Do people with multiple sclerosis perceive upper limb improvements from robotic-mediated therapy? A mixed methods study

BACKGROUND

Robot-mediated training is increasingly considered as a rehabilitation intervention targeting upper limb disability. However, experiences of such an intervention have been rarely explored in the multiple sclerosis population. This mixed methods study sought to explore the impact of an eight week upper limb robotic intervention on experiences of people with multiple sclerosis.

METHODS

Eleven participants (Median EDSS- score: 6.5) with moderate to severe upper limb impairment, performed eight week robot- mediated training of the most affected arm. The training involved a virtual learning platform called I-TRAVLE with duration of 30 min per training session, twice to three times per week. Two subjective questionnaires with items from the Intrinsic Motivation Inventory (IMI) and Credibility and Expectancy Questionnaire (CEQ) were collected bi-weekly during the intervention. Approximately one month after completing the training, three focus groups were conducted. Main themes were identified using thematic analysis.

RESULTS

Results from the IMI and CEQ indicated high patient satisfaction and expectation that the intervention will be beneficial for them. Two main themes were identified: (1) Effect of the intervention on impairment and activity in that participants felt that there was a positive impact of the training on strength, endurance and during activities of daily living and that it met their expectations; (2) Experiences based on system usage from the system in that participants expressed feelings of motivation and self-improvement. The participants also perceived the training as enjoyable and concluded that the use of games instigated a competitive spirit between the participants.

CONCLUSIONS

Robot-mediated training could have a motivating effect and induce a general positive experience while reducing disabilities of people with multiple sclerosis.

Unusual Combination of Gastrointestinal Pathogens Detected by Multiplex PCR

Introduction/Objective

Infectious gastroenteritis (IGE) is a common but complex entity which is a major cause of global morbidity and mortality. IGE is caused by a wide range of etiologic agents such as viruses, bacteria, and parasites. In the United States there are approximately 373 million of IGE cases per year. Most cases of IGE resolve without identification of a specific pathogen. Multiplex molecular assays allow identification of multiple possible pathogens with rapid turnaround time and increased sensitivity, facilitating to formulate an effective treatment plan and control measures.

Methods/Case Report

We present a case of a pediatric patient with no significant past medical history who has been having runny stools that have progressively worsened in the last 3 months and 2 days history of bloody stools with mucus before emergency room presentation. She had no fever, vomiting, joint pain, oral ulcer, and rash. Physical exam showed that the patient appeared well, nontoxic, and vital signs were within normal limit. Copious rhinorrhea was noted. She was at 50th percentile for age on the growth chart. Family denied any recent travel or sick contacts however stated that all the family members have been on well water. Complete blood count was obtained and showed a platelet count of 669 x 10(3)/mcL and WBC of 16.6 x 10(3)/mcL with differential showing absolute lymphocytosis, absolute monocytosis and absolute eosinophilia. Biofire FilmArray gastrointestinal panel performed on the stool detected Giardia lamblia, Campylobacter, Shiga-like toxin producing E. coli and Adenovirus F 40/41. Repeat of the panel per protocol detected the same four pathogens.

Results (if a Case Study enter NA)

N/A.

Conclusion

This case report highlights the significance of detecting multiple causative pathogens. While long term watery diarrhea may guide clinicians to malabsorptive process and the use of well water to Giardia, a sensitive and specific multiplex assay can detect all the pathogens involved in the disease process and greatly simplify the treatment plan for patients. This unusual combination of pathogens can explain the unique symptomology of the patient including long term watery diarrhea, recent bloody diarrhea as well as copious rhinorrhea and failure to thrive.

Acute polymorphic psychosis: An interesting case report

Introduction

Acute Polymorphic Psychotic Disorder is a psychotic disorder with an acute onset, presenting thought and perception disorders variable into hours. Often, an emotional fluctuation is present and it may have a sudden onset and a rapid remission.

Objectives

The review’s objective is to manifest acute polymorhic psychotic disorders and possible effective medical interventions.

Methods

The current case concerns a 52-year old mother of 4 children with the manifestation of acute polymorphic psychotic disorder with a background of a stressful factor. The patient was involuntarily hospitalized in the Psychiatric Hospital of Thessaloniki from 04/01/ 2019 -21/ 01/2019 due to disorganization and acute confusing condition within the last 9 days. Delusional ideas of religious content were first observed, which alternated with ideas of greatness and then persecution, association and self-denial. She also presented auditory hallucinations while there was a fluctuation of emotion from excessive euphoria to depression. The patient had no previous hospitalization in a psychiatric clinic, however, 7 months ago she experienced another acute psychotic epeisode, while at the age of 17 and under the influence of intense stress, she described mood disorders.

