972/S201086 in reducing cartilage loss in OA.Methods:ROCCELLA is a multinational 52-week, multicentre randomized double-blind placebo-controlled dose-ranging phase 2 trial for the treatment of OA (NCT03595618). Eligible patients were aged 40–75 years with a diagnosis of primary femorotibial KOA, a pain score of 40–90mm on a 100 mm Visual Analogue Scale (VAS), predominant medial disease and a combined Kellgren/Lawrence (KL) 2 or 3 and Osteoarthritis Research Society International (OARSI) medial joint space narrowing (JSN) 1 or 2 severity grading range upon central reading of the X-ray. If both knees were eligible, the target knee was selected based first on the highest KL grade, then on the highest JSN grade and finally on the highest pain VAS score at baseline. Patients were randomized 1:1:1:1 to take placebo or three dose levels of GLPG1972/S201086 orally once daily for 52 weeks. The target knee was evaluated by quantitative Magnetic Resonance Imaging (qMRI) at baseline visit, week 28 and week 52, or at early withdrawal.The primary endpoint of the study is change from baseline to week 52 in cartilage thickness of the central medial tibio-femoral compartment (cMTFC) of the target knee. Secondary objectives are safety and tolerability including treatment emergent serious adverse events. Additional secondary structural and clinical efficacy objectives are based on changes from baseline in the target knee: cartilage thickness and bone area on qMRI, KOA “progressor” rates, Joint Space Width on X-ray, pain VAS, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total and sub scores, Patient Global Assessment VAS and the proportion of Outcome Measures in Rheumatology (OMERACT)-OARSI responders. Blood will be collected to assess the pharmacokinetics of GLPG1972/S201086. Planned, exploratory analyses include biochemical biomarkers of cartilage and bone turn-over. The study is designed to maintain the experiment wise type I error at 5%. A Mixed-effects Model for Repeated Measures will be used for the primary analysis. The randomisation was stratified by geographic region.Results:The study started in August 2018 and was fully recruited (N=938) by June 2019. Large numbers of patients with KOA had to be screened to meet the stringent pre-specified selection criteria. The study completion is expected by end of 2020.Conclusion:This is the first large Phase 2 study where patients with primary KOA are treated for 52 weeks with GLPG1972/S201086, an orally administered DMOAD candidate. This clinical trial was designed with a combination of two radiological selection criteria to ensure sufficient structural progression (cartilage loss) in the study population.References:[1]Durigova Met al.Osteoarthritis Cartilage2008;16:1245–52.Acknowledgments:This study was funded by Galapagos NV. Editorial support was provided by Oxford PharmaGenesis and funded by Galapagos NV.Disclosure of Interests:Henri Deckx Employee of: Galapagos, Ellen van der Aar Employee of: Galapagos, Marjolijne van der Stoep Employee of: Galapagos, Marianne Wooning Employee of: Galapagos NV, Katy Bernard Employee of: Institut de Recherches Internationales Servier, Sergey GRANKOV Employee of: Institut de Recherches Internationales Servier, Olivier Imbert Employee of: Institut de Recherches Internationales Servier, Maria Pueyo Employee of: Institut de Recherches Internationales Servier, Felix Eckstein Grant/research support from: Merck, Orthotrphix, Servier, Galapagos, Kolon Tissuegene, Samumed, Novartis, Consultant of: Merck, Bioclinica, Servier, Samumed, Roche, Kolon Tissuegene, Galapagos and Novartis, Employee of: co-owner and employment with Chondrometrics

Abstract Background Motor neuron diseases cause progressive degeneration of upper and lower motor neurons. No Indian studies are available on diffusion tensor imaging (DTI) findings in these patients. Aims This study was done to identify white matter tracts that have reduced fractional anisotropy (FA) in motor neuron disease (MND) patients using tract-based spatial statistics and to correlate FA values with Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) score. Settings and Design A case–control study in a tertiary care hospital. Materials and Methods We did DTI sequence (20 gradient directions, b-value 1,000) in 15 MND patients (10 men and 5 women; mean age: 46.5 ± 16.5 years; 11 amyotrophic lateral sclerosis [ALS], 2 monomelic amyotrophy, 1 progressive muscular atrophy, and 1 bulbar ALS) and 15 age- and sex-matched controls. The data set from each subject was postprocessed using FSL downloaded from the FMRIB Software Library, Oxford, United Kingdom (http://www.fmrib.ox.ac.uk/fsl). Statistical Analysis The statistical permutation tool “randomize” with 5,000 permutations was used to identify voxels that were different between the patient data set and the control data set. Mean FA values of these voxels were obtained separately for each tract as per “JHU white-matter tractography atlas.” SPSS was used to look to correlate tract-wise mean FA value with ALSFRS-R score. Results We found clusters of reduced FA values in multiple tracts in the brain of patients with MND. Receiver operating characteristic curves plotted for individual tracts, showed that bilateral corticospinal tract, bilateral anterior thalamic radiation, bilateral uncinate fasciculus, and right superior longitudinal fasciculus were the best discriminators (area under the curve > 0.8, p < 0.01). FA values did not correlate with ALFRS-R severity score. Conclusion In MND patients, not only the motor tracts, but several nonmotor association tracts are additionally affected, reflecting nonmotor pathological processes in ALS.

