Modifying the Medical Research Council grading system through Rasch analyses

The outcomes of peripheral nerve surgeries in Africa: Narrative synthesis from existing literature

BACKGROUND

In Africa, peripheral nerve pathologies are a major source of disability, and the results of surgical therapies differ greatly among countries. The goal of this narrative review is to compile the most recent data on peripheral nerve surgery results in Africa, pinpoint critical variables that affect surgical outcomes, and offer suggestions for enhancing patient care.

METHODS

A comprehensive literature review was conducted, focusing on studies published over the past four decades. The sources included peer-reviewed journals, hospital records, and reports from healthcare organizations. The review examined outcomes related to functional recovery, quality of life, and postoperative complications.

RESULTS

The outcomes of peripheral nerve surgeries in Africa are influenced by the availability of medical infrastructure, the level of surgeon expertise, and the timeliness of the intervention. Urban centers with better resources tend to report more favorable outcomes, whereas rural areas face significant challenges. Common barriers include limited access to advanced surgical tools, a shortage of specialized surgeons, and inadequate postoperative care and rehabilitation services. Despite these challenges, successful interventions have been reported, particularly in settings where targeted training programs and international collaborations are in place.

CONCLUSION

Enhancing surgeon training programs, building comprehensive postoperative care and rehabilitation facilities, and investing in healthcare infrastructure are critical to improving peripheral nerve surgery results in Africa. International and regional collaborations can be extremely helpful in advancing these initiatives by enabling the sharing of knowledge and granting access to cutting-edge methods. Patients with peripheral nerve injuries across the continent may experience improved functional recovery and overall quality of life if these criteria are met.

Usefulness of somatosensory evoked potentials for monitoring the clinical course of patients with chronic inflammatory demyelinating polyradiculoneuropathy

INTRODUCTION/AIMS

Somatosensory evoked potentials (SSEPs) are described as a supportive tool to diagnose chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); however, there is a lack of studies determining the effectiveness of SSEPs in monitoring the clinical course of individuals with this condition. The aims of this study are to evaluate the utility of SSEPs in monitoring patients with CIDP and to assess their association with clinical outcomes following immunomodulatory therapy.

METHODS

This was a single-center retrospective observational study that included patients who met European Federation of Neurological Societies and Peripheral Nerve Society criteria for CIDP between 2018 and 2023. SSEPs were performed at diagnosis and during follow-up after the start of immunomodulatory treatment. Fisher's exact test was employed to assess the association between clinical improvement and SSEP improvement.

RESULTS

Eighteen patients were included in the study. Ten patients had a typical CIDP pattern and 11 were male. In 17, SSEPs were abnormal prior to the start of immunomodulatory treatment. In patients who showed clinical improvement with immunomodulatory therapy, we observed that 15/17 had partial or complete improvement in SSEPs. Patients who showed no clinical improvement with first-line treatment exhibited worsening SSEPs. There was a significant association between clinical and SSEPs improvement (p = 0.009).

DISCUSSION

We observed a positive association between improvement in SSEPs and clinical improvement in patients with CIDP. Our data suggest that SSEPs may be useful for monitoring the clinical course of patients with CIDP, but additional, larger studies are needed.

Sensitive Identification of Asymmetries and Neuromuscular Deficits in Lower Limb Function in Early Multiple Sclerosis

BACKGROUND

In the early stages of multiple sclerosis (MS), there are no objective sensitive functional assessments to identify and quantify early subclinical neuromuscular deficits and lower limb strength asymmetries during complex movements. Single-countermovement jumps (SLCMJ), a maximum single leg vertical jump, on a force plate allow functional evaluation of unilateral lower limb performance in performance diagnostics and could therefore provide early results on asymmetries in MS.

OBJECTIVE

Objective evaluation of early lower limb neuromuscular deficits and asymmetries in people with multiple sclerosis (pwMS) using SLCMJ on a force plate.

METHODS

A study was conducted with pwMS (N = 126) and healthy controls (N = 97). All participants performed 3 maximal SLCMJs on a force plate. Temporal, kinetic, and power jump parameters were collected. The Expanded Disability Status Scale (EDSS) was performed on all participants. A repeated measures analysis of covariance (ANCOVA) with age, Body-Mass-Index, and gender as covariates was used.

RESULTS

PwMS with normal muscle strength according to the manual muscle tests showed significantly reduced SLCMJ performance compared to HC. In both groups, jumping performance differed significantly between the dominant and non-dominant leg, with higher effect size for pwMS. A significant interaction effect between leg dominance and group was found for propulsive time, where the pwMS showed an even higher difference between the dominant and non-dominant leg compared to HC. Furthermore, there was a significant small correlation between leg asymmetries and EDSS in pwMS.

CONCLUSION

The study shows that the SLCMJ on a force plate is suitable for the early detection of subclinical lower limb neuromuscular deficits and strength asymmetries in MS.

Evaluating Outcomes Following Nerve Repair: Beyond the Medical Research Council

Peripheral nerve injuries are common and remain a significant health challenge. Outcome measurements are used to evaluate injury, monitor recovery after nerve repair, and compare scientific advances. Clinical judgement is required to determine which available tools are most applicable, which requires a vast understanding of the available outcome measurements. In this article we discuss the highest yield tools available for clinical application.

Improving Heckmatt muscle ultrasound grading scale through Rasch analysis

The 4-point Heckmatt grading scale can easily be used to analyze muscle ultrasound images. The scale is used in an expanding set of muscles and neuromuscular disorders. This prompted the need for evaluation of the measurement properties of the scale in its current form. In this retrospective observational study we included muscle ultrasound images from patients who were undergoing an ultrasound exam for either clinical or research purposes. The primary outcome of this study was to investigate and improve the measurement properties of the Heckmatt scale using Rasch analysis. We investigated whether observers consistently used the 4 response categories. Data was available of 30.967 muscle ultrasound images from 1783 patients and 43 different individual muscles. In 8 of the 43 muscles, observers had difficulty to discriminate between the response categories, especially in bulbar muscles. After rescoring to a 3-point scale, the response categories were consistently used in all 43 muscles. In conclusion, a 3-point Heckmatt grading scale leads to improved accurate scoring compared to the original 4-point Heckmatt grading scale. Using the 3-point Heckmatt grading scale will not only simplify the use of the scale but also enhance its application in clinical practice and research purposes.

Epileptic seizures as an initial symptom for Sturge‑Weber syndrome type III: A report of two cases

Sturge-Weber syndrome (SWS) type III, a rare neurocutaneous disorder, presents diagnostic challenges due to its variable clinical manifestations. The present study focuses on enhancing the understanding of this syndrome by conducting a detailed analysis of two pediatric cases and providing a comprehensive review of the existing literature. The cases, managed at the Children's Hospital Affiliated to Shandong University (Jinan, China), highlight the diverse clinical presentations and successful management strategies for SWS type III. In the first case, a 4-year-old male patient exhibited paroxysmal hemiplegia, epileptic seizures and cerebral angiographic findings indicative of left pia mater and venous malformation. The second case involved a 2.5-year-old male patient presenting with recurrent seizures and angiographic findings on the right side. Both cases underscore the importance of considering epileptic seizures, acquired and transient hemiplegia and cognitive impairments in the diagnosis of SWS type III. The present study provides insights into the effective use of both pharmacological and surgical interventions, drawing from the positive outcomes observed in these cases. The findings emphasize the need for heightened awareness and a meticulous approach in diagnosing and treating SWS type III, contributing to the better management and prognosis of this condition.

Quantitative whole-body muscle MRI in idiopathic inflammatory myopathies including polymyositis with mitochondrial pathology: indications for a disease spectrum

OBJECTIVE

Inflammatory myopathies (IIM) include dermatomyositis (DM), sporadic inclusion body myositis (sIBM), immune-mediated necrotizing myopathy (IMNM), and overlap myositis (OLM)/antisynthetase syndrome (ASyS). There is also a rare variant termed polymyositis with mitochondrial pathology (PM-Mito), which is considered a sIBM precursor. There is no information regarding muscle MRI for this rare entity. The aim of this study was to compare MRI findings in IIM, including PM-Mito.

METHODS

This retrospective analysis included 41 patients (7 PM-Mito, 11 sIBM, 11 PM/ASyS/OLM, 12 IMNM) and 20 healthy controls. Pattern of muscle involvement was assessed by semiquantitative evaluation, while Dixon method was used to quantify muscular fat fraction.