Results

The current symptoms subsided after one week from the day of admission. During her hospitalization, a brain CT was performed without presence of pathological findings. Initially, her medication included i.m. haloperidol 15mg / ml daily, followed by a change to per os paliperidone 9mg daily.

Conclusions

Her mental status was improved, with no disturbances of consciousness noted and she was discharged on paliperidone as home medication.

Disclosure

No significant relationships.

Microbiologic Proof-Of-Concept: A Novel Device Combining UV Light And Ozone For Human Skin Antisepsis

Introduction/Objective

Hand hygiene (HH) decreases healthcare-associated infections (HAI). Available products include alcohol-based gels, foams, wipes, and “gold-standard” hand-washing with soap and water. We tested an investigational device (HyLuxO3; GMI, LLC, patent pending) for antimicrobial effect (AME). HyLuxO3 was engineered to deliver UV-C light energy and high velocity O3 airflow to safely achieve human skin antisepsis within OSHA and EPA regulatory limits. Combined UV and O3 has yet to be evaluated for HH and may demonstrate synergistic AME.

Methods

HyLuxO3 was tested on LB agar to titrate device variables to ascertain intensities for optimal AME; later testing was performed on VITRO-SKIN (Florida Suncare Testing, Bunnell, FL), a human skin surrogate. ATCC strains of MRSA, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Candida albicans were used to test AME vs. vegetative microbes; Bacillus atrophaeus spores were used as a surrogate for C. difficile. Tested variables included time under device, [O3], airflow velocity, 222 and/or 254 nm UV light, sample distance from UV lamp, and UV beam width. Positive controls were used to calculate log-kill curves for AME.

Results

Similar results were seen on LB agar and VITRO-SKIN. >7 log-kill and >5 log-kill were acheived vs. vegetative microbes (<30 sec) and spores (60 sec), respectively, under optimized variables. Presence of UV light and sample distance from and time under the device were the most important variables. 254 nm UV had a significantly better AME than 222 nm; combining both UV lamps had a significant synergistic AME. The narrowest UV beam (2 mm) yielded the greatest AME (total energy input kept constant). Adding O3 to UV had a modest but significant synergistic effect; optimal [O3] was 0.3-0.8 ppm. Changing airflow velocity had no significant effect on AME.

Conclusion

HyLuxO3 is a novel device that achieves >7 log-kill vs. common pathogenic vegetative microbes and >5 log-kill vs. spores using combined UV light and [O3] safe for human skin antisepsis (and surface/fomite decontamination)- and- yields such impressive AME on faster timescales than those required by bleach/other chemical products unsuitable for human skin. Future studies on human hands (using many other microbes) will determine if HyLuxO3 meets regulatory and efficacy requirements for use in and beyond healthcare settings, especially with the specter of emerging respiratory viruses.

Upper Limb Rehabilitation in People With Multiple Sclerosis

Background. There has been an increasing research interest in upper limb rehabilitation in multiple sclerosis (MS). The current changes in the research field inquire a new literature review. Objective. This systematic review aimed to provide an overview of the upper limb rehabilitation strategies in people with MS (PwMS). Methods. Articles published in PubMed and Web of Knowledge were selected when written in English, published in the past 25 years, peer reviewed, that included at least 5 PwMS, and described the effects of an intervention study including rehabilitation strategies targeting the upper limbs. Included articles were screened based on title/abstract and full text by 2 independent reviewers. Results. Thirty articles met the criteria and were included for data extraction. Only half of the included studies investigated the effects of a training program specially targeted toward the upper limbs, while in the other studies, a general whole body therapy was used. The therapy content and dosage varied greatly between the different included studies. Multidisciplinary and robot-based rehabilitation were the most investigated rehabilitation strategies and showed to improve upper limb capacity. Strength and endurance training improved the upper limb body functions and structures but did not influence the upper limb capacity and performance. Conclusions. The results of this systematic review indicated that different types of upper limb rehabilitation strategies can improve upper limb function in PwMS. Further research is necessary to compare directly the effects of different rehabilitation strategies and to investigate the optimal therapy dosage according to the upper limb disability level.

Robot-supported upper limb training in a virtual learning environment : a pilot randomized controlled trial in persons with MS

Background

Despite the functional impact of upper limb dysfunction in multiple sclerosis (MS), effects of intensive exercise programs and specifically robot-supported training have been rarely investigated in persons with advanced MS.

Aim

To investigate the effects of additional robot-supported upper limb training in persons with MS compared to conventional treatment only.