An advanced technique for establishing pressure boundary conditions in annular sector cascade experiments has been developed. This novel technique represents an improvement over previous methods and provides the first means by which annular sector boundary conditions that are representative of those which develop in an annular cascade can be established with a high degree of satisfaction. The technique will enable cascade designers to exploit the obvious advantages of annular sector cascade testing: the reduced cost of both facility manufacture and facility operation and the use of engine parts in place of two-dimensional counterparts. By employing an annular sector of deswirl vanes downstream of the annular sector of test vanes, the radial pressure gradient established in the swirling flow downstream of the test vanes is not disturbed. The deswirl vane exit flow—which has zero swirl velocity—can be exhausted without unsteadiness, and without the risk of separation, into a plenum at constant pressure. The pressure ratio across the annular sector of test vanes can be tuned by adjusting the throat area at the deswirl vane exit plane. Flow conditioning systems which utilize the Oxford deswirl vane technology have previously been used to set pressure boundary conditions downstream of fully annular cascades in both model and engine scale (the Isentropic Light Piston Facility at Farnborough) experimental research facilities (Povey, T., Chana, K. S., Oldfield, M. L. G., Jones, T. V., and Owen, A. K., 2001, Proceedings of the ImechE Advances in Fluid Machinery Design Seminar, London, June 13; Povey, T., Chana, K. S., Jones, T. V., and Oldfield, M. L. G., 2003, Advances of CFD in Fluid Machinery Design, ImechE Professional Engineering, London, pp. 65–94). The deswirl vane is particularly suited to the control of highly whirling transonic flows. It has been demonstrated by direct comparison of aerodynamic measurements from fully annular and annular sector experiments that the use of a deswirl vane sector for flow conditioning at the exit of an annular sector cascade represents an attractive novel solution to the boundary condition problem. The annular sector technique is now described.

Pelvic Organ Prolapse (POP) is a debilitating condition affecting about half of all women aged of more than 60 years globally. Reduced levator ani muscle strength in POP is associated with worse symptoms and prognosis. Measurement of levator ani muscle strength can be done with several tools such as perineometer and digital palpation. However, there is currently no study regarding conformity between tests. The aim of this study is to determine the correlation between tests in POP patients. An analytic observational study using cross sectional design was done to determine conformity between perineometer and digital examination using Modified Oxford Grading Scale (MOS) in Dr Cipto Mangunkusumo National General Hospital, Indonesia during the period of July, 2018 to June, 2020. Correlation between tests was determined using Spearman test. Cut-off of perineometer reading for each MOS score was also determined. A total of 110 subjects examined with both perineometer and digital palpation were recruited to the study. Positive correlation was observed between perineometer reading and Modified Oxford Grading Scale (r = 0.790, p < 0.001). According to the result, values between 0.01 – 9.64 cmH2O correspond to very weak pressure (MOS 1); 9.65 – 22.49 cmH2O represent weak pressure (MOS 2); 22.5 – 35.24 cmH2O represent moderate pressure (MOS 3); ≥ 35.25 cmH2O represent good pressure (MOS 4). There was a strong correlation between MOS and perineometer result for measuring levator ani strength in POP patients.

Abstract Background Transverse myelitis is a rare neurological disorder of the spinal cord, caused by inflammation and damage of the myelin sheath of the neurons of the spinal cord across one or more spinal segments. This causes a disruption in the passage of nervous signals leading to motor, sensory, and autonomic dysfunction. This affects the physical and psychological health, as well as the functional status of the patient. This case report presents the physiotherapy evaluation and management of acute transverse myelitis in a pediatric patient. Case presentation A 17-year-old Nigerian male diagnosed with acute transverse myelitis was referred to the physiotherapy team for expert management. The patient presented with severe muscle spasms and frequent jerking movements, shocking sensations, hypertonicity, and spasticity (modified Ashworth scale: 1+ on the right, > 2 on the right), and muscle strength of the lower limbs (Oxford muscle grading: 3/5 on the left, 1/5 on the left) with impaired functional status (Functional Independence Measure: 70/126).The patient tolerated and participated in the physiotherapy interventions (cryotherapy, soft tissue mobilization, splinting) and exercises (free active, resistance and functional exercises) in the ward and outpatient clinic, as well as subsequent home programmes (free active, resistance and functional exercises). The patient also received other medical and pharmacological interventions in the ward. After 23 days of therapy, the patient improved in all clinical outcomes, including muscle spasm and hypertonicity, spasticity (modified Ashworth scale: 0 bilaterally), sensation, and muscle strength (Oxford muscle grading: 5/5 bilaterally). The patient’s overall functional status also improved (Functional Independence Measure: 117/126). Conclusions Physiotherapy improved the symptoms of acute transverse myelitis in this patient. Randomized controlled trials are required to replicate these findings.

Although angiography has been the primary imaging modality used in peripheral vascular intervention, this technique has major limitations due to the evaluation of three-dimensional vessels in two dimensions. Intravascular ultrasound (IVUS) is an important adjunctive tool that can address some of these limitations. This systematic review assesses the appropriateness of IVUS as an imaging modality for guiding peripheral intervention through evidence collection and clinical appraisal of studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a cohort of 48 studies (29 arterial; 19 venous) detailing IVUS use in peripheral vascular intervention were extracted. Qualitative assessment of the studies evaluated pre- and postprocedure efficacy of IVUS and revealed that IVUS-guided peripheral intervention in arterial and venous diagnosis and treatment was superior to other imaging techniques alone. Each study in the cohort was further assessed for reliability and validity using the Oxford Centre for Evidence Based Medicine (CEBM) level of evidence scale. The majority of both arterial (79.3%) and venous (73.7%) studies received a 2b rating, the second highest level of evidence rating. The evidence to date indicates that IVUS results in better clinical outcomes overall and should be more widely adopted as an adjunctive imaging modality during peripheral intervention. (PROSPERO Registration No.: CRD42021232353)

Background: The postpartum period is the period after delivery of conceptus when maternal physiological and anatomical changes return to the non-pregnant state. Pelvic Floor Muscles(PFMs) are interconnected and work together as a unit and collectively help with tightening the loose vagina, urine control, supporting pelvic organs, and enhance intimate health. Diaphragm is the chief muscle of respiration. The role of diaphragm on your core, as well as your pelvic oor. Methods: In a 5-weeks intervention study, 30 participants with features of postpartum were studied. They were divided into 2 groups by Simple Random Sampling; Group A: Experimental Group and Group B: Control Group. Pre and post-treatment data were collected and analyzed using SPSS 22.0. Mann Whitney and Wilcoxon tests were used to nding out the signicance of the treatment. Results: A signicant improvement in strength of PFMs was seen through the Modied Oxford Grading Scale(MOGS) (p‹0.05) after the treatment was found. A greater statistically signicant difference was seen in Group A as compared to Group B. Conclusion: The study concluded that with the combined effect of PFM exercise along with breathing exercise, the experimental group shows signicant improvement in PFMs strength and improves the QoL when compared to control group.