RESULTS

The sIBM typical pattern affecting the lower extremities was not found in the majority of PM-Mito-patients. Intramuscular edema in sIBM and PM-Mito was limited to the lower extremities, whereas IMNM and PM/ASyS/OLM showed additional edema in the trunk. Quantitative assessment showed increased fat content in sIBM, with an intramuscular proximo-distal gradient. Similar changes were also found in a few PM-Mito- and PM/ASyS/OLM patients. In sIBM and PM-Mito, mean fat fraction of several muscles correlated with clinical involvement.

INTERPRETATION

As MRI findings in patients with PM-Mito relevantly differed from sIBM, the attribution of PM-Mito as sIBM precursor should be critically discussed. Some patients in PM/ASyS/OLM and PM-Mito group showed MR-morphologic features predominantly observed in sIBM, indicative of a spectrum from PM/ASyS/OLM toward sIBM. In some IIM subtypes, MRI may serve as a biomarker of disease severity.

Tendon Transfers, Nerve Grafts, and Nerve Transfers for Isolated Radial Nerve Palsy: A Systematic Review and Analysis

BACKGROUND

Isolated radial nerve palsy is a debilitating injury that may potentially be reconstructed with either tendon transfers, nerve grafts, or nerve transfers. Currently, there is no consensus on the optimal technique for reconstruction. We performed a systematic review and analysis to determine which surgical intervention provides the best clinical outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines. Twenty-nine papers met inclusion criteria. Grading scales of function and strength were converted into a tripartite scoring system to compare outcomes between techniques. χ2 analyses were performed with a P value < .05.

RESULTS

Seven hundred fifty-four patients were analyzed. Tendon transfers resulted in the highest percentage of good outcomes (82%) and the lowest percentage of poor outcomes (9%). Tendon transfers were superior to nerve grafts and nerve transfers for restoration of wrist extension. Nerve transfers for wrist extension were superior to nerve transfers for finger extension. Nerve grafts and nerve transfers had equivalent rates of good and poor clinical outcomes.

CONCLUSIONS

This study analyzed reported outcomes of tendon transfers, nerve grafts, and nerve transfers for reconstruction of isolated radial nerve palsy. On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. Tendon transfers should be considered first-line reconstruction for isolated radial nerve palsy as nerve-based reconstruction is less predictable and reproducible.

Guillain-Barré syndrome after surgery: a literature review

Guillain-Barré syndrome (GBS) is a rare postoperative complication that is sometimes characterized by serious motor weakness and prolonged weaning from mechanical ventilation. Although the exact nature of the relationship between GBS and the surgical procedure is still unclear, there is a clear increased incidence of GBS in post-surgical patients compared to non-surgical patients. GBS after surgery is unique in several ways. The course of post-surgical GBS unfolds more rapidly than in other situations where GBS develops, the condition is often more severe, and respiratory muscles are more commonly involved. Prompt diagnosis and appropriate treatment are essential, and the condition can worsen if treated inappropriately. Postoperative sedation, intubation, and restraint use make the diagnosis of GBS difficult, as the onset of symptoms of weakness or numbness in those contexts are not obvious. GBS is often misdiagnosed, being attributed to other postoperative complications, and subsequently mishandled. The lack of relevant information further obscures the clinical picture. We sought to better understand post-surgical GBS by performing an analysis of the relevant literature, focusing on clearly documenting the clinical characteristics, diagnosis, and management of GBS that emerges following surgery. We underscore the importance of physicians being aware of the possibility of GBS after major surgery and of performing a variety of laboratory clinical investigations early on in suspected cases.

Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations

Objective

To formulate the most current, evidence-based recommendations regarding the epidemiology, clinical diagnosis, and radiographic diagnosis of lumbar herniated disk (LDH).

Methods

A systematic literature search in PubMed, MEDLINE, and CENTRAL was performed from 2012 to 2022 using the search terms "herniated lumbar disc", "epidemiology", "prevention" "clinical diagnosis", and "radiological diagnosis". Screening criteria resulted in 17, 16, and 90 studies respectively that were analyzed regarding epidemiology, clinical diagnosis, and radiographic diagnosis of LDH. Using the Delphi method and two rounds of voting at two separate international meetings, ten members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated eleven final consensus statements.

Results

The lifetime risk for symptomatic LDH is 1-3%; of these, 60-90% resolve spontaneously. Risk factors for LDH include genetic and environmental factors, strenuous activity, and smoking. LDH is more common in males and in 30-50 year olds. A set of clinical tests, including manual muscle testing, sensory testing, Lasegue sign, and crossed Lasegue sign are recommended to diagnose LDH. Magnetic resonance imaging (MRI) is the gold standard for confirming suspected LDH.

Conclusions

These eleven final consensus statements provide current, evidence-based guidelines on the epidemiology, clinical diagnosis, and radiographic diagnosis of LDH for practicing spine surgeons worldwide.

Gluteus Repair Yields Satisfactory Clinically Significant Outcome Achievement by 1 Year in Mostly Partial-Thickness Tears With Preoperative Hip Abduction Weakness Associated With Delayed Achievement

PURPOSE

To define the time to achievement of clinically significant outcomes (CSOs) after primary gluteus medius and/or minimus (GM) repair and to identify factors associated with delayed CSO achievement.

METHODS

Patients who underwent primary GM repair between January 2012 and June 2021 with complete preoperative, 6-month, 1-year, and 2-year Hip Outcome Score-Activities of Daily Living (HOS-ADL) were retrospectively identified. Cohort-specific minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated. The time to achievement of MCID and PASS was analyzed using Kaplan-Meier survival analysis. Median time to MCID and PASS achievement was recorded. Multivariate stepwise Cox regressions were used to identify factors associated with delayed CSO achievement.

RESULTS

Fifty GM repairs were identified (age 59.4 ± 9.7 years, body mass index 27.9 ± 6.2, 94% female). Tears were grade 1 in 39 cases, grade 2 in 7 cases, and grade 3 in 4 cases. Endoscopic repair was performed in 35 cases, and open repair was performed in 15 cases. Labral debridement and repair were each performed in 15 cases. Median time to CSO achievement was 5.7 months for MCID and 11.0 months for PASS. The 2-year cumulative probability of MCID and PASS achievement was 92.7% and 66.7%, respectively. Preoperative hip abduction weakness on physical examination was associated with delayed achievement of MCID (hazard ratio 2.27, confidence interval 1.067-7.41, P = .039) and PASS (hazard ratio 3.89, confidence interval 1.341-11.283, P = .012).

CONCLUSIONS

This study demonstrated that in patients undergoing repair of primarily grade 1 GM tears, most achieved MCID by 6 months, and more than one half achieved PASS by 12 months. Preoperative hip abduction weakness on physical examination was associated with delayed CSO achievement.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

What helps patients to prepare for and cope during awake craniotomy? A prospective qualitative study

There is growing interest in awake craniotomies, but some clinicians are concerned that such procedures are poorly tolerated by patients. Therefore, we conducted a study to assess this phenomenon. In this prospective qualitative study, 68 patients who qualified for awake craniotomy were asked to complete the Hospital Anxiety and Depression Scale (HADS)-two days before the surgery and visual analogue scales (VAS) for pain and stress, two days before the surgery and again about two days after. In addition, after their surgery, they took part in a structured interview about what helped them prepare for and cope with the surgery. Most patients tolerated the awake surgery well, scoring low on stress and pain scales. They reported a lower level of stress during the surgery (when questioned afterwards) than before it. Intensity of stress before the surgery correlated negatively with age, positively with HADS anxiety score and positively with stress subsequently experienced during surgery. The level of stress during surgery was associated with stress experienced before the surgery, pain and HADS anxiety and depression scores. Severity of pain during the surgery was positively correlated with stress during surgery and HADS depression and anxiety scores before the surgery. There was no correlation between stress, pain, anxiety and depression and the location of the lesion. Patients have a high tolerance for awake craniotomy. Various factors have an impact on how well patients cope with the operation. Extensive preoperative preparation should be considered a key part of the procedure.

Innovative cellular therapies for autoimmune diseases: expert-based position statement and clinical practice recommendations from the EBMT practice harmonization and guidelines committee

Autoimmune diseases (ADs) are characterized by loss of immune tolerance, high chronicity, with substantial morbidity and mortality, despite conventional immunosuppression (IS) or targeted disease modifying therapies (DMTs), which usually require repeated administration. Recently, novel cellular therapies (CT), including mesenchymal stromal cells (MSC), Chimeric Antigen Receptors T cells (CART) and regulatory T cells (Tregs), have been successfully adopted in ADs. An international expert panel of the European Society for Blood and Marrow Transplantation and the International Society for the Cell and Gene Therapy, reviewed all available evidence, based on the current literature and expert practices, on use of MSC, CART and Tregs, in AD patients with rheumatological, neurological, and gastroenterological indications. Expert-based consensus and recommendations for best practice and quality of patient care were developed to support clinicians, scientists, and their multidisciplinary teams, as well as patients and care providers and will be regularly updated.

