Prognostic impact of respiratory dysfunction in elderly patients with cervical spinal cord injury and/or fractures: a multicenter survey

PURPOSE

To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures.

METHODS

We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups.

RESULTS

Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis.

CONCLUSION

Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor.

Effects of Unilateral Vagotomy on LPS-Induced Aspiration Pneumonia in Mice

Respiratory-related dysphagia and aspiration pneumonia can be attributed to multiple causes. However, reproduction of multiple factor-related respiratory distress and aspiration pneumonia in a single animal model is challenging. To validate animals with vagal nerve palsy as novel models for severe aspiration pneumonia associated with respiratory distress, we investigated the effects of unilateral vagotomy on the swallowing function and severity of pneumonia after forced aspiration in mice. Unilateral vagotomy was performed in C57BL6 male mice that subsequently underwent evaluation of swallowing function by videofluoroscopic swallow study (VFSS) and histological assessments for aspiration pneumonia induced by lipopolysaccharide (LPS). VFSS examinations demonstrated that unilateral vagotomy did not cause apparent aspiration in mice, but it resulted in a significant loss of body weight (BW) due to decreased oral intake. In addition, when aspiration pneumonia was induced by forced administration of LPS, significantly prolonged BW loss and severe infiltration of inflammatory cells associated with aspiration pneumonia were observed in the mice that underwent unilateral vagotomy. In conclusion, the vagotomized mice showed appropriate characteristics as a model of aspiration pneumonia caused by multiple factors, including the paralysis of vocal fold movement and respiratory distress. This model can help elucidate the pathogenesis of aspiration pneumonia and the treatment methods for the respiration-compromised model.

Irreversible facial nerve palsy as a revelator ofparotid gland cancer

<br><b>Introduction:</b> Bell's palsy is still the diagnosis of exclusion. In most patients it does not progress, it is unilateral, and selflimiting. Additionally, the majority of patients recover spontaneously within 3 weeks. It is well known that all patients with irreversible facial nerve paresis (FNP) need further examinations to exclude the organic, infectious, metabolic, and autoimmunological causes of the palsy. The goal of the study was to assess the frequency of malignancies hidden under the diagnosis of "Bell's palsy".</br> <br><b>Aim:</b> We aimed to create a diagnostic algorithm to avoid failures concerning patients whose only symptom of parotid gland cancer was irreversible FNP.</br> <br><b>Material and methods:</b> We analyzed 253 consecutive patients with FNP treated in our department in the last 5 years. The subject of the study was "Bell's palsy" cases. All patients with irreversible FNP were reassessed in 6-12 months. We underlined all shortcomings in the diagnostics of those in whom malignancies were found in MRI of the neck and presented the proposal for a diagnostic algorithm to avoid missing such an entity.</br> <br><b>Results:</b> Bell's palsy was observed in 157/253 patients (62.06%), in 36/157 (22.92%) it remained permanent. In 4/36 patients (11.11%) with irreversible FNP, which constituted 2.54% of all "Bell's palsy" cases, parotid gland deep lobe mass was found in MRI. In one patient, infiltration of the skull base was diagnosed. Adenoid cystic carcinoma was confirmed in final histopathology in all cases.</br> <br><b>Conclusions:</b> Our experience has shown that irreversible FNP can be a revelator of the malignant tumor located in the deep lobe of the parotid gland. Contrast-enhanced MRI covering intra- and extracranial segments of the facial nerve should be ordered in all cases of FNP without recovery after 4 months. Repeated imaging should be considered in undiagnosed cases. The main point of our study is to underline that the assessment of the deep lobe of the parotid gland with MRI should be included in the standard diagnostic protocol in all irreversible "Bell's palsy" cases.</br>.

Transient lateral rectus palsy associated with acute coronary syndrome treated with percutaneous coronary intervention: a case report

BACKGROUND

Patients who experience angina and acute myocardial infarction often receive diagnostic coronary angiography and percutaneous coronary intervention.