Aim and Objective: Assess the effectiveness of an interventional package on pelvic floor muscle strength among women with pelvic floor dysfunction at selected rural community - India. Methodology: A Quantitative research approach with true experimental design was used for the study, Women between 3 months to 1 year post-delivery status either with urinary incontinence, bowel incontinence, pelvic organ prolapses, pelvic pain or dyspareunia in the 26 selected villages which comprised a total of 424 women. Pelvic floor dysfunction was assessed using pelvic floor distress inventory scale. Muscle strength was assessed by per vaginal examination by the investigator and graded using modified Oxford grading scale. Pelvic floor muscle strength was assessed under 5 categories such as Power, Endurance, Repetitions, fast contraction and every timed contraction. Video assisted teaching, demonstration and return demonstration techniques provided by the investigator to strengthen the pelvic floor muscle Result: Women in the experimental group reported good pelvic floor muscle strength in the post test with mean score of 15.81 while women in control group had mean score of 9.52. There was significant improvement noted in all the components of pelvic floor muscle strength such as power, endurance, repetitions, fast contractions and timed contraction scores among women in the experimental group. Conclusion: Pelvic floor dysfunction causes a lot of burden among the women and studies have showed a trend of increasing prevalence. Community based nursing interventions are very much needed to prevent women from encountering pelvic floor dysfunction which will significantly improve their quality of life.

Background Atraumatic sternoclavicular joint (SCJ) instability is rare. Long-term outcomes are presented for patients managed with physiotherapy. A standardised method of assessment and treatment with a structured physiotherapy programme is also presented. Methods Long-term outcome was analysed in this prospectively collected series (2011-2019) of patients who were assigned to a structured physiotherapy programme for atraumatic SCJ instability. Outcome-measures (subjective SCJ grading of joint stability (SSGS score), Oxford shoulder instability score (OSIS adapted for SCJ) and visual analogue scale (VAS) for pain) were collected at discharge and long-term follow up. Results 26 patients (29 SCJ's) responded (return rate 81%). Mean follow-up was 5.1 years (range 0.9-8.3 years). 17/26 patients were hyperlax. 93% (27/29) of SCJs achieved a stable joint on SSGS score. Mean OSIS score at long-term follow up was 33.4 (range 3-48) and VAS 2.7 (range 0-9). 95% who were compliant with physiotherapy had a stable SCJ (mean OSIS 37.8 (SD 7.3) and VAS 1.6 (SD 2.1)). Those non-compliant, 90% were stable but had lower function (mean OSIS 25 (SD 14, p = 0.02) and more pain, VAS 4.9 (SD 2.9, p = 0.006). Conclusion The structured physiotherapy programme is highly effective in treating patients with atraumatic SCJ instability. Compliance was essential in ensuring better outcomes.

Ballooning of the levator hiatus is a unique phenomenon of hyperdistention seen during the Valsalva maneuver in Pelvic Organ Prolapse (POP) patients. Although it is related to the weakness of pelvic floor muscles, there is only limited evidence of its effect on Levator Ani Muscle (LAM) strength, especially in Indonesia. The aim of this study was to describe the prevalence of levator hiatal ballooning in POP patients and its effect on LAM strength. A cross-sectional study was done on POP patients at Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia, from July 2019 to June 2021. Subjects who could not perform the Valsalva maneuver or perineometer and those having a history of perineal rupture were excluded. Subjects were grouped into hiatal ballooning and non-ballooning group based on the maximum hiatal genital length measured using ultrasound examination. Clinical characteristics, hiatal ballooning status, and LAM strength were compared between groups. A total of 99 subjects (47 ballooning and 52 non-ballooning) were recruited during the study. The prevalence of hiatal ballooning in POP patients was 47.5%. There was significantly lower LAM strength in the ballooning group measured by perineometer (p = 0.018). There was a significant relationship between the perineometer result and Modified Oxford Grading Scale result in both groups (p < 0.001). Lower LAM strength was observed in POP patients with hiatal ballooning.

