Sarcopenia and Multisensory Integration Deficit in Post-COVID Syndrome Patients: The Clinical, Ultrasound and Robotic Evaluation Protocol in a Cross-sectional Study

INTRODUCTION

Post-COVID syndrome affects relatively young outpatients with fatigue as the mostly reported symptom. We wondered whether sarcopenia could play a role.

METHODS

Seventy-four outpatients (median age: 53.8 yrs, 45 females), reporting fatigue and persistent mild neurological/motor deficits, completed the Clinical, Ultrasound and Robotic Evaluation protocol 4.8 mos after the infection.

RESULTS

The incidence of sarcopenia was 41%. Sarcopenic patients were older (62.7 vs. 46.4 yrs, P < 0.001), they experienced longer infection (33 vs. 24 days, P = 0.006) and higher incidence of hospitalization (86.6 vs. 29.5%, P < 0.001), they did not report more fatigue (44.5 vs. 48, P = 0.424), but they walked slower (1.27 vs. 1.5 m/sec, P = 0.027).After multivariable adjustment using multiple logistic regression, sarcopenia was dependent on age (odds ratio = 1.09) and on the duration of the disease (odds ratio = 1.04).When expressed as z score, in 79% of patients, the sway path during elastic balance shifted significantly toward negative values with closed eye, indicating multisensory integration deficit.

CONCLUSIONS

Post-COVID syndrome in relatively young outpatients complaining mild motor deficit is associated with high incidence of sarcopenia. In addition, they have multisensory integration deficit that further contributes to symptoms. The Clinical, Ultrasound and Robotic Evaluation protocol is able to objectivize symptoms that common diagnostic tool cannot reveal.

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CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the best diagnostic algorithm for the diagnosis of sarcopenia; (2) Identify and treat two additional factors that help to explain and understand the symptoms reported by relatively young post-COVID syndrome patients; and (3) Extend their diagnostic capability through the use of technology.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

20 years of neuromuscular electrical stimulation in COPD

Although a lung disease, COPD is also associated with extrapulmonary manifestations including, among others, limb muscle dysfunction. Limb muscle dysfunction is a key systemic consequence of COPD that impacts patients' physical activity, exercise tolerance, quality of life and survival. Deconditioning is the main mechanism underlying the development of limb muscle dysfunction in COPD, which can be partially improved with exercise. However, some patients may not be able to tolerate exercise because of incapacitating breathlessness or unwillingness to undertake whole-body exercise. Alternative training modalities that do not give rise to dyspnoea, such as neuromuscular electrical stimulation (NMES), are urged. Over the past 20 years, NMES in COPD has presented conflicting conclusions in meta-analysis. In this review, we try to understand the reason for this result by analysing possible biases and factors that brought conflicting conclusions. We discuss the population (the intervention group, but also the control group), the outcome measures, the frequency of stimulation, the rehabilitation protocol (i.e. NMES alone versus standard care/rehabilitation or NMES plus conventional exercise training versus conventional exercise training alone or NMES versus sham treatment) and the trial design. The main reason for this discrepancy is the lack of dedicated guidelines for NMES. Further research is urged to determine the optimal parameters for an NMES programme. Despite this, NMES appears to be an effective means of enhancing quadriceps strength and exercise capacity in COPD with the potential to break the vicious circle induced by the disease and COPD patients' lifestyle.

Ultrasound Imaging and Guidance for Cervical Myofascial Pain: A Narrative Review

Cervical myofascial pain is a very common clinical condition in the daily practice of musculoskeletal physicians. Physical examination is currently the cornerstone for evaluating the cervical muscles and identifying the eventual presence of myofascial trigger points. Herein, the role of ultrasound assessment in precisely localizing them is progressively mounting in the pertinent literature. Moreover, using ultrasound, not only the muscle tissue but also the fascial and neural elements can be accurately located/evaluated. Indeed, several potential pain generators, in addition to paraspinal muscles, can be involved in the clinical scenario of cervical myofascial pain syndrome. In this article, the authors extensively reviewed the sonographic approach for cervical myofascial pain in order to better diagnose or guide different procedures that can be performed in the clinical practice of musculoskeletal physicians.

