Post-polio Syndrome: More Than Just a Lower Motor Neuron Disease

Return of poliomyelitis: A real risk in a country afflicted by scientific denialism

Vaccine hesitancy fueled by ignorance, negativity, and false information on social media affects public health globally. Brazil's decline in vaccination, influenced by denialism and misinformation, increases the risk of polio reintroduction in Latin America. Combatting scientific Fake News is crucial to prevent irreversible consequences to public health.

Efficacy of REAC Neurobiological Optimization Treatments in Post-Polio Syndrome: A Manual Muscle Testing Evaluation

Background: This study evaluated the effectiveness of radio electric asymmetric conveyer (REAC) neurobiological optimization treatments on muscle strength (MS) in individuals with post-polio syndrome (PPS), a condition causing new muscle weakness in polio survivors. Traditional treatments focus on symptom management, whereas REAC technology uses radio electric symmetric conveyed fields to modulate neurotransmission and cellular function. Methods: This open-label study involved 17 PPS patients who maintained their existing medications. The participants underwent four REAC treatment protocols: neuro-postural optimization (NPO), neuro-psycho-physical optimization (NPPO), neuro-psycho-physical optimization-cervical brachial (NPPO-CB), and neuromuscular optimization (NMO). MS was assessed using manual muscular tests (MMT) before and after each protocol. Results: A statistical analysis via repeated measures ANOVA showed significant MS improvements, particularly in the proximal muscles of the left lower limb (LLL), distal muscles of both lower limbs (LLs), and distal muscles of the left upper limb. The LLL, the most severely affected limb at this study's start, exhibited the greatest improvement. Conclusions: These results suggest REAC treatments could enhance MS in PPS patients, potentially reorganizing motor patterns and reducing functional overload on less affected limbs.

Neurobiological modulation with REAC technology: enhancing pain, depression, anxiety, stress, and quality of life in post-polio syndrome subjects

Post-polio syndrome (PPS) brings new challenges for polio survivors, including muscle decline, pain, depression, and diminished quality of life. This study explored the potential of REAC neuromodulatory treatments to ease pain, improve mood, and enhance quality of life in PPS patients. 17 individuals with PPS (average age 54.8) received three REAC treatments: Neuro Postural Optimization, Neuro Psycho Physical Optimization, and Neuro Psycho Physical Optimization-Cervico Brachial. Pain, depression, anxiety, stress, and quality of life were assessed before and after using established scales. REAC treatments significantly reduced pain across various dimensions, along with depression, anxiety, and stress levels. Additionally, patients reported improved physical and psychological quality of life. This study suggests REAC neuromodulatory treatments as a promising non-invasive option to improve pain, emotional well-being, and quality of life in individuals with PPS.

Limbic Network and Papez Circuit Involvement in ALS: Imaging and Clinical Profiles in GGGGCC Hexanucleotide Carriers in C9orf72 and C9orf72-Negative Patients

Background: While frontotemporal involvement is increasingly recognized in Amyotrophic lateral sclerosis (ALS), the degeneration of limbic networks remains poorly characterized, despite growing evidence of amnestic deficits, impaired emotional processing and deficits in social cognition. Methods: A prospective neuroimaging study was conducted with 204 individuals with ALS and 111 healthy controls. Patients were stratified for hexanucleotide expansion status in C9orf72. A deep-learning-based segmentation approach was implemented to segment the nucleus accumbens, hypothalamus, fornix, mammillary body, basal forebrain and septal nuclei. The cortical, subcortical and white matter components of the Papez circuit were also systematically evaluated. Results: Hexanucleotide repeat expansion carriers exhibited bilateral amygdala, hypothalamus and nucleus accumbens atrophy, and C9orf72 negative patients showed bilateral basal forebrain volume reductions compared to controls. Both patient groups showed left rostral anterior cingulate atrophy, left entorhinal cortex thinning and cingulum and fornix alterations, irrespective of the genotype. Fornix, cingulum, posterior cingulate, nucleus accumbens, amygdala and hypothalamus degeneration was more marked in C9orf72-positive ALS patients. Conclusions: Our results highlighted that mesial temporal and parasagittal subcortical degeneration is not unique to C9orf72 carriers. Our radiological findings were consistent with neuropsychological observations and highlighted the importance of comprehensive neuropsychological testing in ALS, irrespective of the underlying genotype.

Post-polio syndrome - somatosensory dysfunction and its relation to pain: a pilot study with quantitative sensory testing

OBJECTIVE

To explore and characterize somatosensory dysfunction in patients with post-polio syndrome and chronic pain, by conducting examinations with Quantitative Sensory Testing.

DESIGN

A cross-sectional, descriptive, pilot study conducted during 1 month.

SUBJECTS/PATIENTS

Six patients with previously established post-polio syndrome and related chronic pain.

METHODS

All subjects underwent a neurological examination including neuromuscular function, bedside sensory testing, a thorough pain anamnesis, and pain drawing. Screening for neuropathic pain was done with 2 questionnaires. A comprehensive Quantitative Sensory Testing battery was conducted with z-score transformation of obtained data, enabling comparison with published reference values and the creation of sensory profiles, as well as comparison between the study site (more polio affected extremity) and internal control site (less affected extremity) for each patient.

RESULTS

Derived sensory profiles showed signs of increased prevalence of sensory aberrations compared with reference values, especially Mechanical Pain Thresholds, with significant deviation from reference data in 5 out of 6 patients. No obvious differences in sensory functions were seen between study sites and internal control sites.

CONCLUSION

Post-polio syndrome may be correlated with a mechanical hyperalgesia/allodynia and might be correlated to a somatosensory dysfunction. With lack of evident side-to-side differences, the possibility of a generalized dysfunction in the somatosensory system might be considered.

Contribution of CNS and extra-CNS infections to neurodegeneration: a narrative review

Central nervous system infections have been suggested as a possible cause for neurodegenerative diseases, particularly sporadic cases. They trigger neuroinflammation which is considered integrally involved in neurodegenerative processes. In this review, we will look at data linking a variety of viral, bacterial, fungal, and protozoan infections to Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis and unspecified dementia. This narrative review aims to bring together a broad range of data currently supporting the involvement of central nervous system infections in the development of neurodegenerative diseases. The idea that no single pathogen or pathogen group is responsible for neurodegenerative diseases will be discussed. Instead, we suggest that a wide range of susceptibility factors may make individuals differentially vulnerable to different infectious pathogens and subsequent pathologies.

Prevalence and Severity of Central Sensitization in Post-Polio Syndrome: Associations with Clinical Measures and Quality of Life

OBJECTIVES

To investigate the presence and severity of central sensitization (CS) and its associations with clinical measures and quality of life (QoL) in individuals with a history of paralytic poliomyelitis with and without post-polio syndrome (PPS).

METHODS

In this cross-sectional study, we included 98 individuals with a history of poliomyelitis, in whom 82 (83.6%) met the criteria of PPS. We used CS Inventory (CSI) to evaluate the presence and severity of CS. We evaluated the severity of fatigue, pain, polio-related impairments, and QoL using a Numerical Rating Scale in addition to Fatigue Severity Scale, Self-reported Impairments in Persons with late effects of Polio rating scale (SIPP), and Nottingham Health Profile (NHP).