Abstract Background The therapeutic application of cannabidiol (CBD) is gaining interest due to expanding evidence for its use. Objective To summarize the clinical outcomes, study designs and limitations for the use of CBD and nabiximols (whole plant extract from Cannabis sativa L. that has been purified into 1:1 ratio of CBD and delta-9-tetrahydrocannabinol) in the treatment of psychiatric disorders. Materials and method A systematic review was conducted including case reports, case series, open-label trials, non-randomized and randomized controlled trials (RCTs). The search resulted in 23 relevant studies on CBD and nabiximols in the treatment of a wide range of psychiatric disorders. The quality of evidence was judged by using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence that ranges from Level 1 to Level 5 based on the quality and study design. These levels of evidence help in grading the recommendations, including Grade A (strong), Grade B (moderate), Grade C (weak), and Grade D (weakest). Results CBD and CBD-containing compounds such as nabiximols were helpful in alleviating psychotic symptoms and cognitive impairment in patients with a variety of conditions, and several studies provided evidence of effectiveness in the treatment of cannabis withdrawal and moderate to severe cannabis use disorder with Grade B recommendation. There is Grade B recommendation supporting the use of CBD for the treatment of schizophrenia, social anxiety disorder and autism spectrum disorder (ASD), and attention deficit hyperactivity disorder (ADHD). Grade C recommendation exists for insomnia, anxiety, bipolar disorder, posttraumatic stress disorder, and Tourette syndrome. These recommendations should be considered in the context of limited number of available studies. Conclusion CBD and CBD-containing compounds such as nabiximols were helpful in alleviating symptoms of cannabis-related disorders, schizophrenia, social anxiety disorder, and comorbidities of ASD, and ADHD with moderate recommendation. However, there is weaker evidence for insomnia, anxiety, bipolar disorder, posttraumatic stress disorder, and Tourette syndrome. The evidence for the use of CBD and CBD-containing compounds for psychiatric disorders needs to be explored in future studies, especially large-scale and well-designed RCTs.

Aim: To study the effect of Hypopressive exercises to improve pelvic floor muscle strength in women with Pelvic Organ Prolapse.(grade 1and 2). Methods: This is an experimental study conducted on women of urban and rural areas of Kamothe and Kalamboli in India who presented with grade 1 and grade 2 Pelvic Organ Prolapse. 20 women (35 years and above) were recruited after taking their consent. The outcome measures assessed during pre and post evaluation were pelvic floor muscle strength as measured by modified oxford scale and perinometer whereas Pelvic Organ Prolapse symptoms by pelvic floor distress inventory scale-20. Intervention consisted of 6-weeks of Hypopressive exercises with a physiotherapist. The protocol consisted of three sessions weekly with progression in each week. Precautions to be taken during the study were explained to the participants each time. Results: Hypopressive exercises presented positive results with statistically significant difference in pre and post evaluation of outcome measures. Wilcoxon Signed Rank Test analysis reported p-value of 0.00 for modified oxford scale. For perinometer, p-value for peak, average, duration and gradient was 0.00, 0.00, 0.01 and 0.04 respectively. Pelvic Floor Distress Inventory Scale reported p-value of 0.00. Conclusion: Hypopressive exercises exhibited improvements in pelvic floor muscle strength and reducing the symptoms of Pelvic Organ Prolapse.

AbstractDeep learning for image retrieval has been used in this era, but image retrieval with the highest accuracy is the biggest challenge, which still lacks auto-correlation for feature extraction and description. In this paper, a novel deep learning technique for achieving highly accurate results for image retrieval is proposed, which implements a convolutional neural network with auto-correlation, gradient computation, scaling, filter, and localization coupled with state-of-the-art content-based image retrieval methods. For this purpose, novel image features are fused with signatures produced by the VGG-16. In the initial step, images from rectangular neighboring key points are auto-correlated. The image smoothing is achieved by computing intensities according to the local gradient. The result of Gaussian approximation with the lowest scale and suppression is adjusted by the by-box filter with the standard deviation adjusted to the lowest scale. The parameterized images are smoothed at different scales at various levels to achieve high accuracy. The principal component analysis has been used to reduce feature vectors and combine them with the VGG features. These features are integrated with the spatial color coordinates to represent color channels. This experimentation has been performed on Cifar-100, Cifar-10, Tropical fruits, 17 Flowers, Oxford, and Corel-1000 datasets. This study has achieved an extraordinary result for the Cifar-10 and Cifar-100 datasets. Similarly, the results of the study have shown efficient results for texture datasets of 17 Flowers and Tropical fruits. Moreover, when compared to state-of-the-art approaches, this research produced outstanding results for the Corel-1000 dataset.

AimTo assess the severity of dry eye disease (DED) in humans, its impact on quality of life (QoL) and to grade the damage incurred by the anterior ocular surface in patients diagnosed with type 2 diabetes mellitus (T2DM).Patients and methodsForty-six patients (mean age ± SD = 63.8 ± 6.7 years) diagnosed with T2DM were enrolled in the experimental group and 26 healthy individuals constituted the control group (67.9 ± 8.9 years). The diagnosis and gradation of DED were conducted in accordance with the International Task Force severity grading scheme. Disease-specific questionnaires were used to obtain the Ocular Surface Disease Index (OSDI) and assess the negative effects of the disease on the patient’s QoL. The severity of conjunctival redness and corneal/conjunctival staining was assessed by Efron and Oxford scales, respectively.ResultsAccording to OSDI scores, the entire experimental group presented symptoms of DED: 54.4% were diagnosed with mild DED and 46.6% with moderately severe DED. No cases of severe DED were diagnosed in either the experimental or control group. In the control group, 57.7% of individuals did not have the disease. A significant difference between the experimental and control groups was recorded for both OSDI scores (p &lt; 0.01) and health-related QoL (p &lt; 0.01). It was observed that keratopathy influenced the mean OSDI values of patients. The mean OSDI value was 25.14 ± 3 in the experimental group diagnosed with keratopathy, 19.3 ± 3.5 in the subgroup with no indications of corneal injury (p = 0.000002), and 13.0 ± 3.0 in the control group (p &lt; 0.000002). Based on the DEWS scheme, a grade I severity level was observed in 46% of control subjects and 33% of patients diagnosed with T2DM (p = 0.4915); grades II and III were detected in the bulk of the experimental group (p = 0.0051; p = 0.1707). None of the subjects in the control or experimental groups manifested grade IV severity of DED.ConclusionIn comparison to healthy adults, DED adversely impacts the QoL of type 2 DM patients, regardless of the disease’s association with keratopathy.