Urologic latency time during uroflow stop test with electromyography: an incontinence detector in rehabilitation after robotic radical prostatectomy

BACKGROUND

Stress urinary incontinence (UI) is the most common presentation following robot-assisted radical prostatectomy (RARP), but a postoperative non-invasive and objective test is still lacking. To assess pelvic floor integrity after RARP, we recently proposed Uroflow Stop Test (UST) with surface electromyography (EMG).

AIM

Here we provide two new clinical parameters: the neurologic latency time (NLT) and the urologic latency time (ULT) derived from UST-EMG Test. Principal outcome was to evaluate their variation during one year follow-up and ULT ability to predict post-RARP UI.

DESIGN

Observational and longitudinal study.

SETTING

Interdivisional Urology Clinic (Perugia-Terni, Italy).

POPULATION

Patients with prostate cancer treated with a full nerve-sparing RARP who underwent postoperative pelvic floor muscles training (PFMT): a diurnal functional home program and a weekly hospital program with the use of biofeedback, between 1 and 3 months postoperatively.

METHODS

All patients consecutively performed a UST-EMG test at one, three, six, and twelve months after surgery. At each follow-up visit we collected NLT values, ULT values, 5-item 26-Expanded Prostate Cancer Index (EPIC), Incontinence Developed on Incontinence Questionnaire (ICIQ-UI) Short Form and International Prostate Symptom Score (IPSS). We analysed statistically significant differences in NLT and ULT between continent and incontinent patients and we evaluate the diagnostic ability of 1-month post-surgery ULT value to diagnose the presence of postoperative UI.

RESULTS

Sixty patients were enrolled. The mean time to PFMT was 31.08 (range: 30-35) days. Overall IPSS, NLT and ULT had similar trends: progressive decrease until the six months after surgery (1-month vs. 3 months vs. 6 months, P<0.05) to plateau thereafter. When considering the two group of patients, IPSS and NLT were significantly higher in the incontinent group only one month after surgery, while ULT became similar between the two groups at 6 months after surgery. The best cut-off of 1-month ULT values that maximized the Youden function at 12-months resulted 3.13 second.

CONCLUSIONS

NLT and ULT may respectively account for the nerve and the urethral closure system integrity post-RARP. In the first month after RARP, both NLT and ULT differs between incontinent vs. continent patients. NLT become similar between two group after one month, confirming the recovery from neuropraxia, but ULT remains statistically significant different until 3 months postoperatively. The value of 1-month ULT resulted a valid tool to predict incontinence status at 12 months.

CLINICAL REHABILITATION IMPACT

ULT and NLT may be also useful tools to monitor the continence progressive recovery after RARP and they may help rehabilitation specialists to evaluate the ongoing results during postoperative follow-up.

Musculoskeletal Pain Management and Thermotherapy: An Exploratory Analysis of Italian Physicians' Attitude, Beliefs, and Prescribing Habits

Purpose

In Italy, musculoskeletal (MSK) disorders are pervasive with one-third of adults seeking medical consultation for a MSK issue in the past year. MSK pain is often treated with local heat applications (LHAs) which can be integrated into MSK care by different specialists and in different settings. Compared to analgesia and physical exercise, LHAs have been less evaluated, and the quality of randomized clinical trials is generally low. The aim of the survey is to assess the knowledge, attitude, perception/practices of general practitioners (GPs), physiatrists and sports medicine doctors towards thermotherapy as delivered by superficial heat pads or wraps.

Patients and Methods

The survey was conducted between June and September 2022 in Italy. An online questionnaire with 22 multiple-choice questions was administered to explore the demographics and prescribing habits of the participants; the clinical profile of MSK patients; and physicians' attitude and beliefs about the use of thermotherapy/superficial heat applications in MSK pain management.