Identification and functional characterization of a novel heterozygous splice‑site mutation in the calpain 3 gene causes rare autosomal dominant limb‑girdle muscular dystrophy

Limb-girdle muscular dystrophies are a group of extremely heterogenous neuromuscular disorders that manifest with gradual and progressive weakness of both proximal and distal muscles. Autosomal dominant limb-girdle muscular dystrophy (LGMDD4) or calpainopathy is a very rare form of myopathy characterized by weakness and atrophy of both proximal and distal muscles with a variable age of onset. LGMDD4 is caused by germline heterozygous mutations of the calpain 3 (CAPN3) gene. Patients with LGMDD4 often show extreme phenotypic heterogeneity; however, most patients present with gait difficulties, increased levels of serum creatine kinase, myalgia and back pain. In the present study, a 16-year-old male patient, clinically diagnosed with LGMDD4, was investigated. The proband had been suffering from weakness and atrophy of both of their proximal and distal muscles, and had difficulty walking and standing independently. The serum creatine kinase levels (4,754 IU/l; normal, 35-232 IU/l) of the patient were markedly elevated. The younger sister and mother of the proband were also clinically diagnosed with LGMDD4, while the father was phenotypically normal. Whole exome sequencing identified a heterozygous novel splice-site (c.2440-1G>A) mutation in intron 23 of the CAPN3 gene in the proband. Sanger sequencing confirmed that this mutation was also present in both the younger sister and mother of the proband, but the father was not a carrier of this mutation. This splice-site (c.2440-1G>A) mutation causes aberrant splicing of CAPN3 mRNA, leading to the skipping of the last exon (exon 24) of CAPN3 mRNA and resulting in the removal of eight amino acids from the C-terminal of domain IV of the CAPN3 protein. Hence, this splice site mutation causes the formation of a truncated CAPN3 protein (p.Trp814*) of 813 amino acids instead of the wild-type CAPN3 protein that consists of 821 amino acids. This mutation causes partial loss of domain IV (PEF domain) in the CAPN3 protein, which is involved in calcium binding and homodimerization; therefore, this is a loss-of-function mutation. Relative expression of the mutated CAPN3 mRNA was reduced in comparison with the wild-type CAPN3 mRNA in the proband, and their younger sister and mother. This mutation was also not present in 100 normal healthy control individuals of the same ethnicity. The present study reported the first case of CAPN3 gene-associated LGMDD4 in the Chinese population.

Validation of the Patient-Reported Outcomes Measurement Information System (PROMIS®) physical function questionnaire in late-onset Pompe disease using PROPEL phase 3 data

BACKGROUND

The construct validity and interpretation of the Patient-Reported Outcome Measurement Information System (PROMIS®) Physical Function short form 20a (PF20a) questionnaire were evaluated for patients with late-onset Pompe disease (LOPD), a rare, autosomal recessive, progressive neuromuscular disorder treatable by enzyme replacement therapy (ERT).

METHODS

In the phase 3 PROPEL study, adults with LOPD underwent testing of physical functioning and had PRO measurements at baseline and at weeks 12, 26, 38, and 52 while receiving experimental or standard-of-care ERT. All patients were pooled for analyses, without comparisons between treatment groups. Associations and correlations between PROMIS PF20a scores and the 6-minute walk distance (6MWD), % predicted forced vital capacity (FVC), manual muscle test (MMT) of the lower extremities, Gait, Stairs, Gowers' maneuver, Chair (GSGC) score, and Rasch-built Pompe-specific Activity (R-PAct) scale were evaluated by calculating regression coefficients in linear regression models and Pearson correlation coefficients (R); patients' age, sex, race, ERT prior to study, body mass index, and study treatment were included as covariables. The minimal clinically important difference (MCID) of PROMIS PF20a was determined using distribution- and anchor-based methods.

RESULTS

123 patients received at least 1 dose of ERT. In multivariable analyses, PROMIS PF20a scores had strong correlations with R-PAct scores (R = 0.83 at baseline and R = 0.67 when evaluating changes between baseline and 52 weeks) and moderate correlations with the 6MWD (R = 0.57 at baseline and R = 0.48 when evaluating changes between baseline and 52 weeks). Moderate correlations were also observed between PROMIS PF20a and MMT (R = 0.54), GSGC (R=-0.51), and FVC (R = 0.48) at baseline. In multivariable linear regression models, associations were significant between PROMIS PF20a and 6MWD (P = 0.0006), MMT (P = 0.0034), GSGC (P = 0.0278), and R-PAct (P < 0.0001) at baseline, between PROMIS PF20a and 6MWD (P < 0.0001), FVC (P = 0.0490), and R-PAct (P < 0.0001) when combining all measurements, and between PF20a and 6MWD (P = 0.0016) and R-PAct (P = 0.0001) when evaluating changes in scores between baseline and 52 weeks. The anchor-based and distribution-based MCID for a clinically important improvement for PROMIS PF20a were 2.4 and 4.2, respectively.

CONCLUSIONS

PROMIS PF20a has validity as an instrument both to measure and to longitudinally follow physical function in patients with LOPD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03729362. Registered 2 November 2018, https://www.

CLINICALTRIALS

gov/search?term=NCT03729362 .

Disease activity in chronic inflammatory demyelinating polyneuropathy: association between circulating B-cell subsets, cytokine levels, and clinical outcomes

Chronic inflammatory demyelinating polyneuropathy (CIDP), a common and treatable autoimmune neuropathy, is frequently misdiagnosed. The aim of this study is to evaluate the relationship between immunological markers and clinical outcome measures in a mixed cohort of patients with typical CIDP and CIDP variants at different disease stages. Twenty-three typical, 16 multifocal and five distal CIDP patients were included. Twenty-five sex and age-matched healthy controls and 12 patients with Charcot-Marie-Tooth type 1A (CMT1A) disease served as controls. Peripheral B-cell populations were analyzed by flow cytometry. IL6, IL10, TNFA mRNA and mir-21, mir-146a, and mir-155-5p expression levels were evaluated by real-time polymerase chain reaction in peripheral blood mononuclear cells (PBMC) and/or skin biopsy specimens. Results were then assessed for a possible association with clinical disability scores and intraepidermal nerve fiber densities (IENFD) in the distal leg. We detected a significant reduction in naive B cells (P ≤ 0.001), plasma cells (P ≤ 0.001) and regulatory B cells (P < 0.05), and an elevation in switched memory B cells (P ≤ 0.001) in CIDP compared to healthy controls. CMT1A and CIDP patients had comparable B-cell subset distribution. CIDP cases had significantly higher TNFA and IL10 gene expression levels in PBMC compared to healthy controls (P < 0.05 and P ≤ 0.01, respectively). IENFDs in the distal leg showed a moderate negative correlation with switched memory B-cell ratios (r = -0.51, P < 0.05) and a moderate positive correlation with plasma cell ratios (r = 0.46, P < 0.05). INCAT sum scores showed a moderate positive correlation with IL6 gene expression levels in PBMC (r = 0.54, P < 0.05). Altered B-cell homeostasis and IL10 and TNFA gene expression levels imply chronic antigen exposure and overactivity in the humoral immune system, and seem to be a common pathological pathway in both typical CIDP and CIDP variants.

Brief Electrical Stimulation Promotes Recovery after Surgical Repair of Injured Peripheral Nerves

Injured peripheral nerves regenerate their axons in contrast to those in the central nervous system. Yet, functional recovery after surgical repair is often disappointing. The basis for poor recovery is progressive deterioration with time and distance of the growth capacity of the neurons that lose their contact with targets (chronic axotomy) and the growth support of the chronically denervated Schwann cells (SC) in the distal nerve stumps. Nonetheless, chronically denervated atrophic muscle retains the capacity for reinnervation. Declining electrical activity of motoneurons accompanies the progressive fall in axotomized neuronal and denervated SC expression of regeneration-associated-genes and declining regenerative success. Reduced motoneuronal activity is due to the withdrawal of synaptic contacts from the soma. Exogenous neurotrophic factors that promote nerve regeneration can replace the endogenous factors whose expression declines with time. But the profuse axonal outgrowth they provoke and the difficulties in their delivery hinder their efficacy. Brief (1 h) low-frequency (20 Hz) electrical stimulation (ES) proximal to the injury site promotes the expression of endogenous growth factors and, in turn, dramatically accelerates axon outgrowth and target reinnervation. The latter ES effect has been demonstrated in both rats and humans. A conditioning ES of intact nerve days prior to nerve injury increases axonal outgrowth and regeneration rate. Thereby, this form of ES is amenable for nerve transfer surgeries and end-to-side neurorrhaphies. However, additional surgery for applying the required electrodes may be a hurdle. ES is applicable in all surgeries with excellent outcomes.