Abstract Background In many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services. Methods A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the ‘Revised Cochrane risk of bias tool for randomized trials’ (Rob2), the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Discussion To-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes. Systematic review registration PROSPERO 225613

Chemical compounds (drugs) and diseases are among top searched keywords on the PubMed database of biomedical literature by biomedical researchers all over the world (according to a study in 2009). Working with PubMed is essential for researchers to get insights into drugs’ side effects (chemical-induced disease relations (CDR), which is essential for drug safety and toxicity. It is, however, a catastrophic burden for them as PubMed is a huge database of unstructured texts, growing steadily very fast (~28 millions scientific articles currently, approximately two deposited per minute). As a result, biomedical text mining has been empirically demonstrated its great implications in biomedical research communities. Biomedical text has its own distinct challenging properties, attracting much attetion from natural language processing communities. A large-scale study recently in 2018 showed that incorporating information into indenpendent multiple-input layers outperforms concatenating them into a single input layer (for biLSTM), producing better performance when compared to state-of-the-art CDR classifying models. This paper demonstrates that for a CNN it is vice-versa, in which concatenation is better for CDR classification. To this end, we develop a CNN based model with multiple input concatenated for CDR classification. Experimental results on the benchmark dataset demonstrate its outperformance over other recent state-of-the-art CDR classification models. Keywords: Chemical disease relation prediction, Convolutional neural network, Biomedical text mining References [1] Paul SM, S. Mytelka, C.T. Dunwiddie, C.C. Persinger, B.H. Munos, S.R. Lindborg, A.L. Schacht, How to improve R&D productivity: The pharmaceutical industry's grand challenge, Nat Rev Drug Discov. 9(3) (2010) 203-14. https://doi.org/10.1038/nrd3078. [2] J.A. DiMasi, New drug development in the United States from 1963 to 1999, Clinical pharmacology and therapeutics 69 (2001) 286-296. https://doi.org/10.1067/mcp.2001.115132. [3] C.P. Adams, V. Van Brantner, Estimating the cost of new drug development: Is it really $802 million? Health Affairs 25 (2006) 420-428. https://doi.org/10.1377/hlthaff.25.2.420. [4] R.I. Doğan, G.C. Murray, A. Névéol et al., "Understanding PubMed user search behavior through log analysis", Oxford Database, 2009. [5] G.K. Savova, J.J. Masanz, P.V. Ogren et al., "Mayo clinical text analysis and knowledge extraction system (cTAKES): Architecture, component evaluation and applications", Journal of the American Medical Informatics Association, 2010. [6] T.C. Wiegers, A.P. Davis, C.J. Mattingly, Collaborative biocuration-text mining development task for document prioritization for curation, Database 22 (2012) pp. bas037. [7] N. Kang, B. Singh, C. Bui et al., "Knowledge-based extraction of adverse drug events from biomedical text", BMC Bioinformatics 15, 2014. [8] A. Névéol, R.L. Doğan, Z. Lu, "Semi-automatic semantic annotation of PubMed queries: A study on quality, Efficiency, Satisfaction", Journal of Biomedical Informatics 44, 2011. [9] L. Hirschman, G.A. Burns, M. Krallinger, C. Arighi, K.B. Cohen et al., Text mining for the biocuration workflow, Database Apr 18, 2012, pp. bas020. [10] Wei et al., "Overview of the BioCreative V Chemical Disease Relation (CDR) Task", Proceedings of the Fifth BioCreative Challenge Evaluation Workshop, 2015. [11] P. Verga, E. Strubell, A. McCallum, Simultaneously Self-Attending to All Mentions for Full-Abstract Biological Relation Extraction, In Proceedings of the 2018 Conference of the North American Chapter of the Association for Computational Linguistics: Human Language Technologies 1 (2018) 872-884. [12] Y. Shen, X. Huang, Attention-based convolutional neural network for semantic relation extraction, In: Proceedings of COLING 2016, the Twenty-sixth International Conference on Computational Linguistics: Technical Papers, The COLING 2016 Organizing Committee, Osaka, Japan, 2016, pp. 2526-2536. [13] Y. Peng, Z. Lu, Deep learning for extracting protein-protein interactions from biomedical literature, In: Proceedings of the BioNLP 2017 Workshop, Association for Computational Linguistics, Vancouver, Canada, 2016, pp. 29-38. [14] S. Liu, F. Shen, R. Komandur Elayavilli, Y. Wang, M. Rastegar-Mojarad, V. Chaudhary, H. Liu, Extracting chemical-protein relations using attention-based neural networks, Database, 2018. [15] H. Zhou, H. Deng, L. Chen, Y. Yang, C. Jia, D. Huang, Exploiting syntactic and semantics information for chemical-disease relation extraction, Database, 2016, pp. baw048. [16] S. Liu, B. Tang, Q. Chen et al., Drug–drug interaction extraction via convolutional neural networks, Comput, Math, Methods Med, Vol (2016) 1-8. https://doi.org/10.1155/2016/6918381. [17] L. Wang, Z. Cao, G. De Meloet al., Relation classification via multi-level attention CNNs, In: Proceedings of the Fifty-fourth Annual Meeting of the Association for Computational Linguistics 1 (2016) 1298-1307. https://doi.org/10.18653/v1/P16-1123. [18] J. Gu, F. Sun, L. Qian et al., Chemical-induced disease relation extraction via convolutional neural network, Database (2017) 1-12. https://doi.org/10.1093/database/bax024. [19] H.Q. Le, D.C. Can, S.T. Vu, T.H. Dang, M.T. Pilehvar, N. Collier, Large-scale Exploration of Neural Relation Classification Architectures, In Proceedings of the 2018 Conference on Empirical Methods in Natural Language Processing, 2018, pp. 2266-2277. [20] Y. LeCun, L. Bottou, Y. Bengio, P. Haffner, Gradient-based learning applied to document recognition, In Proceedings of the IEEE. 86(11) (1998) 2278-2324. [21] Y. Kim, Convolutional neural networks for sentence classification, ArXiv preprint arXiv:1408.5882. [22] C. Nagesh, Panyam, Karin Verspoor, Trevor Cohn and Kotagiri Ramamohanarao, Exploiting graph kernels for high performance biomedical relation extraction, Journal of biomedical semantics 9(1) (2018) 7. [23] H. Zhou, H. Deng, L. Chen, Y. Yang, C. Jia, D. Huang, Exploiting syntactic and semantics information for chemical-disease relation extraction, Database, 2016.