Results

GPs are at the forefront of the MSK patient journey and preferentially select NSAIDs as first-line option in arthrosis, muscle stiffness, and strain while prescribing heat wraps as preferred choice in presence of muscle spasm/contracture. Similar pattern of prescribing habits was found among specialists who, in contrast to GPs, adopted more frequently ice/cold therapy to relieve pain due to muscle strain and limited paracetamol use. Generally, survey participants agreed on the benefits of thermotherapy in MSK care management, namely increased blood flow and local tissue metabolism as well as connective tissue elasticity and pain relief which all may be of help in attaining pain control and improvement of function.

Conclusion

Our findings provided the basis for further investigations aimed at optimizing the MSK patient journey while building up additional evidence supporting the benefit of using superficial heat applications to effectively manage patients with MSK disorders.

From physical to ultrasound examination in lymphedema: a novel dynamic approach

In daily practice, medical history and physical examination are commonly coupled with anthropometric measurements for the diagnosis and management of patients with lymphatic diseases. Herein, considering the current progress of ultrasound imaging in accurately assessing the superficial soft tissues of the human body; it is noteworthy that ultrasound examination has the potential to augment the diagnostic process. In this sense/report, briefly revisiting the most common clinical maneuvers described in the pertinent literature, the authors try to match them with possible (static and dynamic) sonographic assessment techniques to exemplify/propose an 'ultrasound-guided' physical examination for different tissues in the evaluation of lymphedema.

AB0458 DISEASE ACTIVITY AT CONCEPTION PREDICTS LUPUS FLARE UP TO 2 YEARS AFTER BIRTH: A MULTICENTRE LONG TERM FOLLOW-UP STUDY

Background

Systemic lupus erythematosus (SLE) often affects women in their childbearing years, and pregnancy may affect SLE disease activity during pregnancy and post-partum (1,2). Limited data assessing the likelihood and characteristics of SLE activity in an extended time period post-partum which may be relevant as patients may wish further pregnancies exist.

Objectives

To assess predicting factors that might influence SLE disease activity in women in an extended follow-up period of 2 years after giving birth and clinical assessment every three months.

Methods

The study was design as an international retrospective, data-driven case collection study, enrolling 119 women with a first birth and with a strictly monitored follow-up period of 2 years.

Results

Table 1 shows pregnancy outcomes of all pregnancies. When considering disease manifestations, joint involvement was present in 80% of patients, acute cutaneous in 64%, haematological in 54%and renal in 41%; 75% of patients were positive for anti-dsDNA, 49% for anti-ENA and 37% for anti-Ro/SSA positive. The mean SLE disease activity index 2000(SLEDAI-2k) at diagnosis was 13.5±6.8 and at first birth was 2.8±4.4.

Table 1.

Pregnancy outcomes of all pregnancies and relative breastfeeding data

Pregnancy CharacteristicsAll (214)%OutcomesLive births16979Miscarriages3717.3Stillbirths83.7Maternal and Foetal ComplicationsPrematurity3918.2Pre-eclampsia2310.7HELLP syndrome41.9Placental Infarction125.6Breastfeeding (all pregnancies)Any breastfeeding (n, %)10964.5*Exclusive breastfeeding (n, %)8751.5*Breastfeeding (after first birth)Any breastfeeding (n, %)8773.1**Any breastfeeding duration (months) (m±sd)10.29±10.04Exclusive breastfeeding*** (n, %)6252.1**Exclusive breastfeeding*** duration (months) (m±sd)6.07±6

*Percentages are calculated considering viable babies (total= 169)

**Percentages are calculated considering first birth (total= 119)

***Exclusive breastfeeding was defined as feeding infants only breast milk

At follow-up, 51.3% of patients had at least one flare after a mean time after birth of 9±6.3 months(mean flare per patient 0.94±1.1). The most frequent flare manifestations were joint involvement(48%), followed by renal(33%), cutaneous(28%) and haematologic(20%).

Patients with remission of disease(SLEDAI-2K=0; no clinical or laboratory manifestations of SLE) at conception had significantly lower rates of flares than those not in remission (18/49–37% vs. 43/70–61%;p=0.008) (Figure 1).