Cervical ependymoma en bloc resection

A 58-year-old male was admitted to the authors' department due to cervicothoracic pain and disequilibrium. Physical examination evidenced sensory and motor deficits in the lower limbs. MRI evidenced an expansive intramedullary lesion compatible with ependymoma. The nuances of this surgical access and the management of intradural tumors are discussed.

Phrenic Nerve Transfer to Musculocutaneous Nerve: An Anatomical and Histological Study

BACKGROUND

To restore elbow flexor muscle function in case of traumatic brachial plexus avulsion, the phrenic nerve transfer to the musculocutaneous nerve has become part of clinical practice. The nerve transfer can be done by means of video-assisted thoracic surgery without nerve graft or via supraclavicular approach in combination with an autograft. This study focuses on a detailed microscopic and macroscopic examination of the phrenic nerve. It will allow a better interpretation of existing clinical results and, thus, serve as a basis for future clinical studies.

MATERIAL AND METHODS

An anatomical study was conducted on 28 body donors of Caucasian origin (female n = 14, male n = 14). A sliding caliper and measuring tape were used to measure the diameter and length of the nerves. Sudan black staining was performed on 15 µm thick cryostat sections mounted on glass slides and the number of axons was determined by the ImageJ counting tool. In 23 individuals, the phrenic nerve could be examined on both sides. In 5 individuals, however, only one side was examined. Thus, a total of 51 nerves were examined.

RESULTS

The mean length of the left phrenic nerves (33 cm (29-38 cm)) was significantly longer compared to the mean length of the right phrenic nerves (30 cm (24-33 cm)) (p < 0.001). Accessory phrenic nerves were present in 9 of 51 (18%) phrenic nerves. The mean number of phrenic nerves axons at the level of the first intercostal space in body donors with a right accessory phrenic nerve was significantly greater compared to the mean number of phrenic nerves axons at the same level in body donors without a right accessory phrenic nerve (3145 (range, 2688-3877) vs. 2278 (range, 1558-3276)), p = 0.034. A negative correlation was registered between age and the nerve number of axons in left (0.742, p < 0.001) and right (-0.273, p = 0.197) phrenic nerves. The mean distance from the upper edge of the ventral ramus of the fourth cervical spinal nerve to the point of entrance of the musculocutaneous nerve between the two parts of the coracobrachialis muscle was 19 cm (range, 15-24 cm) for the right and 20 cm (range, 15-25 cm) for the left arm.

CONCLUSIONS

If an accessory phrenic nerve is available, it presumably should be spared. Thus, in that case, a supraclavicular approach in combination with a nerve graft would probably be of advantage.

Statin-induced autoimmune myositis: a proposal of an "experience-based" diagnostic algorithm from the analysis of 69 patients

Statin-induced autoimmune myositis (SIAM) represents a rare clinical entity that can be triggered by prolonged statin treatment. Its pathogenetic substrate consists of an autoimmune-mediated mechanism, evidenced by the detection of antibodies directed against the 3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR Ab), the target enzyme of statin therapies. To facilitate the diagnosis of nuanced SIAM clinical cases, the present study proposes an "experience-based" diagnostic algorithm for SIAM. We have analyzed the clinical data of 69 patients diagnosed with SIAM. Sixty-seven patients have been collected from the 55 available and complete case records regarding SIAM in the literature; the other 2 patients represent our direct clinical experience and their case records have been detailed. From the analysis of the clinical features of 69 patients, we have constructed the diagnostic algorithm, which starts from the recognition of suggestive symptoms of SIAM. Further steps provide for CK values dosage, musculoskeletal MR, EMG/ENG of upper-lower limbs and, Anti-HMGCR Ab testing and, where possible, the muscle biopsy. A global evaluation of the collected clinical features may suggest a more severe disease in female patients. Atorvastatin proved to be the most used hypolipidemic therapy.

Neurological complications of sepsis

PURPOSE OF REVIEW

Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of hospital and ICU admission. The central and peripheral nervous system may be the first organ system to show signs of dysfunction, leading to clinical manifestations such as sepsis-associated encephalopathy (SAE) with delirium or coma and ICU-acquired weakness (ICUAW). In the current review, we want to highlight developing insights into the epidemiology, diagnosis, prognosis, and treatment of patients with SAE and ICUAW.

RECENT FINDINGS

The diagnosis of neurological complications of sepsis remains clinical, although the use of electroencephalography and electromyography can support the diagnosis, especially in noncollaborative patients, and can help in defining disease severity. Moreover, recent studies suggest new insights into the long-term effects associated with SAE and ICUAW, highlighting the need for effective prevention and treatment.

SUMMARY

In this manuscript, we provide an overview of recent insights and developments in the prevention, diagnosis, and treatment of patients with SAE and ICUAW.

Efficacy of functional electrical stimulation in rehabilitating patients with foot drop symptoms after stroke and its correlation with somatosensory evoked potentials-a crossover randomised controlled trial

OBJECTIVE

The connectivity between somatosensory evoked potentials (SEPs) and cortical plasticity remains elusive due to a lack of supporting data. This study investigates changes in pathological latencies and amplitudes of SEPs caused by an acute stroke after 2 weeks of rehabilitation with functional electrical stimulation (FES). Furthermore, changes in SEPs and the efficacy of FES against foot drop (FD) stroke symptoms were correlated using the 10-m walk test and foot-ankle strength.

METHODS

A randomised controlled two-period crossover design plus a control group (group C) was designed. Group A (n = 16) was directly treated with FES, while group B (n = 16) was treated after 2 weeks. The untreated control group of 20 healthy adults underwent repeated SEP measurements for evaluation only.

RESULTS

The repeated-measures ANOVA showed a decrease in tibial nerve (TN) P40 and N50 latencies in group A after the intervention, followed by a decline in non-paretic TN SEP in latency N50 (p < 0.05). Moreover, compared to groups B and C from baseline to 4 weeks, group A showed a decrease in paretic TN latency P40 and N50 (p < 0.05). An increase in FD strength and a reduction in step cadence in group B (p < 0.05) and a positive tendency in FD strength (p = 0.12) and step cadence (p = 0.08) in group A were observed after the treatment time. The data showed a moderate (r = 0.50-0.70) correlation between non-paretic TN latency N50 and step cadence in groups A and B after the intervention time.

CONCLUSION

The FES intervention modified the pathological gait in association with improved SEP afferent feedback. Registered on 25 February 2021 on ClinicalTrials.gov under identifier number: NCT04767360.

Countermovement Jumps Detect Subtle Motor Deficits in People with Multiple Sclerosis below the Clinical Threshold

In the early stages of multiple sclerosis (MS), there are currently no sensitive assessments to evaluate complex motor functions. The countermovement jump (CMJ), a high-challenge task in form of a maximal vertical bipedal jump, has already been investigated as a reliable assessment in healthy subjects for lower extremity motor function. The aim was to investigate whether it is possible to use CMJ to identify subthreshold motor deficits in people with multiple sclerosis (pwMS). All participants (99 pwMS and 33 healthy controls) performed three maximal CMJs on a force plate. PwMS with full motor function and healthy controls (HC) did not differ significantly in age, disease duration, Body Mass Index and the Expanded Disability Scale Score. In comparison to HC, pwMS with full motor function demonstrated a significantly decreased CMJ performance in almost all observed kinetic, temporal and performance parameters (p < 0.05). With increasing disability in pwMS, it was also observed that jump performance decreased significantly. This study showed that the CMJ, as a high challenge task, could detect motor deficits in pwMS below the clinical threshold of careful neurological examination. Longitudinal studies are pending to evaluate whether the CMJ can be used as a standardized measure of disease progression.

Inter-rater reliability of the Rasch-modified medical research council scoring criteria for manual muscle testing in neuromuscular diseases

It was argued that researchers and clinicians are not able to make judgments between most categories of the original Medical Research Council (MRC) scale and that a modified short version would reach higher agreement levels. We aimed to assess the inter-rater reliability for both the original and the Rasch-modified MRC scoring criteria of Manual Muscle Strength tests (MMSt) in patients with neuromuscular diseases. Two MRC scoring criteria were used to score muscle strength using MMSt in 40 muscle groups of the upper and lower limbs in patients with neuromuscular disorders. Three investigators performed the evaluations; the order of the MMSt and the use of the scales were performed according to the preferences of the investigators. The agreement coefficient (Gwet's AC₂ ) was used to compute the reliability. Sixty patients (mean age of 39.3 years ± 15.2) with neuromuscular diseases were included. The mean AC₂ for the muscle groups of the upper limbs ranged from 0.82 to 0.96 using the modified MRC scale and from 0.86 to 0.96 using the original MRC scale. The AC₂ for the lower limb muscle groups ranged from 0.80 to 0.91 (modified MRC scale) and from 0.87 to 0.93 (original MRC scale). These values might be interpreted as "almost perfect agreement" with no significant differences between the scales. The results indicate that both MRC scoring criteria have significant reliability among trained observers. Moreover, the Rasch-modified MRC scale is as reliable as the original MRC scale and can be used in future clinical studies.