Dissolved oxygen (DO), total biomass and oxygen demand of nematode communities in the organic shrimp farms located in Tam Giang commune, Nam Can District, Ca Mau province were investigated in three seasons (March-dry, July-transfer and November-wet season) of 2015. The results showed that most of DO values were within permissible limits. However, the frequency distributions of DO values are very compressed at the lower limit of their scale. Total dry biomass varied from 24.77 to 937.04 µgC/10cm2 while oxygen demand ranged from 3467.39 to 64288.50 nlO2/day/10cm2. These values were slightly high when compared to other studies in the world. The following results recorded that the negatively correlation between DO and oxygen demand of nematode communities in the organic shrimp farms. This may well suggest that respiration and metabolic of nematode communities was high and their impact on oxygen dissolved in surface water. 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Pictorial key to world genera and notes for the identification of British species. Cambridge University Press, for the Linnean Society of London and the Estuarine and Brackish-water Sciences Association 1983.[17]. Andrassy I The determination of volume and weight of nematodes, Acta Zoologica 2 (1956) 1.[18]. J. Vanaverbeke, P. M. Arbizu, H. U. Dahms, H. K. Schminke,. The metazoan meiobenthos along a depth gradient in the Arctic Laptev Sea with special attention to nematode communities, Polar Biology 18 (1997) 391.[19]. K. Soetaert, J. Vanaverbeke, C. Heip, P. M. Herman, J. J. Middelburg, A. Sandee, G. Duineveld, Nematode distribution in ocean margin sediments of the Goban Spur (northeast Atlantic) in relation to sediment geochemistry, Deep Sea Research Part I: Oceanographic Research Papers, 44 (1997) 1671.[20]. D.J. Crisp Methods of the study of marine benthos (N.A. Holme & A.D. McIntyre eds), Blackwell Scientific Publications, Oxford, 1971 197. [21]. N. Smol, K. A. Willems, J. C. 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Introduction This article explores the changing relational quality of “the shadow of hierarchy”, in the context of the merging of platforms with infrastructure as the source of the shadow of hierarchy. In governance and regulatory studies, the shadow of hierarchy (or variations thereof), describes the space of influence that hierarchal organisations and infrastructures have (Héritier and Lehmkuhl; Lance et al.). A shift in who/what casts the shadow of hierarchy will necessarily result in changes to the attendant relational values, logics, and (techno)socialities that constitute the shadow, and a new arrangement of shadow that presents new challenges and opportunities. This article reflects on relevant literature to consider two different ways the shadow of hierarchy has qualitatively changed as platforms, rather than infrastructures, come to cast the shadow of hierarchy – an increase in scalability; and new socio-technical arrangements of (non)participation – and the opportunities and challenges therein. The article concludes that more concerted efforts are needed to design the shadow, given a seemingly directionless desire to enact data-driven solutions. The Shadow of Hierarchy, Infrastructures, and Platforms The shadow of hierarchy refers to how institutional, infrastructural, and organisational hierarchies create a relational zone of influence over a particular space. This commonly refers to executive decisions and legislation created by nation states, which are cast over private and non-governmental actors (Héritier and Lehmkuhl, 2). Lance et al. (252–53) argue that the shadow of hierarchy is a productive and desirable thing. Exploring the shadow of hierarchy in the context of how geospatial data agencies govern their data, Lance et al. find that the shadow of hierarchy enables the networked governance approaches that agencies adopt. This is because operating in the shadow of institutions provides authority, confers bureaucratic legitimacy and top-down power, and offers financial support. The darkness of the shadow is thus less a moral or ethicopolitical statement (such as that suggested by Fisher and Bolter, who use the idea of darkness to unpack the morality of tourism involving death and human suffering), and instead a relationality; an expression of differing values, logics, and (techno)socialities internal and external to those infrastructures and institutions that cast it (Gehl and McKelvey). The shadow of hierarchy might therefore be thought of as a field of relational influences and power that a social body casts over society, by virtue of a privileged position vis-a-vis society. It modulates society’s “light”; the resources (Bourdieu) and power relationships (Foucault) that run through social life, as parsed through a certain institutional and infrastructural worldview (the thing that blocks the light to create the shadow). In this way the shadow of hierarchy is not a field of absolute blackness that obscures, but instead a gradient of light and dark that creates certain effects. The shadow of hierarchy is now, however, also being cast by decentralised, privately held, and non-hierarchal platforms that are replacing or merging with public infrastructure, creating new social effects. Platforms are digital, socio-technical systems that create relationships between different entities. They are most commonly built around a relatively fixed core function (such as a social media service like Facebook), that then interacts with a peripheral set of complementors (advertising companies and app developers in the case of social media; Baldwin and Woodard), to create new relationships, forms of value, and other interactions (van Dijck, The Culture of Connectivity). In creating these relationships, platforms become inherently political (Gillespie), shaping relationships and content on the platform (Suzor) and in embodied life (Ajunwa; Eubanks). While platforms are often associated with optional consumer platforms (such as streaming services like Spotify), they have increasingly come to occupy the place of public infrastructure, and act as a powerful enabler to different socio-technical, economic, and political relationships (van Dijck, Governing Digital Societies). For instance, Plantin et al. argue that platforms have merged with infrastructures, and that once publicly held and funded institutions and essential services now share many characteristics with for-profit, privately held platforms. For example, Australia has had a long history of outsourcing employment services (Webster and Harding), and nearly privatised its entire visa processing data infrastructure (Jenkins). Platforms therefore have a greater role in casting the shadow of hierarchy than before. In doing so, they cast a shadow that is qualitatively different, modulated through a different set of relational values and (techno)socialities. Scalability A key difference and selling point of platforms is their scalability; since they can rapidly and easily up- and down-scale their functionalities in a way that traditional infrastructure cannot (Plantin et al.). The ability to respond “on-demand” to infrastructural requirements has made platforms the go-to service delivery option in the neo-liberalised public infrastructure environment (van Dijck, Governing Digital