RESULTS

CS was present in 52.4% of patients with PPS, of which 63% are classified as severe to extreme. Those with CS reported more severe symptoms, more polio-related impairments, and worse QoL than those without CS. Severity of CS showed significant positive correlations with severity of fatigue, pain, SIPP, and NHP scales in those with PPS. CSI did not indicate CS in any of those without PPS.

CONCLUSION

CS was present in more than half of the individuals with PPS and correlated with more severe pain, fatigue, and more polio-related impairments, in addition to poorer QoL. These findings suggest that CS may contribute to the clinical picture in a subgroup of individuals with PPS. Thus, identification and appropriate management of CS patients may potentially help alleviate their symptoms and improve their QoL.

Post-polio syndrome is not a dysimmune condition

BACKGROUND

Poliomyelitis is a global disabling disease affecting 12-20 million of people. Post poliomyelitis syndrome (PPS) may affect up to 80% of polio survivors: increased muscle weakness, pain, fatigue, functional decline. It relies on aging of an impaired neuro-muscular system with ongoing denervation processes. A late involvement of humoral or cellular pro-inflammatory phenomena is also suspected.

AIM

To assess the dysimmune hypothesis of PPS by comparing lymphocyte subpopulations and humoral immune factors between PPS patients and controls.

DESIGN

Cross-sectional study.

SETTING

Montpellier University Hospital.

POPULATION

Forty-seven PPS and 27 healthy controls.

METHODS

PPS patients and controls were compared on their lymphocyte subpopulations and humoral immune factors (IL-1β, IL-6, IL-8, IL-17, IL-21, IL-22, IL-23, IFN-γ, TNF-α, GM-CSF, RANTES, MCP1, MIP-3a, IL-10, TGF-β, IL4, IL13). Patients were further compared according to their dominant clinical symptoms. Sample size guaranteed a power >90% for all comparisons.

RESULTS

PPS patients and controls were comparable in gender, age and corpulence. Most patients had lower limb motor sequelae (N.=45, 95.7%), a minority had upper limb motor impairment (N.=16, 34.0%). Forty-five were able to walk (94%), 35/45 with technical aids. The median of the two-minute walking test was 110 meters (interquartile range 55; 132). Eighteen (38%) required help in their daily life. Their quality of life was low (SF36). All described an increased muscular weakness, 40 (85%) a general fatigue, and 39 (83%) muscular or joint pain. Blood count, serum electrolytes, T and B lymphocyte subpopulations and cytokines were comparable between patients and controls, except for creatine phospho kinase that was significantly higher in PPS patients. None of these variables differed between the 20/47 patients whose late main symptoms were pain or fatigue, and other patients.

CONCLUSIONS

Our results suggest that PPS is not a dysimmune disease.

CLINICAL REHABILITATION IMPACT

Our results do not sustain immunotherapy for PPS. Our work suggest that PPS may be mostly linked to physiological age-related phenomena in a disabled neuromuscular condition. Thus, our results emphasize the role of prevention and elimination of aggravating factors to avoid late functional worsening, and the importance of rehabilitation programs that should be adapted to patients' specific conditions.

The Role of Epigenetics in Accelerated Aging: A Reconsideration of Later-Life Visual Loss After Early Optic Neuropathy

BACKGROUND

In 2005, we reported 3 patients with bilateral optic nerve damage early in life. These patients had stable vision for decades but then experienced significant bilateral vision loss with no obvious cause. Our hypothesis, novel at that time, was that the late decline of vision was due to age-related attrition of retinal ganglion cells superimposed on a reduced neuronal population due to the earlier injury.

EVIDENCE ACQUISITION

The field of epigenetics provides a new paradigm with which to consider the normal aging process and the impact of neuronal injury, which has been shown to accelerate aging. Late-in-life decline in function after early neuronal injury occurs in multiple sclerosis due to dysregulated inflammation and postpolio syndrome. Recent studies by our group in mice have also demonstrated the possibility of partial reversal of cellular aging and the potential to mitigate anatomical damage after injury and even improve visual function.

RESULTS

The results in mice and nonhuman primates published elsewhere have shown enhanced neuronal survival and visual function after partial epigenetic reprogramming.

CONCLUSIONS

Injury promotes epigenetic aging , and this finding can be observed in several clinically relevant scenarios. An understanding of the epigenetic mechanisms at play opens the opportunity to restore function in the nervous system and elsewhere with cellular rejuvenation therapies. Our earlier cases exemplify how reconsideration of previously established concepts can motivate inquiry of new paradigms.

Post-Viral Pain, Fatigue, and Sleep Disturbance Syndromes: Current Knowledge and Future Directions

Background

Post-viral pain syndrome, also known as post-viral syndrome, is a complex condition characterized by persistent pain, fatigue, musculoskeletal pain, neuropathic pain, neurocognitive difficulties, and sleep disturbances that can occur after an individual has recovered from a viral infection.

Aims

This narrative review provides a summary of the sequelae of post-viral syndromes, viral agents that cause it, and the pathophysiology, treatment, and future considerations for research and targeted therapies.

Methods

Medline, PubMed, and Embase databases were used to search for studies on viruses associated with post-viral syndrome.

Conclusion

Much remains unknown regarding the pathophysiology of post-viral syndromes, and few studies have provided a comprehensive summary of the condition, agents that cause it, and successful treatment modalities. With the COVID-19 pandemic continuing to affect millions of people worldwide, the need for an understanding of the etiology of post-viral illness and how to help individuals cope with the sequalae is paramount.

The involvement of language-associated networks, tracts, and cortical regions in frontotemporal dementia and amyotrophic lateral sclerosis: Structural and functional alterations

BACKGROUND

Language deficits are cardinal manifestations of some frontotemporal dementia (FTD) phenotypes and also increasingly recognized in sporadic and familial amyotrophic lateral sclerosis (ALS). They have considerable social and quality-of-life implications, and adaptive strategies are challenging to implement. While the neuropsychological profiles of ALS-FTD phenotypes are well characterized, the neuronal underpinnings of language deficits are less well studied.

METHODS

A multiparametric, quantitative neuroimaging study was conducted to characterize the involvement of language-associated networks, tracts, and cortical regions with a panel of structural, diffusivity, and functional magnetic resonance imaging (MRI) metrics. Seven study groups were evaluated along the ALS-FTD spectrum: healthy controls (HC), individuals with ALS without cognitive impairment (ALSnci), C9orf72-negative ALS-FTD, C9orf72-positive ALS-FTD, behavioral-variant FTD (bvFTD), nonfluent variant primary progressive aphasia (nfvPPA), and semantic variant PPA (svPPA). The integrity of the Broca's area, Wernicke's area, frontal aslant tract (FAT), arcuate fascicle (AF), inferior occipitofrontal fascicle (IFO), inferior longitudinal fascicle (ILF), superior longitudinal fascicle (SLF), and uncinate fascicle (UF) was quantitatively evaluated. The functional connectivity (FC) between Broca's and Wernicke' areas and FC along the FAT was also specifically assessed.