CASE PRESENTATION

A 54-year-old Persian man with acute coronary syndrome was admitted to the hospital and underwent elective percutaneous coronary intervention. Two hours after the procedure, the patient experienced ophthalmoplegia and diplopia. The diagnosis was abducens nerve palsy resulting in transient lateral rectus palsy. The cause is presumed to have been an ischemic event affecting the unilateral abducens nerve. This could have occurred owing to the microembolism during the percutaneous coronary intervention, which resulted in left lateral rectus palsy. Within 1 month, the diplopia was relieved completely, and the physical examination was normal.

CONCLUSION

The occurrence of neuro-ophthalmic complications that may arise from percutaneous coronary intervention is extremely rare. To our knowledge, this is the second reported case of unilateral rectus palsy associated with percutaneous coronary intervention.

[The progress of clinical research and treatment of monocular elevation deficiency]

Monocular elevation deficiency (MED) is a functional defect in upward eye movement caused by paralysis, restriction, or a combination of factors. The affected eye experiences limited movement in the upward, nasal, and temporal directions, often accompanied by downward deviation and ptosis. Previously known as double elevator palsy (DEP), MED can result from muscle paralysis responsible for upward movement, restriction of the inferior rectus muscle, or lesions in the supranuclear pathway. The Knapp procedure was once the most commonly used surgical approach for MED. However, in cases involving restriction of the inferior rectus muscle, a staged approach combining inferior rectus muscle weakening and subsequent Knapp procedure is necessary to avoid anterior segment ischemia. This has led to the development of alternative surgical techniques, such as single-rectus muscle transposition, partial tendon transposition, and muscle belly transposition. Differentiating MED subtypes based on the underlying paralysis or restriction etiology is crucial for determining the appropriate surgical plan. This review article summarizes the clinical features, classification, and available surgical options for MED, aiming to provide valuable insights for clinical research and treatment.

Risk of Pathological Fracture and Paralysis during Rehabilitation for Patients with Bone Metastases: A Questionnaire-Based Study

BACKGROUND

Bone metastases can cause severe pain, pathological fractures, and spinal cord paralysis, which interrupt treatment for tumors and cause patients to be bedridden. In this study, we aimed to clarify therapists' problems in the rehabilitation of patients with bone metastases and their countermeasures using the results of questionnaires to therapists and recommend safer and more rational rehabilitation.

METHODS

Questionnaire forms were sent to 21 therapists in our department. The questionnaire was conducted anonymously about problems during the rehabilitation procedure such as the risk of pathological fractures and paralysis.

RESULTS

All of the therapists had strong anxiety (43%) or some anxiety (57%) about the risk of pathological fractures or paralysis during a procedure. However, no therapist responded that this had ever occurred. Many of the respondents had changed a procedure to a milder one (81%) or interrupted a procedure (48%) due to the patient's condition on the day. Therapists chose many options to reduce the risk of pathological fractures and paralysis during the procedure. Among them, "pre-rehabilitation referral to orthopedic surgeon" (86%), "consultation with a doctor about changes in patient's symptoms and findings" (86%), and "regular cooperation between multiple occupations" (67%) were frequently selected.

CONCLUSIONS

Our questionnaire survey of therapists regarding the treatment of patients with bone metastases found that there was considerable anxiety about the risk of pathological fractures and paralysis during treatment. Our findings suggest that it is necessary to strengthen cooperation with multiple occupations, especially those in the orthopedic field.

Unilateral diaphragmatic palsy and pleuropericarditis in a patient with granulomatosis with polyangiitis: a case report

BACKGROUND

Granulomatosis with polyangiitis (GPA) is a rare small vessel vasculitis predominantly affecting upper and lower respiratory tract and kidneys. Unilateral diaphragmatic palsy could be a rare manifestation of GPA. Here we report a case of GPA in a 45-year-old male with unilateral diaphragmatic palsy with pleuropericarditis.

CASE PRESENTATION

We report a case of a 45-year-old Khas male who presented with acute onset chest pain and shortness of breath who had elevated right hemidiaphragm, bilateral pleural effusion and pericardial effusion who was later diagnosed as GPA.

CONCLUSIONS

GPA should be suspected in all patients with diaphragmatic palsy and pleuropericarditis with appropriate clinical and laboratory picture.