Societies). For instance, services providers like Amazon Web Services or Microsoft Azure provide on demand computing capacity for many nations’ most valuable services, including their intelligence and security capabilities (Amoore, Cloud Ethics; Konkel). The value of such platforms to government lies in the reduced cost and risk that comes with using rented capabilities, and the enhanced flexibility to increase or decrease their usage as required, without any of the economic sunk costs attached to owning the infrastructure. Scalability is, however, not just about on-demand technical capability, but about how platforms can change the scale of socio-technical relationships and services that are mediated through the platform. This changes the relational quality of the shadow of hierarchy, as activities and services occurring within the shadow are now connected into a larger and rapidly modulating scale. Scalability allows the shadow of hierarchy to extend from those in proximity to institutions to the broader population in general. For example, individual citizens can more easily “reach up” into governmental services and agencies as a part of completing their everyday business through platform such as MyGov in Australia (Services Australia). Using a smartphone application, citizens are afforded a more personalised and adaptive experience of the welfare state, as engaging with welfare services is no-longer tied to specific “brick-and-mortar” locations, but constantly available through a smartphone app and web portal. Multiple government services including healthcare and taxation are also connected to this platform, allowing users to reach across multiple government service domains to complete their personal business, seeking information and services that would have once required separate communications with different branches of government. The individual’s capacities to engage with the state have therefore upscaled with this change in the shadow, retaining a productivity and capacity enhancing quality that is reminiscent of older infrastructures and institutions, as the individual and their lived context is brought closer to the institutions themselves. Scale, however, comes with complications. The fundamental driver for scalability and its adaptive qualities is datafication. This means individuals and organisations are inflecting their operational and relational logics with the logic of datafication: a need to capture all data, at all times (van Dijck, Datafication; Fourcade and Healy). Platforms, especially privately held platforms, benefit significantly from this, as they rely on data to drive and refine their algorithmic tools, and ultimately create actionable intelligence that benefits their operations. Thus, scalability allows platforms to better “reach down” into individual lives and different social domains to fuel their operations. For example, as public transport services become increasingly datafied into mobility-as-a-service (MAAS) systems, ride sharing and on-demand transportation platforms like Uber and Lyft become incorporated into the public transport ecosystem (Lyons et al.). These platforms capture geospatial, behavioural, and reputational data from users and drivers during their interactions with the platform (Rosenblat and Stark; Attoh et al.). This generates additional value, and profits, for the platform itself with limited value returned to the user or the broader public it supports, outside of the transport service. It also places the platform in a position to gain wider access to the population and their data, by virtue of operating as a part of a public service. In this way the shadow of hierarchy may exacerbate inequity. The (dis)benefits of the shadow of hierarchy become unevenly spread amongst actors within its field, a function of an increased scalability that connects individuals into much broader assemblages of datafication. For Eubank, this can entrench existing economic and social inequalities by forcing those in need to engage with digitally mediated welfare systems that rely on distant and opaque computational judgements. Local services are subject to increased digital surveillance, a removal of agency from frontline advocates, and algorithmic judgement at scale. More fortunate citizens are also still at risk, with Nardi and Ekbia arguing that many digitally scaled relationships are examples of “heteromation”, whereby platforms convince actors in the platform to labour for free, such as through providing ratings which establish a platform’s reputational economy. Such labour fuels the operation of the platform through exploiting users, who become both a product/resource (as a source of data for third party advertisers) and a performer of unrewarded digital labour, such as through providing user reviews that help guide a platform’s algorithm(s). Both these examples represent a particularly disconcerting outcome for the shadow of hierarchy, which has its roots in public sector institutions who operate for a common good through shared and publicly held infrastructure. In shifting towards platforms, especially privately held platforms, value is transmitted to private corporations and not the public or the commons, as was the case with traditional infrastructure. The public also comes to own the risks attached to platforms if they become tied to public services, placing a further burden on the public if the platform fails, while reaping none of the profit and value generated through datafication. This is a poor bargain at best. (Non)Participation Scalability forms the basis for a further predicament: a changing socio-technical dynamic of (non)participation between individuals and services. According to Star (118), infrastructures are defined through their relationships to a given context. These relationships, which often exist as boundary objects between different communities, are “loosely structured in common use, and become tightly bound in particular locations” (Star, 118). While platforms are certainly boundary objects and relationally defined, the affordances of cloud computing have enabled a decoupling from physical location, and the operation of platforms across time and space through distributed digital nodes (smartphones, computers, and other localised hardware) and powerful algorithms that sort and process requests for service. This does not mean location is not important for the cloud (see Amoore, Cloud Geographies), but platforms are less likely to have a physically co-located presence in the same way traditional infrastructures had. Without the same institutional and infrastructural footprint, the modality for participating in and with the shadow of hierarchy that platforms cast becomes qualitatively different and predicated on digital intermediaries. Replacing a physical and human footprint with algorithmically supported and decentralised computing power allows scalability and some efficiency improvements, but it also removes taken-for-granted touchpoints for contestation and recourse. For example, ride-sharing platform Uber operates globally, and has expressed interest in operating in complement to (and perhaps in competition with) public transport services in some cities (Hall et al.; Conger). Given that Uber would come to operate as a part of the shadow of hierarchy that transport