RESULTS

Patients with nfvPPA and svPPA exhibit distinctive patterns of gray and white matter degeneration in language-associated brain regions. Individuals with bvFTD exhibit Broca's area, right FAT, right IFO, and UF degeneration. The ALSnci group exhibits Broca's area atrophy and decreased FC along the FAT. Both ALS-FTD cohorts, irrespective of C9orf72 status, show bilateral FAT, AF, and IFO pathology. Interestingly, only C9orf72-negative ALS-FTD patients exhibit bilateral uncinate and right ILF involvement, while C9orf72-positive ALS-FTD patients do not.

CONCLUSIONS

Language-associated tracts and networks are not only affected in language-variant FTD phenotypes but also in ALS and bvFTD. Language domains should be routinely assessed in ALS irrespective of the genotype.

Amyotrophic Lateral Sclerosis and Other Motor Neuron Diseases

OBJECTIVE

This article reviews the clinical spectrum of amyotrophic lateral sclerosis (ALS), its variant presentations, and the approach to diagnosis and management. This review includes a detailed discussion of current and emerging disease-modifying therapies and the management of respiratory and bulbar manifestations of disease. An updated review of ALS genetics and pathophysiology is also provided. This article also touches on several other important motor neuron diseases.

LATEST DEVELOPMENTS

A new set of simplified diagnostic criteria may help identify patients at earlier stages of the disease. A coformulation of sodium phenylbutyrate and tauroursodeoxycholic acid has been shown to have a significant benefit on disease progression and survival, leading to approval by regulatory authorities in the United States and Canada. An oral formulation of edaravone and an antisense oligonucleotide to a SOD1 gene variation (tofersen) have also recently been approved by the US Food and Drug Administration (FDA). Phase 3 trials of intrathecal mesenchymal stem cells failed to meet primary end points for efficacy. Updated American Academy of Neurology quality measures for the care of patients with ALS were published in 2023.

ESSENTIAL POINTS

There has been continued progress in ALS genetics, diagnosis, and disease-modifying therapies. However, we still lack a definitive biomarker or a treatment that can halt the progression or reverse the course of disease. The evolving understanding of the genetic and pathophysiologic underpinnings of disease offers promise for more effective and clinically meaningful treatments in the future.

Radiological correlates of pseudobulbar affect: Corticobulbar and cerebellar components in primary lateral sclerosis

INTRODUCTION

Pseudobulbar affect (PBA) is a distressing symptom of a multitude of neurological conditions affecting patients with a rage of neuroinflammatory, neurovascular and neurodegenerative conditions. It manifests in disproportionate emotional responses to minimal or no contextual stimulus. It has considerable quality of life implications and treatment can be challenging.

METHODS

A prospective multimodal neuroimaging study was conducted to explore the neuroanatomical underpinnings of PBA in patients with primary lateral sclerosis (PLS). All participants underwent whole genome sequencing and screening for C9orf72 hexanucleotide repeat expansions, a comprehensive neurological assessment, neuropsychological screening (ECAS, HADS, FrSBe) and PBA was evaluated by the emotional lability questionnaire. Structural, diffusivity and functional MRI data were systematically evaluated in whole-brain (WB) data-driven and region of interest (ROI) hypothesis-driven analyses. In ROI analyses, functional and structural corticobulbar connectivity and cerebello-medullary connectivity alterations were evaluated separately.

RESULTS

Our data-driven whole-brain analyses revealed associations between PBA and white matter degeneration in descending corticobulbar as well as in commissural tracts. In our hypothesis-driven analyses, PBA was associated with increased right corticobulbar tract RD (p = 0.006) and decreased FA (p = 0.026). The left-hemispheric corticobulbar tract, as well as functional connectivity, showed similar tendencies. While uncorrected p-maps revealed both voxelwise and ROI trends for associations between PBA and cerebellar measures, these did not reach significance to unequivocally support the "cerebellar hypothesis".

CONCLUSIONS

Our data confirm associations between cortex-brainstem disconnection and the clinical severity of PBA. While our findings may be disease-specific, they are consistent with the classical cortico-medullary model of pseudobulbar affect.

Ovalbumin-specific CD4+ and CD8+ T cells contribute to different susceptibility for Theiler's murine encephalomyelitis virus persistence

Theiler's murine encephalomyelitis virus (TMEV) is the causative agent of TMEV-induced demyelinating disease (TMEV-IDD); a well-established animal model for the chronic progressive form of human multiple sclerosis (MS). In susceptible mice with an inadequate immune response, TMEV-IDD is triggered by virus persistence and maintained by a T cell mediated immunopathology. OT-mice are bred on a TMEV-resistant C57BL/6 background and own predominantly chicken ovalbumin (OVA)-specific populations of CD8⁺ T cells (OT-I) or CD4⁺ T cells (OT-II), respectively. It is hypothesized that the lack of antigen specific T cell populations increases susceptibility for a TMEV-infection in OT-mice on a TMEV-resistant C57BL/6 background. OT-I, OT-II, and C57BL/6 control mice were infected intracerebrally with the TMEV-BeAn strain. Mice were scored weekly for clinical disease and after necropsy, histological and immunohistochemical evaluation was performed. OT-I mice started to develop progressive motor dysfunction between 7 and 21 days post infection (dpi), leading up to hind limb paresis and critical weight loss, which resulted in euthanasia for humane reasons between 14 and 35 dpi. OT-I mice displayed a high cerebral virus load, an almost complete absence of CD8⁺ T cells from the central nervous system (CNS) and a significantly diminished CD4⁺ T cell response. Contrarily, only 60% (12 of 20) of infected OT-II mice developed clinical disease characterized by mild ataxia. 25% of clinically affected OT-II mice (3 of 12) made a full recovery. 5 of 12 OT-II mice with clinical disease developed severe motor dysfunction similar to OT-I mice and were euthanized for humane reasons between 13 and 37 dpi. OT-II mice displayed only low virus-immunoreactivity, but clinical disease correlated well with severely reduced infiltration of CD8⁺ T cells and the increased presence of CD4⁺ T cells in the brains of OT-II mice. Though further studies are needed to reveal the underlying pathomechanisms following TMEV infection in OT mice, findings indicate an immunopathological process as a main contributor to clinical disease in OT-II mice, while a direct virus-associated pathology may be the main contributor to clinical disease in TMEV-infected OT-I mice.