Early onset horizontal gaze palsy and progressive scoliosis due to a noncanonical splicing-site variant and a missense variant in the ROBO3 gene

BACKGROUND

Homozygous or compound heterozygous ROBO3 gene mutations cause horizontal gaze palsy with progressive scoliosis (HGPPS). This is an autosomal recessive disorder that is characterized by congenital absence or severe restriction of horizontal gaze and progressive scoliosis. To date, almost 100 patients with HGPPS have been reported and 55 ROBO3 mutations have been identified.

METHODS

We described an HGPPS patient and performed whole-exome sequencing (WES) to identify the causative gene.

RESULTS

We identified a missense variant and a splice-site variant in the ROBO3 gene in the proband. Sanger sequencing of cDNA revealed the presence of an aberrant transcript with retention of 700 bp from intron 17, which was caused by a variation in the noncanonical splicing site. We identified five additional ROBO3 variants, which were likely pathogenic, and estimated the overall allele frequency in the southern Chinese population to be 9.44 × 10-4 , by a review of our in-house database.

CONCLUSION

This study has broadened the mutation spectrum of the ROBO3 gene and has expanded our knowledge of variants in noncanonical splicing sites. The results could help to provide more accurate genetic counseling to affected families and prospective couples. We suggest that the ROBO3 gene should be included in the local screening strategy.

Noncanonical splice-site variant in peripheral myelin protein 22 gene (PMP22) in a patient with hereditary neuropathy with liability to pressure palsies

AIM

Hereditary neuropathy with liability to pressure palsies (HNPP) is a peripheral neuropathy with autosomal dominant inheritance. Diagnosis can be made from the characteristic abnormalities determined by nerve conduction studies (NCS), including subclinical deficits at physiological compression sites. Heterozygous deletion of the chromosome 17p11.2-p12 region including the peripheral myelin protein 22 gene (PMP22) is the cause in the majority of cases. However, the loss of function of PMP22 due to frameshift-causing insertion/deletion, missense, nonsense, or splice-site disrupting variants cause HNPP in some patients. We report a case of a patient diagnosed with HNPP on the basis of clinical features and the results of NCS. No deletions of PMP22 were detected by fluorescence in situ hybridization.

METHODS

We performed direct nucleotide sequence analysis and identified a heterozygous variant, c.78 + 3G > T, in PMP22. Since this variant is located outside the canonical splice site at the exon 2-intron 2 junction, we investigated whether the variant causes aberrant splicing and leads to the skipping of exon 2 of PMP22 by in vitro minigene splicing assay.

RESULTS

We demonstrated that the c.78 + 3G > T variant causes the skipping of exon 2 and leads to loss of function of the mutant allele.

CONCLUSION

Searching for sequence variants located outside the canonical splice sites should also be considered even when deletion of PMP22 is not found in a patient with a clinical diagnosis suggesting HNPP.

Prognostic factors for failed Pavlik harness treatment in infants with developmental dysplasia of the hip: a retrospective cohort study

PURPOSE

Pavlik harness treatment is the most common treatment in newborns diagnosed with developmental dysplasia of the hip (DDH). The success rates and predictors for failure have been debated over the last decade. In this study, we explored our treatment failure rate and potential prognostic factors that could predict the failure of Pavlik harness (PH) treatment in patients with DDH.

METHODS

Two hundred and sixty-five patients were treated with PH based on the Graf hip types of classification. Age, gender, first born status, family history, foot deformity, plagiocephaly, breech presentation, hip abduction, hip stability, Graf hip type, Galeazzi sign, bilateralism, and femoral nerve palsy were tested as predictors for failure in multivariate logistic regression mode. Success and failure were determined by the normalization of the hip based on the Graf hip classification.

RESULTS

The failure rate of patients treated with Pavlik harness was 16.6% which is within the reported range of failure rate. The mean age of patients who were successfully treated was 6.73 weeks in comparison to 8.84 weeks for those who failed. Age, plagiocephaly, hip instability, Graf classification, and the development of femoral nerve palsy were found to be predictors for failure of PH treatment upon univariate analysis only. However, only the presence of Galeazzi sign, hip instability, high grades of Graf hip classification, and the development of femoral nerve palsy proved to be independent predictors for failed PH treatment upon multivariate logistic regression analysis.