Methods

Seventeen persons with MS (pwMS) (median Expanded Disability Status Scale of 8, range 3.5–8.5) were included in a pilot RCT comparing the effects of additional robot-supported training to conventional treatment only. Additional training consisted of 3 weekly sessions of 30 min interacting with the HapticMaster robot within an individualised virtual learning environment (I-TRAVLE). Clinical measures at body function (Hand grip strength, Motricity Index, Fugl-Meyer) and activity (Action Research Arm test, Motor Activity Log) level were administered before and after an intervention period of 8 weeks. The intervention group were also evaluated on robot-mediated movement tasks in three dimensions, providing active range of motion, movement duration and speed and hand-path ratio as indication of movement efficiency in the spatial domain. Non-parametric statistics were applied.

Results

PwMS commented favourably on the robot-supported virtual learning environment and reported functional training effects in daily life. Movement tasks in three dimensions, measured with the robot, were performed in less time and for the transporting and reaching movement tasks more efficiently. There were however no significant changes for any clinical measure in neither intervention nor control group although observational analyses of the included cases indicated large improvements on the Fugl-Meyer in persons with more marked upper limb dysfunction.

Conclusion

Robot-supported training lead to more efficient movement execution which was however, on group level, not reflected by significant changes on standard clinical tests. Persons with more marked upper limb dysfunction may benefit most from additional robot-supported training, but larger studies are needed.

Trial registration

This trial is registered within the registry Clinical Trials GOV (NCT02257606).

Persisting anorectal dysfunction after rectal cancer surgery

AIM

Sphincter-saving rectal cancer management affects anorectal function. This study evaluated persisting anorectal dysfunction and its impact on patients' well-being.

METHOD

Seventy-nine patients with a follow-up of 12-37 (median 22) months and 79 age- and sex-matched control subjects completed questionnaires.

RESULTS

The median number of diurnal bowel movements was three in patients and one in controls (P < 0.0001). Nocturnal defaecation occurred in 53% of patients. The median Vaizey score was 8 in patients and 4 in controls (P < 0.0001). Urgency without incontinence was reported by 47% of patients and 49% of controls (P = 0.873), soiling by 28% of patients and 3% of controls (P < 0.0001), incontinence for flatus by 73% of patients and 49% of controls (P = 0.0019), and incontinence for solid stools by 16% of patients and 4% of controls (P = 0.0153). Incontinence of liquid stools occurred in 17 of 20 patients and in one of five controls who had liquid stools (P = 0.0123). Incontinence for gas, liquid or solid stool occurred once or more weekly in 47%, 19% and 6% of patients respectively. Evacuation difficulties were reported by 98% of patients, but also by 77% of controls. Neoadjuvant radio(chemo)therapy adversely affected defaecation frequency and continence. Incontinence was associated with severe discomfort in 50% of patients, severe anxiety in 40% and severe embarrassment in 48%.

CONCLUSION

Anorectal dysfunction is a frequent problem after management of rectal cancer with an impact on the well-being of patients.

Treatment options to improve anorectal function following rectal resection: a systematic review

AIM

Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery.

METHOD

Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life.

RESULTS

The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re-education (n=7), colonic irrigation (n=2) and sacral nerve stimulation (SNS) (n=6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re-education or SNS. Three studies reported improved quality of life after pelvic floor re-education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS.

CONCLUSION

Conservative therapies such as pelvic floor re-education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence-based conclusions.

Burkitt's lymphoma in the base of the tongue: differential diagnosis and management

Burkitt's lymphoma is the most common malignancy in African children but can occur sporadically in every country. It is one of the most aggressive malignancies in the human body, and in the past the prognosis was very poor. However, complex chemotherapy regimens can now cure approximately 50-80% of adult patients with Burkitt's lymphoma or small noncleaved lymphoma, and in pediatric populations the cure rate is even higher. Although the African type has a preference to the head and neck region (whereas the sporadic type to the abdomen), involvement of the base of the tongue is extremely rare as only 1 case has ever been reported in the English literature. The present study describes a patient with Burkitt's lymphoma presenting as a single mass in the base of the tongue without any abdominal or other extra-abdominal involvement. The patient was submitted to chemotherapy (intravenous and intrathecal) and skull radiotherapy. Today, 17 months after the diagnosis, the patient is disease free. Physicians should be aware of the extranodal manifestations of Burkitt's lymphoma and their differential diagnosis in order to achieve early diagnosis and treatment.