The Fight against Poliovirus Is Not Over

Poliovirus (PV), the virus that causes both acute poliomyelitis and post-polio syndrome, is classified within the Enterovirus C species, and there are three wild PV serotypes: WPV1, WPV2 and WPV3. The launch of the Global Polio Eradication Initiative (GPEI) in 1988 eradicated two of the three serotypes of WPV (WPV2 and WPV3). However, the endemic transmission of WPV1 persists in Afghanistan and Pakistan in 2022. There are cases of paralytic polio due to the loss of viral attenuation in the oral poliovirus vaccine (OPV), known as vaccine-derived poliovirus (VDPV). Between January 2021 and May 2023, a total of 2141 circulating VDPV (cVDPV) cases were reported in 36 countries worldwide. Because of this risk, inactivated poliovirus (IPV) is being used more widely, and attenuated PV2 has been removed from OPV formulations to obtain bivalent OPV (containing only types 1 and 3). In order to avoid the reversion of attenuated OPV strains, the new OPV, which is more stable due to genome-wide modifications, as well as sabin IPV and virus-like particle (VLP) vaccines, is being developed and offers promising solutions for eradicating WP1 and VDPV.

The risk of post-polio syndrome among immigrant groups in Sweden

To examine the risk of post-polio syndrome (PPS) in immigrant groups using native Swedish-born individuals as referents. This is a retrospective study. The study population included all individuals aged 18 years and older registered in Sweden. PPS was defined as having at least one registered diagnosis in the Swedish National Patient Register. The incidence of post-polio in different immigrant groups, using Swedish-born individuals as referents, was assessed by Cox regression, with hazard ratios (HRs) and 99% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, co-morbidities, and neighbourhood socioeconomic status. In total 5300 post-polio cases were registered, 2413 males and 2887 females. Fully adjusted HRs (99% CI) in immigrants versus Swedish-born were 1.77 in men (1.52-2.07) and 1.39 (1.19-1.62) in women. Statistically significant excess risks of post-polio were found in the following subgroups: men and women from Africa, HRs (with 99% CI) 7.40 (5.17-10.59) and 8.39 (5.44-12.95), respectively, and Asia, HRs 6.32 (5.11-7.81) and 4.36 (3.38-5.62) respectively, and in men from Latin America, HR 3.66 (2.17-6.18). It is of importance to be aware of risks of PPS in immigrants settled in Western countries, and that it is more common in immigrants from regions of the world where polio is still prevalent. Patients with PPS need treatment and proper follow-up until polio has been eradicated through global vaccination programs.

The multitaskers of the brain: Glial responses to viral infections and associated post-infectious neurologic sequelae

Many viral infections cause acute and chronic neurologic diseases which can lead to degeneration of cortical functions. While neurotropic viruses that gain access to the central nervous system (CNS) may induce brain injury directly via infection of neurons or their supporting cells, they also alter brain function via indirect neuroimmune mechanisms that may disrupt the blood-brain barrier (BBB), eliminate synapses, and generate neurotoxic astrocytes and microglia that prevent recovery of neuronal circuits. Non-neuroinvasive, neurovirulent viruses may also trigger aberrant responses in glial cells, including those that interfere with motor and sensory behaviors, encoding of memories and executive function. Increasing evidence from human and animal studies indicate that neuroprotective antiviral responses that amplify levels of innate immune molecules dysregulate normal neuroimmune processes, even in the absence of neuroinvasion, which may persist after virus is cleared. In this review, we discuss how select emerging and re-emerging RNA viruses induce neuroimmunologic responses that lead to dysfunction of higher order processes including visuospatial recognition, learning and memory, and motor control. Identifying therapeutic targets that return the neuroimmune system to homeostasis is critical for preventing virus-induced neurodegenerative disorders.

Transferencia del flexor hallucis longus en un paciente con síndrome pospoliomielítico con déficit de la función del tendón tibial posterior. Reporte de un caso y técnica quirúrgica

El síndrome pospoliomielítico con déficit de la función del tendón tibial posterior puede presentarse con un pie equino flexible y marcha equina (steppage) en algunos pacientes. Se describe el caso de una paciente que solo conservaba la función muscular del tendón flexor hallucis longus y se decidió su transferencia al mediopié para obtener un pie plantígrado y restaurar la dorsiflexión.

Thalamic pathology in frontotemporal dementia: Predilection for specific nuclei, phenotype-specific signatures, clinical correlates, and practical relevance

BACKGROUND

Frontotemporal dementia (FTD) phenotypes are classically associated with distinctive cortical atrophy patterns and regional hypometabolism. However, the spectrum of cognitive and behavioral manifestations in FTD arises from multisynaptic network dysfunction. The thalamus is a key hub of several corticobasal and corticocortical circuits. The main circuits relayed via the thalamic nuclei include the dorsolateral prefrontal circuit, the anterior cingulate circuit, and the orbitofrontal circuit.

METHODS

In this paper, we have reviewed evidence for thalamic pathology in FTD based on radiological and postmortem studies. Original research papers were systematically reviewed for preferential involvement of specific thalamic regions, for phenotype-associated thalamic disease burden patterns, characteristic longitudinal changes, and genotype-associated thalamic signatures. Moreover, evidence for presymptomatic thalamic pathology was also reviewed. Identified papers were systematically scrutinized for imaging methods, cohort sizes, clinical profiles, clinicoradiological associations, and main anatomical findings. The findings of individual research papers were amalgamated for consensus observations and their study designs further evaluated for stereotyped shortcomings. Based on the limitations of existing studies and conflicting reports in low-incidence FTD variants, we sought to outline future research directions and pressing research priorities.

RESULTS

FTD is associated with focal thalamic degeneration. Phenotype-specific thalamic traits mirror established cortical vulnerability patterns. Thalamic nuclei mediating behavioral and language functions are preferentially involved. Given the compelling evidence for considerable thalamic disease burden early in the course of most FTD subtypes, we also reflect on the practical relevance, diagnostic role, prognostic significance, and monitoring potential of thalamic metrics in FTD.

CONCLUSIONS

Cardinal manifestations of FTD phenotypes are likely to stem from thalamocortical circuitry dysfunction and are not exclusively driven by focal cortical changes.

Energy conservation, minimum steps, and adaptations when needed: A scoping review

Background/objective

Although many therapeutic approaches use energy conservation, only a few effectively report the steps involved. Thus, it is intended to identify energy conservation practices to be organized in flexible and adaptable stages.

Methods

A scoping review was carried out, whose search strategies were applied in seven databases (CINAHL, Cochrane Library, Portal BVS, PsycINFO, PubMed, Scopus, and Web of Science) following guidelines by Arksey and O’Malley on the Rayyan software. Searches were carried out from January 2010 to December 2020. Inclusion of refered publications with different study designs, participation of adults with or by demands of energy conservation, joint protection, and control of fatigue and/or pain. Exclusion of productions without an occupational therapist or involving merely pharmacological or surgical therapeutic strategies.

Results

653 articles were identified, after the selection and eligibility steps, 30 articles were full review, 18 articles were included and 635 excluded. Energy conservation studies have been increasingly focusing on neurological and systemic diseases, especially regarding symptoms of fatigue and pain. The findings were arranged in six strategies whose interventions are essentially based on guidelines and setting goals for patients, client-centered approach. Merely supervised interventions are less frequent. The number of sessions is closed, but the duration of treatment is not yet.

Conclusions

The signs of pain and fatigue are confirmed as indicators of energy conservation strategies, this delivery can be condensed from planning and organization, priorities, activity analysis, balance between activity and rest, outsourcing of tasks and physical/environmental adaptation.