CONCLUSIONS

Pavlik harness treatment is a successful treatment with an average success of 83.4%. Several independent predictors for failure of PH treatment have been identified. These include a positive Galeazzi sign, a frankly dislocated hip, Graf types III and IV, and the development of femoral nerve palsy.

A novel rat model for longitudinal electrophysiological evaluation after cold-induced brain injury

OBJECTIVE

Cerebral contusion models of cold-induced injury are widely used in animal studies. However, owing to the difficulty of longitudinal recording of electrical stimulation transcranial motor evoked potential (tcMEP) in brain injury models of incomplete paralysis, to the authors' knowledge there have been no multimodal evaluations of cold-induced brain injury models that have included motor function and electrophysiological and histological evaluations. Therefore, in this study the authors aimed to perform a multimodal evaluation of a rat model of brain injury.

METHODS

A brain injury model in female rats and a tcMEP recording technique based on the authors' previous study were established to enable multifaceted analysis, including longitudinal electrophysiological evaluation.

RESULTS

The model showed incomplete paralysis of the right forelimb. Motor function showed recovery over time, and histological evaluation showed tissue changes associated with cerebral contusion. In addition, stable tcMEP waveforms were recorded before and after surgery and up to 4 weeks after injury. The tcMEP amplitude decreased significantly after injury and recovered over time. Furthermore, the amplitudes at 1, 7, and 14 days after injury were significantly lower than those at preinjury (p < 0.0006, p < 0.0007, and p < 0.0067, respectively).

CONCLUSIONS

In the present study, the authors established a novel cold-induced brain injury rat model and technique that allowed for the evaluation of longitudinal tcMEP recording and demonstrated that multimodal evaluation for brain injury can be performed. This model can potentially be applied in future investigations of various therapies for brain injury.

Factors Affecting Participation in Telerehabilitation Using Transcranial Direct Current Stimulation for Patients with Poststroke Paralysis in South Korea

Background: The coronavirus disease 2019 pandemic has expanded noncontact health care systems worldwide. Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technology that enables treatment monitoring under remote supervision. We investigated the factors affecting patients' decision to participate in telerehabilitation (TR) using tDCS for motor function recovery after suffering a stroke. Materials and Methods: Four medical institutions surveyed 156 patients with poststroke paralysis. The participants were asked whether they would participate in TR therapy using tDCS in the future. We performed logistic regression analysis to examine the factors-demographic data, stroke characteristics, arm function, gait, and cognitive function-that influenced participants' decisions. Results: Of the participants, 66% (103/156) reported that they would participate in TR using tDCS in the future. Participants' monthly salary was a single significant independent factor influencing their decision to participate. Those earning greater than 5 million KRW (4,000 USD) were more likely to engage in TR via tDCS than those earning less than 1 million KRW (800 USD). The most common barriers to participation in telemedicine included the preference for face-to-face treatment and unfamiliarity. The expected medical expenses of TR using tDCS were 46,154 KRW (37 USD) per session. Conclusions: Most participants with poststroke paralysis responded positively to TR using tDCS for hand function recovery. For telemedicine to work effectively in a situation wherein face-to-face rehabilitation is impossible, prior discussion at the governmental level is essential for determining medical finances.

Low-Volume Targeted Interscalene Brachial Plexus Block in the Emergency Department as a Safer Alternative for Pain Control for Glenohumeral Reduction: A Case Series

BACKGROUND

Acute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation.

CASE SERIES

We report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5-10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement.