Free-Jet Rotational Spectrum and ab Initio Calculations of Formanilide

Formanilide has been investigated by free-jet millimeter-wave absorption spectroscopy. The rotational spectrum of the conformer with the formyl hydrogen anti to the phenyl group has been assigned. Several rotational transitions of the ground state have been measured for both normal and ND isotopic species. All the atoms of the peptidic group are coplanar to the ring. Copyright 2001 Academic Press.

Conformational equilibrium and potential energy surface of 1-fluorobutane by microwave spectroscopy and Ab initio calculations

The rotational spectra of four (GT, TT, TG, and GG) of the five possible conformers of 1-fluorobutane have been assigned by combining free jet and conventional microwave spectroscopy. The geometry optimization was performed at the MP2 (full) level of theory with the 6-31G (d) and 6-311G (d, p) basis sets and by using the B3LYP (3df, 3pd) density functional method. The relative stability of the five rotamers is calculated at the QCISD (T)/6-311G (d, p) level of theory. In spite of the fact that ab initio calculations indicated the unobserved GG' conformer to be more stable than at least one of the observed conformers it was not possible to detect its rotational spectrum. GT and TG are the most and the least stable species, respectively. The rotational spectra of several vibrational satellites of the four conformers have been studied by conventional microwave spectroscopy. The overall conformational equilibrium is governed by the two-dimensional potential energy surface of the skeletal torsions MeC-CC and FC-CC, which have been evaluated by a flexible model analysis, based on the experimental values of the relative conformational and vibrational energy spacings, and on the shifts of second moments of inertia upon conformational change and vibrational excitation. The relative energy of the fifth stable conformer (GG') was determined to be 333 cm(-1) from flexible model calculations, and to be 271 cm(-1) from the most accurate ab initio calculations.

Investigation of the Rotational Spectrum of Pyrimidine from 3 to 337 GHz: Molecular Structure, Nuclear Quadrupole Coupling, and Vibrational Satellites

A comprehensive reinvestigation of the rotational spectrum of pyrimidine was carried out by using several different spectrometers. All singly substituted 13C- and 15N-isotopic species of pyrimidine have been measured in natural abundance with millimeter-wave free jet and waveguide Fourier transform microwave techniques, and complete rs and r0 heavy atom geometries have been determined. The ground state rotational spectrum in the centimeter-wave region was measured at sub-Doppler resolution of the cavity Fourier transform spectrometer and all elements in the inertial and principal nuclear quadrupole-coupling tensors of the nitrogen nuclei in pyrimidine have been determined. The room-temperature spectrum was measured up to 337 GHz and J = 66 with BWO-based spectrometers and sextic level centrifugal distortion constants in the rotational Hamiltonian have been determined for the ground state and three lowest vibrational fundamentals of pyrimidine. Copyright 1999 Academic Press.

Millimeter-Wave Absorption Free Jet Spectrum, Barriers to Internal Rotation, and Torsional Relaxation in p-Anisaldehyde

The rotational spectrum of p-anisaldehyde in a supersonic expansion has been investigated in the frequency range 60-78 GHz. Transitions up to J = 57 measured for the anti and syn conformers have been used to determine complete sets of fourth-order centrifugal distortion constants. Methyl group internal rotation splittings have also been observed for some of the lines and have yielded the respective barriers for both conformers. A vibrational satellite observed for each of the two conformers has been assigned to the respective first excited methoxy torsional state. The jet conditions, in particular the stagnation pressure of the carrier gas, can be adjusted to control the degree of cooling achieved in the expansion. This possibility has been exploited in the present work to enhance the intensities of the observed vibrational satellites. Applying a two-dimensional flexible model to the methoxyl and aldehydic groups torsions, the potential energy and structural deformation parameters transferred from anisole and benzaldehyde have been found to be suitable to describe these motions in p-anisaldehyde. Mixing of anti and syn conformations has been found to be insignificant within the first 82 calculated torsional eigenstates and therefore less likely to explain the intermediate bands observed in the low-resolution microwave spectrum than the internal vibrational relaxation suggested by R. K. Bohn, M. S. Farag, C. M. Ott, J. Radhakrishnan, S. A. Sorenson, and N. S. True (1992, J. Mol. Struct. 268, 107-121). A qualitative discussion of relaxation among the torsional states and its effect on the rotational spectrum is given. Copyright 1997 Academic Press. Copyright 1997Academic Press

Stress relaxation behaviour of trabecular bone specimens

The present study defines several conditions under which stress relaxation tests can be performed and investigates the viscoelastic behaviour of trabecular bone in compression through a series of stress relaxation tests at three strain levels and in three loading directions of each cubic specimen. A viscoelastic model is proposed to characterize the behaviour of trabecular bone and a spectrum of relaxation times is determined. Trabecular bone from the femoral head is non-linearly viscoelastic and displays anisotropic behaviour, which cannot be more symmetric elastically than orthotropic.