Trial Registration, OSF

https://osf.io/rsyq4.

Post-Polio Syndrome in a Primary Care Setting: A Case Report

Post-Polio Syndrome (PPS) is a sequela of poliovirus infection that causes weakness in previously infected polio patients years after the initial infection. The diagnosis is one of exclusion and entails the following: 1) a prior episode of poliomyelitis with residual motor neuron function loss, 2) a period of at least 15 years or more after the acute onset of polio with neurologic and functional stability, and 3) a gradual onset of new weakness and abnormal muscle fatigability that has persisted for at least one year. While the exact etiology is unknown, the prevalence of PPS has increased as patients who have previously survived polio are getting older. In this report, we discuss a patient presenting to his primary care provider for evaluation of worsening lower extremity weakness over the course of the past three years. In addition to general characteristics of PPS, we will review the use of electromyography (EMG)/nerve conduction studies and imaging for evaluation. This report will also review prevention methods with vaccinations and identify potential treatment regimens including aerobic exercise and medications ranging from tricyclic antidepressants (TCAs) to dopamine agonists. The goal of this paper is to not only shine a light on PPS in general, but to show how social determinants i.e., economic stability, healthcare access and quality of health may affect the diagnosis of uncommon conditions.

Changes in neuromuscular function in elders: Novel techniques for assessment of motor unit loss and motor unit remodeling with aging

Functional muscle fiber denervation is a major contributor to the decline in physical function observed with aging and is now a recognized cause of sarcopenia, a muscle disorder characterized by progressive and generalized degenerative loss of skeletal muscle mass, quality, and strength. There is an interrelationship between muscle strength, motor unit (MU) number, and aging, which suggests that a portion of muscle weakness in seniors may be attributable to the loss of functional MUs. During normal aging, there is a time-related progression of MU loss, an adaptive sprouting followed by a maladaptive sprouting, and continuing recession of terminal Schwann cells leading to a reduced capacity for compensatory reinnervation in elders. In amyotrophic lateral sclerosis, increasing age at onset predicts worse survival ALS and it is possible that age-related depletion of the motor neuron pool may worsen motor neuron disease. MUNE methods are used to estimate the number of functional MU, data from MUNIX arguing for motor neuron loss with aging will be reviewed. Recently, a new MRI technique MU-MRI could be used to assess the MU recruitment or explore the activity of a single MU. This review presents published studies on the changes of neuromuscular function with aging, then focusing on these two novel techniques for assessment of MU loss and MU remodeling.

Is post-COVID syndrome an autoimmune disease?

INTRODUCTION

: Coronavirus disease 2019 (COVID-19) causes a long-term and persistent condition with clinical features similar to previous virulent outbreaks and other epidemics. Currently, post-COVID syndrome (PCS) is recognized as a new entity in the context of SARS-CoV-2 infection. Though its pathogenesis is not completely understood, persistent inflammation from acute illness and the development of autoimmunity play a critical role in its development. As the pandemic develops, the increasing latent and overt autoimmunity cases indicate that PCS is at the intersection of autoimmunity.

AREAS COVERED

The mechanisms involved in the emergence of PCS, their similarities with post-viral and post-care syndromes, its inclusion in the spectrum of autoimmunity and possible targets for its treatment.

EXPERT OPINION

An autoimmune phenomenon plays a major role in most causative theories explaining PCS. Due to the wide scope of symptoms and pathophysiology associated with PCS, there is a need for both PCS definition and classification criteria (including severity scores). Longitudinal and controlled studies are necessary to better understand this new entity, and to confirm that PCS is the chronic phase of COVID-19 as well as to find what additional factors participate into its development. With the high prevalence of COVID-19 cases worldwide, together with the current evidence on latent autoimmunity in PCS, we may observe an increase of autoimmune diseases (ADs) in the coming years. Vaccination's effect on the development of PCS and ADs will also receive attention in the future. Health and social care services need to develop a new framework to deal with PCS.

Why does viral RNA sometimes persist after recovery from acute infections?

DNA viruses often persist in the body of their host, becoming latent and recurring many months or years later. By contrast, most RNA viruses cause acute infections that are cleared from the host as they lack the mechanisms to persist. However, it is becoming clear that viral RNA can persist after clinical recovery and elimination of detectable infectious virus. This persistence can either be asymptomatic or associated with late progressive disease or nonspecific lingering symptoms, such as may be the case following infection with Ebola or Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Why does viral RNA sometimes persist after recovery from an acute infection? Where does the RNA come from? And what are the consequences?

Unexplained post-acute infection syndromes

SARS-CoV-2 is not unique in its ability to cause post-acute sequelae; certain acute infections have long been associated with an unexplained chronic disability in a minority of patients. These post-acute infection syndromes (PAISs) represent a substantial healthcare burden, but there is a lack of understanding of the underlying mechanisms, representing a significant blind spot in the field of medicine. The relatively similar symptom profiles of individual PAISs, irrespective of the infectious agent, as well as the overlap of clinical features with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), suggest the potential involvement of a common etiopathogenesis. In this Review, we summarize what is known about unexplained PAISs, provide context for post-acute sequelae of SARS-CoV-2 infection (PASC), and delineate the need for basic biomedical research into the underlying mechanisms behind this group of enigmatic chronic illnesses.

Long-term outcomes of pediatric infections: from traditional infectious diseases to long Covid

There is limited evidence available on the long-term impact of SARS-CoV-2 infection in children. In this article, the authors analyze the recent evidence on pediatric long Covid and lessons learnt from a pediatric post-Covid unit in Rome, Italy. To gain a better understanding of the concerns raised by parents and physicians in relation to the potential long-term consequences of this novel infection, it is important to recognize that long-term effect of a post-infectious disease is not a new phenomenon.

Is Poliomyelitis Sequelae A Disadvantage for Recovery from Covid-19 ARDS: A Case Report

We present a case with acute respiratory distress syndrome due to COVID-19 who had poliomyelitis sequelae. He was hospitalized in the intensive care unit and supported by non-invasive mechanical ventilation for 7 days. IL-6 inhibitor was administered due to cytokine storm. No steroid or sedative agents were administered. Early mobilization was performed in the intensive care unit. One month after discharge, physical examination revealed COVID-19 infection did not cause significant changes in muscle strength and physical performance in this patient with poliomyelitis sequelae. It is important to promote early mobilization in the intensive care unit to prevent post-intensive care syndrome in COVID-19 acute respiratory distress syndrome.