Benefit of high-dose oral riboflavin therapy in riboflavin transporter deficiency

Riboflavin transporter deficiency (RTD) is a progressive inherited neuropathy of childhood onset, characterised by pontobulbar palsy, sensorineural deafness, sensory ataxia, muscle weakness, optic atrophy and respiratory failure. Riboflavin supplementation is beneficial in short-term reports, but the quantum of benefit in various clinical domains is not well understood. A PubMed search was conducted, which identified 94 genetically confirmed cases of RTD who received riboflavin supplementation and had follow-up assessments. Information on the clinical and functional status before and after riboflavin supplementation was collected and analysed. Seventy-six of the 94 patients (80.9%) showed an overall improvement after riboflavin supplementation, and the remaining (19.1%) were stable, though some patients had deteriorations in individual domains with no reported deaths. The domains that had the highest rates of response to riboflavin supplementation were gross motor function (93.3% improved), bulbar palsy (91.3%) and ataxia (90.0%). Improvements were also seen in limb muscle weakness, audiology, facial nerve palsy and respiratory function. Despite treatment, many patients required assistance to ambulate and had severe or profound hearing loss and some remained gastrostomy or tracheostomy dependent. Riboflavin supplementation is a lifesaving intervention for patients with RTD and results in a profound improvement in several functional domains, with early diagnosis and treatment further improving outcomes. Despite treatment, patients are left with residual disability. There is a need to accurately measure functional outcomes in children with RTD and develop additional disease-modifying therapies.

Resolving Co-Contraction of the Elbow in Patient with Sequelae of Obstetric Brachial Plexus Palsy: A Cohort Study

BACKGROUND

Obstetric brachial plexus palsy can cause deformities of the upper extremity in up to 92% of patients. Elbow reconstruction is difficult because co-contraction of the elbow flexor (EF) and elbow extensor (EE) muscles makes the traditional treatment strategy ineffective. The authors propose a novel strategy to minimize the effect of co-contraction, comprising transfer of an EF to the triceps and a staged gracilis muscle transplantation [functioning free muscle transplantation (FFMT)] to augment EF. The authors hypothesize this will lead to improved elbow flexion and extension, as well as decreased elbow flexion contracture.

METHODS

A single-center retrospective review of patients who received a gracilis FFMT for EF after EF-to-EE transfer was performed. EF/EE strength and range of motion data were collected from the last clinical visit. Patients were excluded if they had fewer than 1.5 years of follow-up. A control group with sequelae of obstetric brachial plexus palsy and nonsurgical treatment was used for comparison.

RESULTS

Twenty-one patients were included. Average age at muscle transfer was 7.6 ± 5.5 years (range, 3 to 22 years) and at gracilis FFMT was 10.4 ± 6.0 years (range, 5 to 26 years). Average follow-up was 7.3 ± 6.5 years (range, 1.5 to 14.8 years). After EF-to-EE transfer, EE strength increased significantly from Medical Research Council grade 2.2 ± 0.4 to 3.4 ± 0.5 ( P < 0.0001) and EF decreased from 3.2 ± 1.1 to 1.1 ± 1.1 ( P < 0.0001) and recovered to grade 3.3 ± 0.7 after gracilis FFMT. EF contracture was significantly lower compared with that in the nonsurgical cohort ( P = 0.029).

CONCLUSION

Patients who undergo EF-to-EE transfer followed by gracilis FFMT have equivalent EF strength with significantly improved EE and improved elbow flexion contracture.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Uncovering and leveraging the return of voluntary motor programs after paralysis using a bi-cortical neuroprosthesis

Rehabilitative and neuroprosthetic approaches after spinal cord injury (SCI) aim to reestablish voluntary control of movement. Promoting recovery requires a mechanistic understanding of the return of volition over action, but the relationship between re-emerging cortical commands and the return of locomotion is not well established. We introduced a neuroprosthesis delivering targeted bi-cortical stimulation in a clinically relevant contusive SCI model. In healthy and SCI cats, we controlled hindlimb locomotor output by tuning stimulation timing, duration, amplitude, and site. In intact cats, we unveiled a large repertoire of motor programs. After SCI, the evoked hindlimb lifts were highly stereotyped, yet effective in modulating gait and alleviating bilateral foot drag. Results suggest that the neural substrate underpinning motor recovery had traded-off selectivity for efficacy. Longitudinal tests revealed that the return of locomotion after SCI was correlated with recovery of the descending drive, which advocates for rehabilitation interventions directed at the cortical target.