'Man-in-the-barrel' syndrome: a case report of bilateral arm paresis following cardiac arrest

'Man-in-the-barrel syndrome' (MIBS) is a neurological phenotype with brachial diplegia, normal sensation, and preserved motor function of the lower limb. Severe hypotension leading to watershed infarctions leading to this phenotype has been reported. The pathogenesis of MIBS is believed to be cerebral hypoperfusion leading to border zone infarctions between the territories of the anterior and middle cerebral arteries.

Case Report and Discussion

A 49-year-old chronic alcoholic hypertensive Indian male was evaluated for barrel syndrome after a cardiac arrest. MRI confirmed hyperintensities between the territories of the anterior and middle cerebral arteries bilaterally.

Conclusion

Person in barrel syndrome is a rare neurological syndrome. MIB is common after cerebral hypoperfusion and carries a poor prognosis. Identification of the underlying cause is important because the management and prognosis vary based on the etiology.

Predicting later categories of upper limb activity from earlier clinical assessments following stroke: an exploratory analysis

BACKGROUND

Accelerometers allow for direct measurement of upper limb (UL) activity. Recently, multi-dimensional categories of UL performance have been formed to provide a more complete measure of UL use in daily life. Prediction of motor outcomes after stroke have tremendous clinical utility and a next step is to explore what factors might predict someone's subsequent UL performance category.

PURPOSE

To explore how different machine learning techniques can be used to understand how clinical measures and participant demographics captured early after stroke are associated with the subsequent UL performance categories.

METHODS

This study analyzed data from two time points from a previous cohort (n = 54). Data used was participant characteristics and clinical measures from early after stroke and a previously established category of UL performance at a later post stroke time point. Different machine learning techniques (a single decision tree, bagged trees, and random forests) were used to build predictive models with different input variables. Model performance was quantified with the explanatory power (in-sample accuracy), predictive power (out-of-bag estimate of error), and variable importance.

RESULTS

A total of seven models were built, including one single decision tree, three bagged trees, and three random forests. Measures of UL impairment and capacity were the most important predictors of the subsequent UL performance category, regardless of the machine learning algorithm used. Other non-motor clinical measures emerged as key predictors, while participant demographics predictors (with the exception of age) were generally less important across the models. Models built with the bagging algorithms outperformed the single decision tree for in-sample accuracy (26-30% better classification) but had only modest cross-validation accuracy (48-55% out of bag classification).

CONCLUSIONS

UL clinical measures were the most important predictors of the subsequent UL performance category in this exploratory analysis regardless of the machine learning algorithm used. Interestingly, cognitive and affective measures emerged as important predictors when the number of input variables was expanded. These results reinforce that UL performance, in vivo, is not a simple product of body functions nor the capacity for movement, instead being a complex phenomenon dependent on many physiological and psychological factors. Utilizing machine learning, this exploratory analysis is a productive step toward the prediction of UL performance. Trial registration NA.

Iatrogenic Nerve Injuries of the Upper Extremity: A Critical Analysis Review

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Iatrogenic nerve injuries may occur after any intervention of the upper extremity.

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Causes of iatrogenic nerve lesions include direct sharp or thermal injury, retraction, compression from implants or compartment syndrome, injection, patient positioning, radiation, and cast/splint application, among others.

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Optimal treatment of iatrogenic peripheral nerve lesions relies on early and accurate diagnosis.

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Advanced imaging modalities (e.g., ultrasound and magnetic resonance imaging) and electrodiagnostic studies aid and assist in preoperative planning.

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Optimal treatment of iatrogenic injuries is situation-dependent and depends on the feasibility of direct repair, grafting, and functional transfers.

Spinal cord motor disorders

Spinal cord diseases are frequently devastating due to the precipitous and often permanently debilitating nature of the deficits. Spastic or flaccid paraparesis accompanied by dermatomal and myotomal signatures complementary to the incurred deficits facilitates localization of the insult within the cord. However, laboratory studies often employing disease-specific serology, neuroradiology, neurophysiology, and cerebrospinal fluid analysis aid in the etiologic diagnosis. While many spinal cord diseases are reversible and treatable, especially when recognized early, more than ever, neuroscientists are being called to investigate endogenous mechanisms of neural plasticity. This chapter is a review of the embryology, neuroanatomy, clinical localization, evaluation, and management of adult and childhood spinal cord motor disorders.

Clinical Significance of Myositis-Specific and Myositis-Associated Antibody Profiles in Dermatomyositis

Background

Myositis-specific autoantibodies (MSA) and myositis-associated autoantibodies (MAA) are clinically useful biomarkers that point to the diagnosis, clinical manifestations, and prognosis of dermatomyositis (DM).

Materials and Methods

To estimate the prevalence of MSA as well as MAA and analyze possible clinical correlations of these autoantibodies in patients diagnosed with DM, we conducted a cross-sectional study of 30 patients who were diagnosed with DM.

Results

MSA were positive in 19 patients (63%) in which Mi 2 was positive in 8 (27%) patients, and this was the most frequently found MSA. A total of 11 (36.7%) patients showed positive MAA. AntiPM/Scl 75 and anti-Ro 52 were positive in 5 (16.7%) patients each and these were the most commonly found MAA. Anti-La was absent in all our patients. There were 8 (27%) patients in whom both MSA and MAA were positive. Either MSA and/or MAA were positive in 22 (73%) patients. On a bivariate analysis, the patients who were positive for anti-PM/Scl 75 showed a significant difference in manifesting cutaneous ulcers (P value 0.023). It was also found that anti-SAE-positive patients showed a significant difference with malignancy (P value 0.014). Anti-Ro 52-positive patients were less likely to have symmetrical proximal muscle weakness (P value 0.006).

Conclusions

All patients who were anti-MDA 5 positive had myositis and none of the anti-MDA 5-positive patients had rapidly progressive interstitial lung disease (RPILD). More than one MSA in the same patient was noted in three patients.

Validity and Reliability of Wearable Motion Sensors for Clinical Assessment of Shoulder Function in Brachial Plexus Birth Injury

The modified Mallet scale (MMS) is commonly used to grade shoulder function in brachial plexus birth injury (BPBI) but has limited sensitivity and cannot grade scapulothoracic and glenohumeral mobility. This study aims to evaluate if the addition of a wearable inertial movement unit (IMU) system could improve clinical assessment based on MMS. The system validity was analyzed with simultaneous measurements with the IMU system and an optical camera system in three asymptomatic individuals. Test-retest and interrater reliability were analyzed in nine asymptomatic individuals and six BPBI patients. IMUs were placed on the upper arm, forearm, scapula, and thorax. Peak angles, range of motion, and average joint angular speed in the shoulder, scapulothoracic, glenohumeral, and elbow joints were analyzed during mobility assessments and MMS tasks. In the validity tests, clusters of reflective markers were placed on the sensors. The validity was high with an error standard deviation below 3.6°. Intraclass correlation coefficients showed that 90.3% of the 69 outcome scores showed good-to-excellent test-retest reliability, and 41% of the scores gave significant differences between BPBI patients and controls with good-to-excellent test-retest reliability. The interrater reliability was moderate to excellent, implying that standardization is important if the patient is followed-up longitudinally.

Disease activity in chronic inflammatory demyelinating polyneuropathy: A comparative study of clinical and skin biopsy markers

INTRODUCTION/AIMS

Epidermal nerve fiber involvement in chronic inflammatory demyelinating neuropathy (CIDP) has been reported in a limited number of patients. We quantified small-fiber involvement in a mixed cohort of patients with typical CIDP and CIDP variants to evaluate relationships with clinical outcome measures at different disease stages.

METHODS

Intraepidermal nerve fiber densities (IENFDs) were evaluated by skin punch biopsies of 23 patients with CIDP and 13 healthy controls at the forearm, thigh, and distal leg. Skin sections were optimally interpreted in all three regions in 16 CIDP patients and 10 age- and sex-matched healthy controls. Statistical analysis was performed in these subjects.