Clusters of anatomical disease-burden patterns in ALS: a data-driven approach confirms radiological subtypes

Amyotrophic lateral sclerosis (ALS) is associated with considerable clinical heterogeneity spanning from diverse disability profiles, differences in UMN/LMN involvement, divergent progression rates, to variability in frontotemporal dysfunction. A multitude of classification frameworks and staging systems have been proposed based on clinical and neuropsychological characteristics, but disease subtypes are seldom defined based on anatomical patterns of disease burden without a prior clinical stratification. A prospective research study was conducted with a uniform imaging protocol to ascertain disease subtypes based on preferential cerebral involvement. Fifteen brain regions were systematically evaluated in each participant based on a comprehensive panel of cortical, subcortical and white matter integrity metrics. Using min–max scaled composite regional integrity scores, a two-step cluster analysis was conducted. Two radiological clusters were identified; 35.5% of patients belonging to ‘Cluster 1’ and 64.5% of patients segregating to ‘Cluster 2’. Subjects in Cluster 1 exhibited marked frontotemporal change. Predictor ranking revealed the following hierarchy of anatomical regions in decreasing importance: superior lateral temporal, inferior frontal, superior frontal, parietal, limbic, mesial inferior temporal, peri-Sylvian, subcortical, long association fibres, commissural, occipital, ‘sensory’, ‘motor’, cerebellum, and brainstem. While the majority of imaging studies first stratify patients based on clinical criteria or genetic profiles to describe phenotype- and genotype-associated imaging signatures, a data-driven approach may identify distinct disease subtypes without a priori patient categorisation. Our study illustrates that large radiology datasets may be potentially utilised to uncover disease subtypes associated with unique genetic, clinical or prognostic profiles.

The effect of adding whole-body vibration exercises to home exercise program on muscle strength in patients with post-polio syndrome

Objectives

This study aims to understand the effectiveness of whole-body vibration (WBV) exercises performed with home exercise program in patients with post-polio syndrome (PPS) in terms of muscle strength, fatigue, the quality of life, and laboratory parameters.

Patients and methods

Between October 2015 and March 2016, a total of 14 patients (7 males, 7 females; mean age: 45.1±6.6 years; range, 34 to 57 years) who were diagnosed with PPS were included in the study. The patients were randomized into two groups: the first group received WBV, home exercise program and patient education while the second (control) group received home exercise program and patient education. The patients were evaluated by knee isometric and isokinetic peak torque, Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS), Nottingham Health Profile (NHP), serum creatine kinase, aspartate aminotransferase, and alanine aminotransferase at baseline and at the end of the treatment.

Results

At the end of the treatment, the exercise program administered to the patients was found to be effective in increasing knee muscle strength in PPS patients (p<0.05). This difference was more apparent on the sequela side, isometric extension peak torque in the group with WBV. There was no significant change in the markers of muscle damage or NHP in both groups.

Conclusion

Inclusion of WBV in home exercise program in PPS patients does not seem to be superior, except for reducing the effect of fatigue on the patient's life.

Phenotypic categorisation of individual subjects with motor neuron disease based on radiological disease burden patterns: A machine-learning approach

Motor neuron disease is an umbrella term encompassing a multitude of clinically heterogeneous phenotypes. The early and accurate categorisation of patients is hugely important, as MND phenotypes are associated with markedly different prognoses, progression rates, care needs and benefit from divergent management strategies. The categorisation of patients shortly after symptom onset is challenging, and often lengthy clinical monitoring is needed to assign patients to the appropriate phenotypic subgroup. In this study, a multi-class machine-learning strategy was implemented to classify 300 patients based on their radiological profile into diagnostic labels along the UMN-LMN spectrum. A comprehensive panel of cortical thickness measures, subcortical grey matter variables, and white matter integrity metrics were evaluated in a multilayer perceptron (MLP) model. Additional exploratory analyses were also carried out using discriminant function analyses (DFA). Excellent classification accuracy was achieved for amyotrophic lateral sclerosis in the testing cohort (93.7%) using the MLP model, but poor diagnostic accuracy was detected for primary lateral sclerosis (43.8%) and poliomyelitis survivors (60%). Feature importance analyses highlighted the relevance of white matter diffusivity metrics and the evaluation of cerebellar indices, cingulate measures and thalamic radiation variables to discriminate MND phenotypes. Our data suggest that radiological data from single patients may be meaningfully interpreted if large training data sets are available and the provision of diagnostic probability outcomes may be clinically useful in patients with short symptom duration. The computational interpretation of multimodal radiology datasets herald viable diagnostic, prognostic and clinical trial applications.

Non-infectious mechanisms of neurological damage due to infection

Infections of the nervous system is a growing aspect of clinical neurology. Accumulating knowledge in early diagnosis, course, therapy and prognosis is enlarging the clinical tools required for effective therapy. Of special importance is the ability to differentiate between proper infections, where anti-microbial agents, when available, should be introduced and used and post infectious conditions where therapy is mainly directed against the host immune system. The two conditions sometimes overlap, a situation that requires the ability to combine clinical skills with the use of laboratory tools such as polymerase chain reaction (PCR), serology, and antigenic detection. In the era of the SARS-CoV-2 pandemic, the need to make this distinction is emphasized as correct diagnosis of post infectious conditions and expedited therapy is important and sometimes lifesaving. We here attempt to present several infectious agents and their possible indirect damage to the nervous system causing in some cases significant neurological deficits. We try to limit our focus on those mechanisms which do not involve the direct tissue damage by the infectious agents but rather are connected to para- and post-infectious mechanisms. We attempt to delineate the features that will enable to tailor the correct diagnosis and following the effective therapy.

Imaging data reveal divergent longitudinal trajectories in PLS, ALS and poliomyelitis survivors: Group-level and single-subject traits

Imaging profiles from a longitudinal single-centre motor neuron disease study are presented. A standardized T1-weighted MRI protocol was implemented to characterise cortical disease burden trajectories across the UMN (upper motor neuron) - LMN (lower motor neuron) spectrum of motor neuron diseases (MNDs) (Tahedl et al., 2021). Patients with amyotrophic lateral sclerosis (ALS n = 61), patients with primary lateral sclerosis (PLS n = 23) and poliomyelitis survivors (PMS n = 45) were included. Up to four longitudinal scans were available for each patient, separated by an inter-scan-interval of four months. Individual and group-level cortical thickness profiles were appraised using a normalisation procedure with reference to subject-specific control groups. A z-scoring approach was utilised, where each patients' cortex was first segmented into 1000 cortical regions, and then rated as 'thin', 'thick', or 'comparable' to the corresponding region of a demographically-matched control cohort. Fractions of significantly 'thin' and 'thick' patches were calculated across the entire cerebral vertex as well as in specific brain regions, such as the motor cortex, parietal, frontal and temporal cortices. This approach allows the characterisation of disease burden in individual subjects as well as at a group-level, both cross-sectionally and longitudinally. The presented framework may aid the interpretation of individual cortical disease burden in other patient cohorts.

Extra-motor manifestations in post-polio syndrome (PPS): fatigue, cognitive symptoms and radiological features

BACKGROUND

There is a paucity of cerebral neuroimaging studies in post-polio syndrome (PPS), despite the severity of neurological and neuropsychological sequelae associated with the condition. Fatigue, poor concentration, limited exercise tolerance, paraesthesia and progressive weakness are frequently reported, but the radiological underpinnings of these symptoms are poorly characterised.