Two Cases of Periodic Paralysis Associated With MCM3AP Variants

OBJECTIVES

Periodic paralysis is a rare genetic condition characterized by episodes of neuromuscular weakness, often provoked by electrolyte abnormalities, physiologic stress, physical exertion, and diet. In addition to mutations in genes coding for skeletal muscle ion channels, in 2019, Gustavasson et al discovered that the MCM3AP gene could be responsible for periodic paralysis. In this study, we present 2 individuals with clinical episodes of periodic paralysis who have variants in the MCM3AP gene.

METHODS

Two unrelated probands were independently evaluated with clinical, genetic, and electrodiagnostic testing.

RESULTS

Proband 1 is a 46-year-old man who presented with decades of ongoing episodic weakness and fatigue, clinically diagnosed with periodic paralysis and supported by electrodiagnostic studies. Proband 2 is a 34-year-old woman with a history of episodic paralysis since childhood. Genetic testing in both individuals revealed potentially pathogenic variants in the MCM3AP gene.

CONCLUSIONS

Periodic paralysis is a condition that significantly affects the lives of those diagnosed. The results illustrate that MCM3AP gene variants can been associated with a clinical and electrodiagnostic presentation of periodic paralysis. Additional future research should focus on clarifying any relationship between these genetic variants and the disease, as well as other possible genetic causes.

Multiple Factors Influence the Incubation Period of ALS Prion-like Transmission in SOD1 Transgenic Mice

Mutations in superoxide dismutase 1 (SOD1) that are associated with amyotrophic lateral sclerosis (ALS) cause its misfolding and aggregation. Prior studies have demonstrated that the misfolded conformation of ALS-SOD1 can template with naïve SOD1 "host proteins" to propagate, spread, and induce paralysis in SOD1 transgenic mice. These observations have advanced the argument that SOD1 is a host protein for an ALS conformer that is prion-like and experimentally transmissible. Here, we investigated the propagation of different isolates of G93A-SOD1 ALS conformers using a paradigm involving transmission to mice expressing human G85R-SOD1 fused to yellow fluorescent protein (G85R-SOD1:YFP). In these studies, we also utilized a newly developed line of mice in which the G85R-SOD1:YFP construct was flanked by loxp sites, allowing its temporal and spatial regulation. We used methods in which the G93A ALS conformers were injected into the sciatic nerve or hindlimb muscle of adult transgenic mice. We observed that the incubation period to paralysis varied significantly depending upon the source of inoculum containing misfolded G93A SOD1. Serial passage and selection produced stable isolates of G93A ALS conformers that exhibited a defined minimum incubation period of ~2.5 months when injected into the sciatic nerve of young adult mice. As expected, neuronal excision of the transgene in loxpG85R-SOD1:YFP mice blocked induction of paralysis by transmission of G93A ALS conformers. Our findings indicate that G93A ALS conformers capable of inducing disease require neuronal expression of a receptive host SOD1 protein for propagation, with a defined incubation period to paralysis.

Cranial nerve VI palsy in chronic sphenoid sinusitis

Sphenoid sinusitis is a rare disease associated with life-threatening complications that can be avoided with early recognition and timely treatment. Here, we present a case of a woman in her 80s admitted for symptomatic anaemia likely secondary to a gastrointestinal bleed with left cranial nerve (CN) VI palsy incidentally discovered on physical examination. CT and MRI were suggestive of chronic left sphenoid sinusitis with possible involvement of the left cavernous sinus. Surgical treatment was deferred due to high cardiac risk for perioperative mortality and recent ischaemic stroke. Despite antibiotic treatment, the patient's CN VI palsy remained unchanged. This report contributes to the current understanding of sphenoid sinusitis by presenting a complex case of chronic sphenoid sinusitis in which urgent surgical intervention was deferred due to the patient's multiple comorbidities. Furthermore, it highlighted the importance of the CN examination and imaging modalities in diagnosing sphenoid sinusitis.