RESULTS

The IENFDs in forearm, thigh, and distal leg were similar among seven typical CIDP and nine CIDP variants. IENFDs in those regions were significantly reduced in CIDP compared with healthy controls, with a moderate negative correlation with scores on the International Neuropathy Cause and Treatment (INCAT) Upper Limb Functional Disability Scale. The reduction in IENFD compared with controls was more remarkable in the distal leg. In clinically unstable CIDP patients, the IENFDs of distal leg and forearm were significantly reduced compared with stable CIDP patients and controls. Stable CIDP patients had significantly reduced IENFDs in distal leg and forearm compared with controls.

DISCUSSION

In this exploratory study, we confirm that small fibers are also affected in CIDP. Larger studies are needed to explore longitudinal changes of IENFD in CIDP and its relation to disease stage.

Rehabilitation of Post-COVID-19 Musculoskeletal Sequelae in Geriatric Patients: A Case Series Study

The musculoskeletal system is affected in over 40% of patients with Coronavirus disease 2019 (COVID-19). There is an increased need for post-acute rehabilitation after COVID-19, especially in elderly people with underlying health problems. The aim of this study was to evaluate the benefits of an early and goal-orientated rehabilitation program using combined approaches, robotic medical devices together with other rehabilitation techniques and therapies, in elderly people after acute COVID-19. Ninety-one patients (62.64 ± 14.21 years) previously diagnosed with severe SARS-CoV-2 infection were admitted to the Medical Rehabilitation Clinical Hospital Baile Felix, Romania, for medical rehabilitation, but only six patients (85.33 ± 3.07 years) met the inclusion criteria and participated in the study. The rehabilitation treatment was complex, performed over 4 weeks, and included combined approaches: exercise therapy, robotic gait training, occupational therapy, and massages. Activity and participation evaluation were performed using the Barthel Index and Functional Independence Measure for activities of daily living (ADLs). Assessments were performed at admission and discharge from the rehabilitation clinic. Lokomat patients' reports revealed that the patients had improved motor control (with one exception). The measurement of functional ability revealed an improvement in most cases. This study presents some of the first data on outcomes of COVID-19 patients' musculoskeletal rehabilitation in our country. Early complex medical rehabilitation improved functional independence and autonomy in ADLs in very old patients, post-COVID-19.

Assessment of motor limb strength by neuroscience nurses: variations in practice and associated challenges

BACKGROUND

Limb strength is a central component of neurological assessment and monitoring in nursing practice, yet there is a lack of research examining the tools used by nurses or challenges nurses encounter when using these tools. The evidence base is lacking to inform effective practice and the underpinning educational approaches.

AIM

To determine which tools are used by UK and Irish neuroscience nurses in the assessment of limb strength and the associated challenges and variations in practice.

METHODS

This study used an online self-reported survey design to ascertain which tools neuroscience nurses used and their experience of using these (n=160).

FINDINGS

Practices varied, with a dominance of two tools being used in practice: the Medical Research Council scale and the 'normal power' to 'no movement' scale found on the neurological observation chart. Most respondents used the same tool across all conditions.

CONCLUSION

This study highlights variations in assessment practice and the absence of a sound evidence base behind choice of motor limb strength assessment tools used.

Comparative study of preoperative functional imaging combined with tractography for prediction of iatrogenic motor deficits

OBJECTIVE

Robust preoperative imaging can improve the extent of resection in patients with brain tumors while minimizing postoperative neurological morbidity. Both structural and functional imaging techniques can provide helpful preoperative information. A recent study found that transcranial magnetic stimulation (TMS) tractography has significant predictive value for permanent deficits. The present study directly compares the predictive value of TMS tractography and task-based functional MRI (fMRI) tractography in the same cohort of glioma patients.

METHODS

Clinical outcome data were collected from charts of patients with motor eloquent glioma and preoperative fMRI and TMS studies. The primary outcome was a new or worsened motor deficit present at the 3-month postoperative follow-up, which was termed a "permanent deficit." Postoperative MR images were overlaid onto preoperative plans to determine which imaging features were resected. Multiple fractional anisotropic thresholds (FATs) were screened for both TMS and fMRI tractography. The predictive value of the various thresholds was modeled using receiver operating characteristic curve analysis.

RESULTS

Forty patients were included in this study. Six patients (15%) sustained permanent postoperative motor deficits. A significantly greater predictive value was found for TMS tractography than for fMRI tractography regardless of the FAT. Despite 35% of patients showing clinically relevant neuroplasticity captured by TMS, only 2.5% of patients showed a blood oxygen level–dependent signal displaced from the precentral gyrus. Comparing the best-performing FAT for both modalities, TMS seeded tractography showed superior predictive value across all metrics: sensitivity, specificity, positive predictive value, and negative predictive value.

CONCLUSIONS

The results from this study indicate that the prediction of permanent deficits with TMS tractography is superior to that with fMRI tractography, possibly because TMS tractography captures clinically relevant neuroplasticity. However, future large-scale prospective studies are needed to fully illuminate the proper role of each modality in comprehensive presurgical workups for patients with motor-eloquent tumors.

Assessment timing and choice of outcome measure in determining treatment response in chronic inflammatory demyelinating polyneuropathy: A post hoc analysis of the PRISM trial

INTRODUCTION/AIMS

Treatment response and its timing are variable in chronic inflammatory demyelinating polyneuropathy (CIDP). In this study we assessed the variability using multiple outcome measures.

METHODS

We performed a post hoc analysis of the PRISM trial, a 24-week prospective, multicenter, single-arm, open-label, phase III study of a 10% intravenous immunoglobulin preparation for CIDP. We ascertained timing of response with primary/secondary outcome measures.

RESULTS

At 6 weeks after treatment initiation, 13 of 40 subjects (32.5%) were defined as responders on the primary outcome measure, the adjusted Inflammatory Neuropathy Cause And Treatment (INCAT) scale. This increased to 20 of 41 (48.8%) at 12 weeks and to 32 of 42 (76.2%) at 24 weeks. Use of minimal important difference (MID)-determined amelioration of the inflammatory Rasch-built Overall Disability Scale (I-RODS), or of the Medical Research Council sum score (MRCSS), or of dominant hand-grip strength, in addition to the adjusted INCAT, indicated a sensitivity of 41.7% in identifying adjusted INCAT nonresponders at week 12 who subsequently responded at week 24. Specificity was 60% vs INCAT nonresponders at week 24. Consideration of amelioration of any amplitude on any secondary outcome measure indicated a 75% sensitivity, but only 30% specificity vs adjusted INCAT nonresponders at week 24.

DISCUSSION

Immunoglobulin treatment continuation may be justified for up to 24 weeks in CIDP. Additional outcome measures may help in the early treatment stages to predict delayed response on the adjusted INCAT. However, their use is limited by high false-positive rates. More robust, reliable, and relevant outcome measures are needed to detect early improvement in immunoglobulin-treated CIDP.

ScapuloThoracic Arthrodesis for Facio-Scapulo-Humeral Dystrophy: Outcomes at mean 7.3 years [3.5-13] follow-up. CT measurement of the fixation position of the arthrodesis and radioclinical correlations

INTRODUCTION

Scapulothoracic arthrodesis may be proposed to patients having facio-scapulohumeral dystrophy to achieve gains in shoulder motion and pain relief. This study aimed to assess shoulder motion, pain and functional scores at last follow-up and to present a method of computed tomography measurements of the position of the scapulothoracic arthrodesis and study their correlations with shoulder motion.

PATIENTS AND METHODS

Seven patients (11 arthrodesis) were included. Shoulder motion, pain, respiratory function and deltoid strength were compared with preoperative values and Constant, Brooke and Vignos scores were assessed at last follow-up. The elevation/depression and upward/downward position of the scapula were measured by performing postoperative 3D CT reconstruction. The protraction/retraction position was measured with 2D CT reconstructions on axial view. Correlations between these measurements and shoulder flexion and abduction were analysed. All complications were searched.

RESULTS

We found a significant improvement in mean VAS (from 3±2 to 1±1, p=0,008) shoulder flexion (64°± 11 to 113°±20, p=0,003) and abduction (from 63°±9 to 92°±13°, p=0,004). Postoperative external rotation wasn't significantly different (from 49°±19 to 43°±10, p=0,112) and on internal rotation, the hand reached on average the 9th thoracic vertebra (S1-T2). Scapulothoracic arthrodesis was mainly positioned in regard to the 1^st and the 6^th rib. The mean protraction/retraction position was 38,5°±8° and the mean scapular upward/downward rotation position was 92°±15°. No correlations were found between the scapular position and shoulder flexion and abduction.