OBJECTIVE

The aim of this study is to evaluate cortical and subcortical alterations in a cohort of adult polio survivors to explore the anatomical substrate of extra-motor manifestations.

METHODS

Thirty-six patients with post-polio syndrome, a disease-control group with amyotrophic lateral sclerosis patients and a cohort of healthy individuals were included in a prospective neuroimaging study with a standardised clinical and radiological protocol. Validated clinical instruments were utilised to assess mood, cognitive and behavioural domains and specific aspects of fatigue. Cortical thickness analyses, subcortical volumetry, brainstem segmentation and region-of-interest (ROI) white matter analyses were undertaken to assess regional grey and white matter alterations.

RESULTS

A high proportion of PPS patients exhibited apathy, verbal fluency deficits and reported self-perceived fatigue. On ROI analyses, cortical atrophy was limited to the cingulate gyrus, and the temporal pole and subcortical atrophy were only detected in the left nucleus accumbens. No FA reductions were noted to indicate white matter degeneration in any of the lobes.

CONCLUSIONS

Despite the high incidence of extra-motor manifestations in PPS, only limited cortical, subcortical and white matter degeneration was identified. Our findings suggest that non-structural causes, such as polypharmacy and poor sleep, may contribute to the complex symptomatology of post-polio syndrome.

Propagation patterns in motor neuron diseases: Individual and phenotype-associated disease-burden trajectories across the UMN-LMN spectrum of MNDs

Motor neuron diseases encompass a divergent group of conditions with considerable differences in clinical manifestations, survival, and genetic vulnerability. One of the key aspects of clinical heterogeneity is the preferential involvement of upper (UMN) and lower motor neurons (LMN). While longitudinal imaging patters are relatively well characterized in ALS, progressive cortical changes in UMN,- and LMN-predominant conditions are seldom evaluated. Accordingly, the objective of this study is the juxtaposition of longitudinal trajectories in 3 motor neuron phenotypes; a UMN-predominant syndrome (PLS), a mixed UMN-LMN condition (ALS), and a lower motor neuron condition (poliomyelitis survivors). A standardized imaging protocol was implemented in a prospective, multi-timepoint longitudinal study with a uniform follow-up interval of 4 months. Forty-five poliomyelitis survivors, 61 patients with amyotrophic lateral sclerosis (ALS), and 23 patients with primary lateral sclerosis (PLS) were included. Cortical thickness alterations were evaluated in a dual analysis pipeline, using standard cortical thickness analyses, and a z-score-based individualized approach. Our results indicate that PLS patients exhibit rapidly progressive cortical thinning primarily in motor regions; ALS patients show cortical atrophy in both motor and extra-motor regions, while poliomyelitis survivors exhibit cortical thickness gains in a number of cerebral regions. Our findings suggest that dynamic cortical changes in motor neuron diseases may depend on relative UMN and/or LMN involvement, and increased cortical thickness in LMN-predominant conditions may represent compensatory, adaptive processes.

Advancing therapies for viral infections using mechanistic computational models of the dynamic interplay between the virus and host immune response

The COVID-19 pandemic has highlighted a need for improved frameworks for drug discovery, repurposing, clinical trial design and therapy optimization and personalization. Mechanistic computational models can play an important role in developing these frameworks. We discuss how mechanistic models, which consider viral entry, replication in target cells, viral spread in the body, immune response, and the complex factors involved in tissue and organ damage and recovery, can clarify the mechanisms of humoral and cellular immune responses to the virus, viral distribution and replication in tissues, the origins of pathogenesis and patient-to-patient heterogeneity in responses. These models are already improving our understanding of the mechanisms of action of antivirals and immune modulators. We discuss how closer collaboration between the experimentalists, clinicians and modelers could result in more predictive models which may guide therapies for viral infections, improving survival and leading to faster and more complete recovery.

Pathological neural networks and artificial neural networks in ALS: diagnostic classification based on pathognomonic neuroimaging features

The description of group-level, genotype- and phenotype-associated imaging traits is academically important, but the practical demands of clinical neurology centre on the accurate classification of individual patients into clinically relevant diagnostic, prognostic and phenotypic categories. Similarly, pharmaceutical trials require the precision stratification of participants based on quantitative measures. A single-centre study was conducted with a uniform imaging protocol to test the accuracy of an artificial neural network classification scheme on a cohort of 378 participants composed of patients with ALS, healthy subjects and disease controls. A comprehensive panel of cerebral volumetric measures, cortical indices and white matter integrity values were systematically retrieved from each participant and fed into a multilayer perceptron model. Data were partitioned into training and testing and receiver-operating characteristic curves were generated for the three study-groups. Area under the curve values were 0.930 for patients with ALS, 0.958 for disease controls, and 0.931 for healthy controls relying on all input imaging variables. The ranking of variables by classification importance revealed that white matter metrics were far more relevant than grey matter indices to classify single subjects. The model was further tested in a subset of patients scanned within 6 weeks of their diagnosis and an AUC of 0.915 was achieved. Our study indicates that individual subjects may be accurately categorised into diagnostic groups in an observer-independent classification framework based on multiparametric, spatially registered radiology data. The development and validation of viable computational models to interpret single imaging datasets are urgently required for a variety of clinical and clinical trial applications.

Risk factors for functional deterioration in a cohort with late effects of poliomyelitis: A ten-year follow-up study

BACKGROUND

More than 7000 patients developed poliomyelitis during the main epidemic in the fifties in Israel. In recent years, there is a further deterioration in their condition due to accelerated aging process and post-polio syndrome.

OBJECTIVE

To evaluate the risk factors for the progression of functional status in a cohort of patients with late effect of poliomyelitis over a period of ten years.

METHODS

A cross-sectional cohort study including 82 individuals with late effect of poliomyelitis evaluated over ten years. Mean age was 67±8.5 years, 52.4%were men and 79.3%were Jewish. Functional status was evaluated by activities of daily living (ADL) questionnaire. Risk factors, including general comorbidities, history of poliomyelitis infection, use of assistive devices, employment, and physical activity statuses were evaluated using specific questionnaires.

RESULTS

Independence in ADL functions deteriorated significantly over ten years. Older age, ethnicity, use of a wheelchair, and use of orthotic devices in childhood were risk factors for deterioration in ADL function. No correlation was found between the presence of other comorbidities or poliomyelitis parameters and worsening of ADL functions.

CONCLUSIONS

Late effect of poliomyelitis was associated with deterioration in ADL functions probably due to the combined effect of the initial severity of the paralytic poliomyelitis symptoms and accelerated aging.

[Post-polio Syndrome in the Perioperative Phase]

Due to the numerous poliomyelitis epidemics that have continued over the last decades and the post-polio syndrome (PPS) that occurs 10 - 30 years after poliomyelitis infection, the prevalence of PPS is also expected to increase in Europe. At the same time, due to the musculoskeletal disorders associated with the underlying disease, PPS patients often require surgery for which special anaesthetic requirements must be taken into account. In this analysis we summarise the current evidence and recommendations.