A 25-kDa stretch of the extracellular domain of the human interferon gamma receptor is required for full ligand binding capacity

We investigated which is the shortest fragment of the interferon gamma receptor with ligand binding capacity. A recombinant soluble interferon gamma receptor produced in Escherichia coli was subjected to controlled digestion with several proteolytic enzymes. The fragments generated were assayed by four approaches for interferon gamma binding. A 25-kDa polypeptide comprising residues 6-227 of the mature protein was produced by sequential digestion with trypsin and proteinase K. It was identified as the shortest receptor domain with full interferon gamma binding capacity as judged by ligand blots. The proteolytic fragments were further tested for ligand binding by interferon gamma affinity chromatography. A 15-kDa polypeptide comprising amino acids 94-227 produced by digestion with endoproteinase Glu-C was found to bind with low affinity to immobilized interferon gamma. This fragment, which does not show ligand binding capacity on protein blots, was immunoprecipitated as a complex with interferon gamma by anti-interferon gamma antibodies. It also competed for the binding of radiolabeled interferon gamma to the cell surface receptor when it was assayed as a mixture of the proteolytic products, but not after separation from the cleaved rest of the molecule. The 15-kDa polypeptide probably carries the ligand-binding domain or part of it, but it lacks sequences essential for full interferon gamma binding capacity. The stretch between amino acids 6 and 21 which does not include any disulfide bonds seems to be essential for the receptor to show full activity. The digestion with endoproteinase Glu-C revealed that cysteine residues 60 and 68 of the interferon gamma receptor form a disulfide bond.

One interferon gamma receptor binds one interferon gamma dimer

We investigated the stoichiometry of the interferon gamma and interferon gamma receptor interaction, using recombinant interferon gamma and recombinant soluble interferon gamma receptor, applying chemical cross-linking and chromatographic techniques, and analyzing the resulting products in denaturing polyacrylamide gels. Interferon gamma cross-linked to itself produced a major band of an apparent molecular mass of 34 kDa, which suggests that it exists as a dimer in physiological buffer and which agrees with published data. Soluble interferon gamma receptor cross-linked to itself produced mainly a 28-kDa band, suggesting that the interferon gamma receptor exists as a monomer. Interferon gamma cross-linked to the soluble interferon gamma receptor resulted in the formation of two main products of apparent molecular masses of 60 and 44 kDa. The predominant 60-kDa band resulted from the cross-linking of one interferon gamma dimer (34 kDa) to one interferon gamma receptor molecule (27 kDa). The 44-kDa band was formed by the cross-linking of one interferon gamma molecule to one interferon gamma receptor. Kinetic studies showed that the cross-linking of interferon gamma dimer to the soluble receptor proceeds through the intermediate formed by cross-linking one molecule of the interferon gamma dimer to the receptor. Reducing and dissociating agents inhibited complex formation. When chromatographed on Sephadex G-100, interferon gamma was eluted as a protein of 34-kDa molecular mass, the soluble interferon gamma receptor as a protein of 40 kDa, and their mixture was eluted in one peak corresponding to an apparent molecular mass of 73 kDa. Sodium dodecyl sulfate-polyacrylamide gel analysis of the eluted mixture showed the presence of both interferon gamma and interferon gamma receptor at a ratio of 2:1. The found results suggest that the interferon gamma receptor binds interferon gamma as a dimer.

Fibrinogen mediated activation of platelet aggregation and thromboxane A2 release: pathological implications in vascular disease

The effect of a human fibrinogen preparation on in vitro platelet aggregation was assessed. Platelets were obtained from healthy volunteers. Human fibrinogen induced platelet aggregation in 65% of platelet rich plasma samples and enhanced submaximal platelet aggregation induced by heparin or by several conventional agonists in all samples. Aggregation induced by fibrinogen alone was reversed by the in vitro addition of human albumin. Fibrinogen induced aggregation was associated with the release of the vasoconstrictor, thromboxane A2. Preincubation with indomethacin inhibited both the aggregation and the release of thromboxane A2. Fibrinogen had no effect on in vitro vascular prostaglandin I2 synthesis (rat aortic rings) during a 60 minute incubation. The observed effects of fibrinogen on platelet function may be relevant to clinical conditions in which hyperaggregability of platelets is associated with hyperfibrinogenemia and thrombosis.