CONCLUSIONS

Scapulothoracic arthrodesis for facioscapulohumeral dystrophy improved pain, shoulder flexion and abduction and provided good functional outcomes at 3,5 to 13 years of follow up. A method of CT assessment of the position of the arthrodesis is presented to analyse precisely the position of the scapula but no correlations with shoulder motions were found. Preoperative evaluation of deltoid function and scapular winging seemed to be the most important predictors of shoulder motions gains after this procedure.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Demographic, clinical, laboratory data, prognostic, and treatment features of patients with antisynthetase syndrome: An international, two-center cohort study

Objectives: To compare clinical, demographic, laboratory data, prognostic and treatment characteristics of patients with antisynthetase syndrome (ASSD) treated in two different centers of India and Brazil.

Patients and methods: This international, two-center, retro-prospective cohort study which was conducted at two tertiary rheumatology centers (one in Brazil and one in India) between January 2000 to January 2020 included a total of 115 patients with ASSD (21 males, 94 females; mean age; at disease diagnosis at 40.3; range, 18 to 80 years). Demographic, clinical and laboratory data of the patients were recorded. Clinical involvement was evaluated.

Results: Of the patients, 81 were Brazilians and 34 were of Indian origin. The Indian group exhibited a greater delay in diagnosis after the onset of symptoms compared to Brazilian patients (12 vs. 6 months, respectively; p=0.026). Brazilian patients exhibited a significantly higher prevalence of joint and lung involvement, mechanic’s hands, and Raynaud’s phenomenon. Anti-Jo-1 was the most common autoantibodies in both groups. Systemic arterial hypertension, followed by diabetes mellitus were the most prevalent comorbidities. Concerning previously used drugs, the Indian patients had a larger group of patients treated with antimalarials, whereas the Brazilian group used more azathioprine and intravenous immunoglobulin. A higher proportion of Indian patients was treated with one immunosuppressive drug (70.6%), while the Brazilian group were often treated using two immunosuppressive drugs (33%). Comparison between the severity and prognosis showed that Brazilian group had a higher number of relapses, and during follow-up, the global mortality rates were similar in both groups (6.2% for Brazilian vs. 8.8% for Indian).

Conclusion: Brazilian and Indian patients with ASSD have comparable epidemiological characteristics such as age at the time of disease diagnosis, and sex distribution, and autoantibodies. Diagnostic delay is seen in Indian patients, and Brazilians exhibit a higher prevalence of joint and lung involvement, mechanic’s hands, Raynaud’s phenomenon with a higher number of relapses, although the mortality rate seems to be similar in both groups.

Pragmatic guide to peripheral nerve disease and the role of clinical biomarkers

In clinical neurology practice, there are few sensitive, specific and responsive serological biomarkers reflecting pathological processes affecting the peripheral nervous system. Instead, we rely on surrogate multimodality biomarkers for diagnosis and management. Correct use and interpretation of the available tests is essential to ensure that appropriate treatments are used and adjusted in a timely fashion. The incorrect application or interpretation of biomarkers can result in misdiagnosis and delays in appropriate treatment. Here, we discuss the uses and limitations of such biomarkers and discuss possible future developments.

Diagnosis of Guillain-Barré syndrome and use of Brighton criteria in Peruvian hospitals

BACKGROUND

Guillain-Barré syndrome (GBS) is an autoimmune disease of the peripheral nervous system that caused multiple epidemiological outbreaks in Peru during 2018 and 2019. It is usually diagnosed using the Brighton criteria (BC).

OBJECTIVE

We aimed to determine the performance of Peruvian neurologists in diagnosing GBS based on the BC, along with its associated factors.

METHODS

This was a retrospective multicenter cohort study. We included patients diagnosed with GBS between 2007 and 2018 in three public hospitals in Lima, Peru. We collected data regarding demographic, clinical and management characteristics. We evaluated the use of the BC for confirmatory diagnosis of GBS and developed a logistic regression model to identify factors associated with its use.

RESULTS

Out of 328 cases, we reviewed 201 available charts. The median age was 48 years, with male predominance. Over half of the patients presented an inadequate motor examination according to their Medical Research Council (MRC) score. Additional testing included lumbar puncture and electrophysiological testing, in over 70% of the cases. The BC showed certainty level 1 in 13.4% and levels 2 and 3 in 18.3%. Neither the quality of the motor examination nor the type of institution showed any association with the BC.

CONCLUSIONS

Level 1 diagnostic certainty of the BC was met in less than one quarter of the cases with a GBS diagnosis in three centers in Lima, Peru, between 2007 and 2018. This level was not significantly associated with being treated in a specialized institute, rather than in a general hospital.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy

BACKGROUND

Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies.

METHODS

A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire.

RESULTS

Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher.

CONCLUSION

Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Demographic, clinical, laboratory data, prognostic, and treatment features of patients with antisynthetase syndrome: An international, two-center cohort study

Objectives

To compare clinical, demographic, laboratory data, prognostic and treatment characteristics of patients with antisynthetase syndrome (ASSD) treated in two different centers of India and Brazil.

Patients and methods

This international, two-center, retro-prospective cohort study which was conducted at two tertiary rheumatology centers (one in Brazil and one in India) between January 2000 to January 2020 included a total of 115 patients with ASSD (21 males, 94 females; mean age; at disease diagnosis at 40.3; range, 18 to 80 years). Demographic, clinical and laboratory data of the patients were recorded. Clinical involvement was evaluated.

Results

Of the patients, 81 were Brazilians and 34 were of Indian origin. The Indian group exhibited a greater delay in diagnosis after the onset of symptoms compared to Brazilian patients (12 vs. 6 months, respectively; p=0.026). Brazilian patients exhibited a significantly higher prevalence of joint and lung involvement, mechanic's hands, and Raynaud's phenomenon. Anti-Jo-1 was the most common autoantibodies in both groups. Systemic arterial hypertension, followed by diabetes mellitus were the most prevalent comorbidities. Concerning previously used drugs, the Indian patients had a larger group of patients treated with antimalarials, whereas the Brazilian group used more azathioprine and intravenous immunoglobulin. A higher proportion of Indian patients was treated with one immunosuppressive drug (70.6%), while the Brazilian group were often treated using two immunosuppressive drugs (33%). Comparison between the severity and prognosis showed that Brazilian group had a higher number of relapses, and during follow-up, the global mortality rates were similar in both groups (6.2% for Brazilian vs. 8.8% for Indian).

Conclusion

Brazilian and Indian patients with ASSD have comparable epidemiological characteristics such as age at the time of disease diagnosis, and sex distribution, and autoantibodies. Diagnostic delay is seen in Indian patients, and Brazilians exhibit a higher prevalence of joint and lung involvement, mechanic's hands, Raynaud's phenomenon with a higher number of relapses, although the mortality rate seems to be similar in both groups.

Reconstruction of C5-C8 (T1 Hand) Brachial Plexus Paralysis in a Series of 52 Patients

PURPOSE

A C5-C8 brachial plexus root injury, also known as a T1 hand, is associated with paralysis of shoulder abduction or external rotation and elbow flexion, accompanied by variable elbow, wrist, thumb, or finger extension deficits. We report the results of reconstruction for C5-C8 brachial plexus paralysis in 52 patients operated upon within 12 months of injury and having at least 24 months of follow-up.

METHODS

We considered surgery to be indicated if, by the fifth month after trauma, shoulder abduction and external rotation and elbow flexion remained paralyzed. Root grafting was possible in 35% of the patients and was performed concomitantly with nerve transfers. Shoulder motion was reconstructed by transferring the spinal accessory to the suprascapular nerve. Elbow flexion was restored by transferring fascicles from either the median or ulnar nerve to the biceps motor branch. When needed, elbow extension was reconstructed by transferring 1 motor branch of the flexor carpi ulnaris to the triceps lower medial head motor branch. Wrist extension was restored by transferring the distal anterior interosseous nerve to the extensor carpi radialis brevis motor branch.

RESULTS

Within 12 months of injury, we observed preserved or spontaneous recovery of elbow, wrist, finger, and thumb extension in 25%, 12%, 50%, and 68% of patients, respectively. After surgical reconstruction, improved range of motion for shoulder, elbow flexion, and wrist extension scoring at least M3 was present in 90% of our patients. All 10 patients in whom a motor branch of the flexor carpi ulnaris was used for triceps reconstruction recovered elbow extension, while flexor carpi ulnaris function was preserved.

CONCLUSIONS

In approximatively 90% of our patients, distal nerve transfers resulted in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Contemporary challenges in the diagnosis and management of chronic inflammatory demyelinating polyneuropathy

INTRODUCTION

Despite extensive research, multiple inter-related diagnostic and management challenges remain for chronic inflammatory demyelinating polyneuropathy (CIDP).