authorities cast over said cities, it would not be unreasonable to expect Uber to be subject to comparable advocacy, adjudication, transparency, and complaint-handling requirements. Unfortunately, it is unclear if this would be the case, with examples suggesting that Uber would use the scalability of its platform to avoid these mechanisms. This is revealed by ongoing legal action launched by concerned Uber drivers in the United Kingdom, who have sought access to the profiling data that Uber uses to manage and monitor its drivers (Sawers). The challenge has relied on transnational law (the European Union’s General Data Protection Regulation), with UK-based drivers lodging claims in Amsterdam to initiate the challenge. Such costly and complex actions are beyond the means of many, but demonstrate how reasonable participation in socio-technical and governance relationships (like contestations) might become limited, depending on how the shadow of hierarchy changes with the incorporation of platforms. Even if legal challenges for transparency are successful, they may not produce meaningful change. For instance, O’Neil links algorithmic bias to mathematical shortcomings in the variables used to measure the world; in the creation of irritational feedback loops based on incorrect data; and in the use of unsound data analysis techniques. These three factors contribute to inequitable digital metrics like predictive policing algorithms that disproportionately target racial minorities. Large amounts of selective data on minorities create myopic algorithms that direct police to target minorities, creating more selective data that reinforces the spurious model. These biases, however, are persistently inaccessible, and even when visible are often unintelligible to experts (Ananny and Crawford). The visibility of the technical “installed base” that support institutions and public services is therefore not a panacea, especially when the installed base (un)intentionally obfuscates participation in meaningful engagement like complaints handling. A negative outcome is, however, also not an inevitable thing. It is entirely possible to design platforms to allow individual users to scale up and have opportunities for enhanced participation. For instance, eGovernance and mobile governance literature have explored how citizens engage with state services at scale (Thomas and Streib; Foth et al.), and the open government movement has demonstrated the effectiveness of open data in understanding government operations (Barns; Janssen et al.), although these both have their challenges (Chadwick; Dawes). It is not a fantasy to imagine alternative configurations of the shadow of hierarchy that allow more participatory relationships. Open data could facilitate the governance of platforms at scale (Box et al.), where users are enfranchised into a platform by some form of membership right and given access to financial and governance records, in the same way that corporate shareholders are enfranchised, facilitated by the same app that provides a service. This could also be extended to decision making through voting and polling functions. Such a governance form would require radically different legal, business, and institutional structures to create and enforce this arrangement. Delacoix and Lawrence, for instance, suggest that data trusts, where a trustee is assigned legal and fiduciary responsibility to achieve maximum benefit for a specific group’s data, can be used to negotiate legal and governance relationships that meaningfully benefit the users of the trust. Trustees can be instructed to only share data to services whose algorithms are regularly audited for bias and provide datasets that are accurate representations of their users, for instance, avoiding erroneous proxies that disrupt algorithmic models. While these developments are in their infancy, it is not unreasonable to reflect on such endeavours now, as the technologies to achieve these are already in use. Conclusions There is a persistent myth that data will yield better, faster, more complete results in whatever field it is applied (Lee and Cook; Fourcade and Healy; Mayer-Schönberger and Cukier; Kitchin). This myth has led to data-driven assemblages, including artificial intelligence, platforms, surveillance, and other data-technologies, being deployed throughout social life. The public sector is no exception to this, but the deployment of any technological solution within the traditional institutions of the shadow of hierarchy is fraught with challenges, and often results in failure or unintended consequences (Henman). The complexity of these systems combined with time, budgetary, and political pressures can create a contested environment. It is this environment that moulds societies' light and resources to cast the shadow of hierarchy. Relationality within a shadow of hierarchy that reflects the complicated and competing interests of platforms is likely to present a range of unintended social consequences that are inherently emergent because they are entering into a complex system – society – that is extremely hard to model. The relational qualities of the shadow of hierarchy are therefore now more multidimensional and emergent, and experiences relating to socio-technical features like scale, and as a follow-on (non)participation, are evidence of this. Yet by being emergent, they are also directionless, a product of complex systems rather than designed and strategic intent. This is not an inherently bad thing, but given the potential for data-system and platforms to have negative or unintended consequences, it is worth considering whether remaining directionless is the best outcome. There are many examples of data-driven systems in healthcare (Obermeyer et al.), welfare (Eubanks; Henman and Marston), and economics (MacKenzie), having unintended and negative social consequences. Appropriately guiding the design and deployment of theses system also represents a growing body of knowledge and practical endeavour (Jirotka et al.; Stilgoe et al.). Armed with the knowledge of these social implications, constructing an appropriate social architecture (Box and Lemon; Box et al.) around the platforms and data systems that form the shadow of hierarchy should be encouraged. This social architecture should account for the affordances and emergent potentials of a complex social, institutional, economic, political, and technical environment, and should assist in guiding the shadow of hierarchy away from egregious challenges and towards meaningful opportunities. To be directionless is an opportunity to take a new direction. The intersection of platforms with public institutions and infrastructures has moulded society’s light into an evolving and emergent shadow of hierarchy over many domains. With the scale of the shadow changing, and shaping participation, who benefits and who loses out in the shadow of hierarchy is also changing. Equipped with insights into this change, we should not hesitate to shape this change, creating or preserving relationalities that offer the best outcomes. Defining, understanding, and practically implementing what the “best” outcome(s) are would be a valuable next step in this endeavour, and should prompt considerable discussion. 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