Imaging data indicate cerebral reorganisation in poliomyelitis survivors: Possible compensation for longstanding lower motor neuron pathology

A standardised, single-centre cross-sectional imaging protocol was utilised to investigate cortical grey matter and cerebral white matter alterations in 36 poliomyelitis survivors in contrast to healthy individuals and patients with amyotrophic lateral sclerosis (ALS) as a 'disease-control' group. [1] T1-weighted imaging and 32-direction diffusion tensor imaging data were obtained on a 3 Tesla Philips Achieva MRI system, using an IR-SPGR sequence and SE-EPI sequence respectively. Raw region-of-interest data and percentage change with respect to reference estimated marginal mean values are presented for grey and white matter metrics in key anatomical regions. Poliomyelitis survivors exhibit no frank grey or white matter degeneration. To the contrary, increased partial volumes can be detected in the brainstem, cerebellum and occipital lobes compared to healthy individuals. Higher fractional anisotropy was also noted in the corticospinal tracts, cerebellum, bilateral mesial temporal lobes and inferior frontal brain regions in poliomyelitis survivors in contrast to controls. Anatomical patterns of superior integrity metrics in polio survivors were concordant with anatomical regions of focal degeneration in ALS. Our imaging data indicate cortical and white matter reorganisation in polio survivors, which may be interpreted as compensatory adaptation to severe lower motor neuron injury acquired in infancy.

Not Your Average Mediastinal Mass: A Case of a Large Mediastinal Teratoma in a Patient With a History of Polio Disease

Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease.

Evaluation and categorisation of individual patients based on white matter profiles: Single-patient diffusion data interpretation in neurodegeneration

The majority of radiology studies in neurodegenerative conditions infer group-level imaging traits from group comparisons. While this strategy is helpful to define phenotype-specific imaging signatures for academic use, the meaningful interpretation of single scans of individual subjects is more important in everyday clinical practice. Accordingly, we present a computational method to evaluate individual subject diffusion tensor data to highlight white matter integrity alterations. Fifty white matter tracts were quantitatively evaluated in 132 patients with amyotrophic lateral sclerosis (ALS) with respect to normative values from 100 healthy subjects. Fractional anisotropy and radial diffusivity alterations were assessed individually in each patient. The approach was validated against standard tract-based spatial statistics and further scrutinised by the assessment of 78 additional data sets with a blinded diagnosis. Our z-score-based approach readily detected white matter degeneration in individual ALS patients and helped to categorise single subjects with a 'blinded diagnosis' as likely 'ALS' or 'control'. The group-level inferences from the z-score-based approach were analogous to the standard TBSS output maps. The benefit of the z-score-based strategy is that it enables the interpretation of single DTI datasets as well as the comparison of study groups. Outputs can be summarised either visually by highlighting the affected tracts, or, listing the affected tracts in a text file with reference to normative data, making it particularly useful for clinical applications. While individual diffusion data cannot be visually appraised, our approach provides a viable framework for single-subject imaging data interpretation.

Palliative Care for Polio and Postpolio Syndrome

Palliative care is a team-based approach focusing on relief of physical, psychosocial, and existential distress and communication about serious illness. Patients with poliomyelitis and postpolio syndrome are at risk for contractures and can benefit from involvement of physical and occupational therapy. Hypersialorrhea can be treated with anticholinergic medications, botox, or radiation. Patients with dyspnea may require noninvasive positive pressure ventilation ± opioids or benzodiazepines. Constipation is often due to autonomic dysfunction and decreased mobility. There is a higher burden of anxiety. Early conversations about patients' goals and values as it relates to their health may help frame future decision-making.

Joint and Back Pain: Medications and Role of Injection Therapy for Destructive Joint

Postpolio syndrome (PPS) is a sequela with symptoms that often occur in patients who previously survived poliomyelitis. Pain is a characteristic feature of PPS. Although poliomyelitis is no longer commonly seen in the western world, there is a significant portion of patients living with PPS. Recognizing the signs of PPS is integral in developing treatment plans. Conservative management is routinely considered first-line therapy; however, alternate treatments, pharmacologic and minimally invasive, are used in more refractory cases. Approaching patients living with pain and PPS requires a holistic approach and an understanding of the efficacy of available treatment modalities.

Screening for oropharyngeal dysphagia in adult patients with neuromuscular diseases using the Sydney Swallow Questionnaire

INTRODUCTION/AIMS

Oropharyngeal dysphagia is common in patients with neuromuscular diseases (NMDs). Its early recognition is vital for proper management. We tested a large cohort of adult NMD patients for oropharyngeal dysphagia using the Sydney Swallow Questionnaire (SSQ). We also looked for possible differences in characteristics of oropharyngeal dysphagia in various NMD groups and diseases. Finally, we compared results of this screening with those from their corresponding medical records for eventual "clinical history" of dysphagia.

METHODS

We asked patients to fill in the SSQ during follow-up outpatient visits at our neuromuscular reference center. A total score above the cutoff score of 118.5 out of 1700 was indicative of oropharyngeal dysphagia.

RESULTS

Of the 304 adult patients assessed for eligibility, 201 NMD patients (96 women and 105 men, aged 49.0 ± 16.2 years) were included and tested in this study. Oropharyngeal dysphagia was detected in 45% of all the NMD patients when using the SSQ, whereas only 12% had a positive medical record for dysphagia. The median SSQ scores for patients with myotonic syndromes (including myotonic dystrophy type 1), with amyotrophic lateral sclerosis, and with facioscapulohumeral dystrophy were above the cutoff score. The SSQ scores obtained revealed distinct oropharyngeal dysphagia characteristics in the different NMD groups and diseases.

DISCUSSION

The SSQ tests positively for oropharyngeal dysphagia in a higher proportion of NMD patients compared with their medical records. The distinct oropharyngeal dysphagia characteristics we revealed in different NMD groups and diseases may help to elaborate adapted clinical approaches in the management of oropharyngeal dysphagia.

Effects of muscle strengthening and cardiovascular fitness activities for poliomyelitis survivors: A systematic review and meta-analysis

OBJECTIVE

To evaluate and assess the effectiveness of muscle strengthening and cardiovascular interventions in improving outcomes in poliomyelitis (polio) survivors.

DATA SOURCES

A systematic literature search was conducted in Medline, PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar for experimental and observational studies. Study selection and extraction: Screening, data-extraction, risk of bias and quality assessment were carried out independently by the authors. The quality appraisal and risk of bias were assessed using the Downs and Black Checklist. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed to increase clarity of reporting.

DATA SYNTHESIS

A total of 21 studies that met all the inclusion criteria were subjected to statistical analyses according to intervention (muscle strengthening or cardiovascular fitness). A random-effects meta-analysis showed a statistically significant effect for the exercise interventions favouring improvement in outcomes according to the International Classification of Functioning, Disability and Health (ICF).

CONCLUSION

This review provides further insight into the effects associated with muscle strengthening and cardiovascular interventions among polio survivors, and helps to further identify the current state of research in this area. Future research is needed, focusing on individualized approaches to exercise with polio survivors and specific exercise prescription recommendations, based on established frameworks, such as the ICF.