Feasibility and Efficacy of the Newly Developed Robotic Hybrid Assistive Limb Shoulder Exercises in Patients with C5 Palsy during the Acute Postoperative Phase

Background and Objectives: Although postoperative C5 palsy is a frequent complication of cervical spine surgery, no effective therapeutic rehabilitation approach has been established for postoperative C5 palsy. The purpose of this study was to find evidence confirming the effectiveness and feasibility of robotic Hybrid Assistive Limb (HAL) shoulder exercises for C5 palsy. Materials and Methods: In this before-after, uncontrolled case series clinical study, we performed a mean of 11.7 shoulder training sessions using a shoulder HAL immediately after the onset of C5 palsy in seven shoulders of six patients who developed postoperative C5 palsy and had difficulty raising their shoulder during the acute postoperative phase of cervical spine surgery. Shoulder HAL training was introduced as early as possible after evaluating the general condition of all inpatients who developed C5 palsy. Patients underwent shoulder abduction training using shoulder HAL on an inpatient and outpatient basis at 2-week or 1-month intervals. Adverse events associated with shoulder HAL training were investigated. The shoulder abduction angle and power without the shoulder HAL were evaluated before shoulder HAL usage, at every subsequent session, and upon completion of all sessions. Results: Severe adverse events due to shoulder HAL training were not reported. After completion of all shoulder HAL sessions, all patients showed improved shoulder elevation, while shoulder abduction angle and power improved over time. Conclusions: Shoulder elevation training with HAL in patients in the acute stage of postoperative C5 palsy has the potential to demonstrate improvement in shoulder joint function with a low risk of developing severe adverse events.

A porcine model of postoperative hemi-diaphragmatic paresis to evaluate a unilateral diaphragmatic pacemaker

Unilateral phrenic nerve damage is a dreaded complication in congenital heart surgery. It has deleterious effects in neonates and children with uni-ventricular circulation. Diaphragmatic palsy, caused by phrenic nerve damage, impairs respiratory function, especially in new-borns, because their respiration depends on diaphragmatic contractions. Furthermore, Fontan patients with passive pulmonary perfusion are seriously affected by phrenic nerve injury, because diaphragmatic contraction augments pulmonary blood flow. Diaphragmatic plication is currently employed to ameliorate the negative effects of diaphragmatic palsy on pulmonary perfusion and respiratory mechanics. This procedure attenuates pulmonary compression by the abdominal contents. However, there is no contraction of the plicated diaphragm and consequently no contribution to the pulmonary blood flow. Hence, we developed a porcine model of unilateral diaphragmatic palsy in order to evaluate a diaphragmatic pacemaker. Our illustrated step-by-step description of the model generation enables others to replicate and use our model for future studies. Thereby, it might contribute to investigation and advancement of potential improvements for these patients.

Sabin polio virus protein 1 (VP1) evolution in patients with acute flaccid paralysis from 2010 to 2016 in Uganda

Acute flaccid paralysis (AFP) is a rare side effect of the oral polio vaccine but can be associated with outbreaks and permanent disability in patients harboring circulating vaccine-derived polioviruses (cVDPVs). With the advancement of polio abolition in a glimpse, cVDPVs are causing outbreaks and slowing the polio eradication process. The polio virus protein 1 (VP1) contains the binding site that is key for virus transmission. Understanding the evolution of VP1 among AFP patients could yield more insight into the early events of cVDPVs. Polioviruses were identified from stool specimens of AFP patients using cell culture; and confirmed by the real time RT PCR intra-typic differentiation and vaccine-derived poliovirus assays. Seventy-nine (79) Sabin-like poliovirus 1 (SL1) and 86 Sabin-like poliovirus 3 (SL3) were sequenced. The VP1 amino acid substitutions T106A in Sabin poliovirus 1 and A54V in Sabin poliovirus 3 were common among the AFP patients as has been found in previous studies. Other substitutions that were associated with AFP were: T290A and A54T in SL1 and SL3 respectively. Nucleotide mutations that were common among the AFP patients included T402C, C670A, and T816C in SL1, and G22A, C375Y, A472R, and A694T in SL3 polioviruses. Characterizing mutations that are associated with AFP could contribute to efforts pursued to mitigate the risk of vaccine-derived polioviruses and promote development of safer vaccines.