AREAS COVERED

A literature review was performed on diagnosis and treatment in CIDP. The clinical features and disease course were evaluated. Investigative techniques, including electrophysiology, cerebrospinal fluid examination, neuropathology, imaging and neuroimmunology, were considered in relation to technical aspects, sensitivity, specificity, availability and cost. Available evidenced-based treatments and those with possible efficacy despite lack of evidence, were considered, as well as current methods for evaluation of treatment effects.

EXPERT OPINION

CIDP remains a clinical diagnosis, supported first and foremost by electrophysiology. Other investigative techniques have limited impact. Most patients with CIDP respond to available first-line treatments and immunosuppression may be efficacious in those who do not. Consideration of the natural history and of the high reported remission rate, of under-recognised associated disabling features, of treatment administration modalities and assessment methods, require enhanced attention.

Causes and consequences of diagnostic delay in Guillain-Barré syndrome in a U.K. tertiary centre

INTRODUCTION/AIMS

Understanding the potential causes and consequences of diagnostic delay in Guillain-Barré syndrome (GBS) could improve quality of care and outcomes. We aimed to determine these.

METHODS

We retrospectively reviewed records of subjects with GBS, admitted to our centre at University Hospitals Birmingham, U.K., between January 2005 and December 2020. We evaluated time to diagnosis from presentation, factors associated with diagnostic delay and its potential consequences.

RESULTS

We included 119 consecutive subjects. Diagnostic delay >5 days from first presentation occurred in 27/119 (22.7%) of patients. Diagnostic delay was associated with age >60 years (OR: 3.58; 95% CI: 1.44-8.85), pre-existing cardiac/respiratory disease (OR: 4.10; 95% CI: 1.46-11.54), pre-existing diabetes (OR: 10.38; 95% CI: 2.47-43.69), documented normal initial neurological examination (OR: 2.49; 95% CI: 1.03-6.02), initial assessment by primary care (OR: 3.33; 95% CI: 1.22-9.10) and >1 visit for medical attention (OR: 10.29; 95% CI: 3.81-27.77). Diagnostic delay was not associated with length of in-patient stay, ICU admission, ventilation, ability to walk at discharge, or in-patient mortality. Independent associations with diagnostic delay were observed for >1 visit for medical attention (OR: 10.15; 95% CI: 3.64-28.32) and pre-existing cardiac/respiratory disease (OR: 3.98; 95% CI: 1.19-13.28). An association of diagnostic delay with in-patient mortality was ascertained specifically in subjects with classic GBS (OR: 5.33; 95% CI: 1.1-25.87).

DISCUSSION

Diagnostic delay in GBS results from patient-specific factors and patient pathways. A high index of suspicion is appropriate for certain patient groups. Prospective studies are needed to further investigate this topic. This article is protected by copyright. All rights reserved.

Occurrence of osmotic demyelination syndrome in diabetes mellitus: A case report and literature review of various etiologies for osmotic demyelination syndrome

Osmotic demyelination syndrome is a rare condition reported mainly in the case of rapid correction of hyponatremia, but it can occur even in the case of complicated diabetes mellitus either during rapid correction of hyperglycemia or anytime during the complicated diabetes mellitus. We report a case of complicated diabetes mellitus developing osmotic demyelination syndrome. The patient had presented with altered sensorium and seizure, which was initially diagnosed as hyperglycemia, but during his treatment, the magnetic resonance imaging of brain revealed central pontine myelinolysis. Our search on the causes of osmotic demyelination syndrome other than rapid correction of hyponatremia has revealed several other causes like autoimmune liver disease, Sjogren’s syndrome and non-Hodgkin’s lymphoma in addition to diabetes mellitus.

Are there any differences between the shoulder-arm sling and figure-of-eight bandage in the conservative treatment of paediatric clavicle fractures?

PURPOSE

Clavicle fractures are treated conservatively in the paediatric age group, except in rare types of fractures. We investigated whether there was a difference between using shoulder-arm sling and figure-of-eight bandage in this age group.

METHODS

This study was designed as a retrospective study. In all, 41 children among 53 who underwent conservative treatment with a shoulder-arm sling or figure-of-eight bandage between 2014 and 2019 were included in the study and divided into two groups. Treatment results were compared clinically with respect to pain intensity, muscle strength and radiological examinations.

RESULTS

Group A comprised 20 children with a figure-of-eight bandage and group B comprised 21 children with shoulder sling. According to the Robinson classification, ten fractures were displaced in group A and 12 in group B (p = 0.647). The mean time until the first appointment after the index visit that started the management course was 25.5 days (21 to 31) in group A and 24 days (20 to 30) in group B (p = 0.129). Fracture healing was observed in all patients at the first follow-up and the treatment was discontinued. There was no difference between the groups in the muscle strength examination and shoulder joint range of movement examination at the first-year follow-up (p = 1.00).

CONCLUSION

In the paediatric age group, there was no significant difference between shoulder-arm sling and figure-of-eight bandage in the conservative treatment of clavicle fractures. Since the shoulder-arm sling is more suitable for treatment, it may be the primary preference.

LEVEL OF EVIDENCE

Level III (retrospective comparative study).

Natural History of Facioscapulohumeral Dystrophy in Children: A 2-Year Follow-up

Background and Objectives

Data on the natural history of facioscapulohumeral dystrophy (FSHD) in childhood are limited and critical for improved patient care and clinical trial readiness. Our objective was to describe the disease course of FSHD in children.

Methods

We performed a nationwide, single-center, prospective cohort study of FSHD in childhood assessing muscle functioning, imaging, and quality of life over 2 years of follow-up.

Results

We included 20 children with genetically confirmed FSHD who were 2 to 17 years of age. Overall, symptoms were slowly progressive, and the mean FSHD clinical score increased from 2.1 to 2.8 (p = 0.003). The rate of progression was highly variable. At baseline, 16 of 20 symptomatic children had facial weakness; after 2 years, facial weakness was observed in 19 of 20 children. Muscle strength did not change between baseline and follow-up. The most frequently and most severely affected muscles were the trapezius and deltoid. The functional exercise capacity, measured with the 6-minute walk test, improved. Systemic features were infrequent and nonprogressive. Weakness-associated complications such as lumbar hyperlordosis and dysarthria were common, and their prevalence increased during follow-up. Pain and fatigue were frequent complaints in children, and their prevalence also increased during follow-up. Muscle ultrasonography revealed a progressive increase in echogenicity.

Discussion

FSHD in childhood has a slowly progressive but variable course over 2 years of follow-up. The most promising outcome measures to detect progression were the FSHD clinical score and muscle ultrasonography. Despite this disease progression, an improvement on functional capacity may still occur as the child grows up. Pain, fatigue, and a decreased quality of life were common symptoms and need to be addressed in the management of childhood FSHD. Our data can be used to counsel patients and as baseline measures for treatment trials in childhood FSHD.

Disease Progression and Mutation Pattern in a Large Cohort of LGMD R1/LGMD 2A Patients from India

Calpainopathy is caused by mutations in the CAPN3. There is only one clinical and genetic study of CAPN3 from India and none from South India. A total of 72 (male[M]:female [F] = 34:38) genetically confirmed probands from 72 independent families are included in this study. Consanguinity was present in 54.2%. The mean age of onset and duration of symptoms are 13.5 ± 6.4 and 6.3 ± 4.7 years, respectively. Positive family history occurred in 23.3%. The predominant initial symptoms were proximal lower limb weakness (52.1%) and toe walking (20.5%). At presentation, 97.2% had hip girdle weakness, 69.4% had scapular winging, and 58.3% had contractures. Follow-up was available in 76.4%, and 92.7% were ambulant at a mean age of 23.7 ± 7.6 years and duration of 4.5 years, remaining 7.3% became wheelchair-bound at 25.5 ± 5.7 years of age (mean duration = 13.5 ± 4.6), 4.1% were aged more than 40 years (duration range = 5–20). The majority remained ambulant 10 years after disease onset. Next-generation sequencing (NGS) detected 47 unique CAPN3 variants in 72 patients, out of which 19 are novel. Missense variants were most common occurring in 59.7% (homozygous = 29; Compound heterozygous = 14). In the remaining 29 patients (40.3%), at least one suspected loss of function variant was present. Common recurrent variants were c.2051–1G > T and c.2338G > C in 9.7%, c.1343G > A, c.802–9G > A, and c.1319G > A in 6.9% and c.1963delC in 5.5% of population. Large deletions were observed in 4.2%. Exon 10 mutations accounted for 12 patients (16.7%). Our study highlights the efficiency of NGS technology in screening and molecular diagnosis of limb-girdle muscular dystrophy with recessive form (LGMDR1) patients in India.