Figure 1.

Flare proportion: Survival Curve based on remission status at conception of the patients included in the study.

Patients who experienced a flare during pregnancy (17 patients), when compared to those who did not, had higher rates of flares during follow-up (76% vs. 47%, respectively, p=0.019), lower time for first flare (4.4±2.3 months vs. 10.3±6.5, respectively, p<0.001), lower rate of remission of disease at conception (12% vs. 46%, respectively, p<0.001), lower rates of SLEDAI 2K at conception (5.9±5.6 vs. 2.3±4, respectively, p<0.001) and lower rates of exclusive breastfeeding (24% vs. 57%, respectively, p=0.009).

Remission of disease and flares during pregnancy remained significantly associated with the development of flares during follow-up after multivariate analysis.

Conclusion

Remission at conception can influence SLE disease positively, even at long-term. Planned pregnancy counseling is fundamental when managing SLE patients.

References

[1]Tincani A, Nalli C, Khizroeva J, Bitsadze V, Lojacono A, Andreoli L, et al. Autoimmune diseases and pregnancy. Best Pract Res Clin Endocrinol Metab 2019;33.

[2]Clowse MEB, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum 2005;52:514–521.

Disclosure of Interests

None declared

From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach

Lymphedema is a disorder characterized by the accumulation of protein-rich lymphatic fluid in the cutaneous and subcutaneous tissue. Based on the underlying causes, it is classified into primary and secondary forms. The use of ultrasound has recently become widespread in the field of lymphedema - especially for its diagnosis and treatment planning. In this study, we briefly reviewed the anatomy and histology of the skin and subcutaneous tissue - to propose a standardized ultrasound assessment of the superficial tissues in patients with upper-/lower-limb lymphedema. We believe that identification of the sono-histological patterns of the dermo-epidermal complex and subcutaneous tissue has place to serve as a simple and reproducible strategy to evaluate their edema diseases that are often subject to an inaccurate diagnosis in daily clinical practice.

Mortality and clinical outcomes in patients with COVID-19 pneumonia treated with non-invasive respiratory support: A rapid review

Introduction and aim

Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been widely employed to treat acute respiratory failure secondary to COVID-19 pneumonia, but their role in terms of efficacy and safety are still debated. The aim of this review was to analyse mortality and intubation rates in COVID-19 patients treated with NIV/CPAP.

Methods

Rapid review methodology was applied to include all the studies published since December-2019 until November-2020 with available data on in-hospital mortality in COVID-19 patients treated with NIV or CPAP.

Results

23 manuscripts were included (4776 patients, 66% males, 46% with hypertension). 46% of patients received non-invasive respiratory support, of which 48.4% with CPAP, 46% with NIV, and 4% with either CPAP or NIV. Non-invasive respiratory support failed in 47.7% of patients, of which 26.5% were intubated and 40.9% died. In-hospital mortality was higher in patients treated with NIV compared with CPAP (35.1% vs. 22.2%). Complications were under-reported, but mostly not related to CPAP/NIV treatment.

Conclusion

CPAP and NIV appear equally and frequently applied in patients with COVID-19 pneumonia, but associated with high mortality. Robust evidence is urgently needed to confirm the clinical efficacy of non-invasive respiratory support in COVID-19-related ARDS.

Role of frailty in functional recovery after hip fracture, the variable impact in restoring autonomy

BACKGROUND

In an old or very older adult, frailty is a common geriatric syndrome resulting from aging-associated decline including loss of autonomy related to multiple pathologies.

AIM

The study aims to evaluate the frailty affects on functional and rehabilitative recovery of the elderly patient.

DESIGN

This is a retrospective study of subjects over 65 years old who underwent hip surgery following a traumatic femoral fracture.

SETTING

Patients admitted to intensive rehabilitation department after hip fracture event.

POPULATION

The sudy include records of 350 patients over-65-year-old with hip fracture treated in hospital with surgery.

METHODS

Patients enrolled were classified into three groups: youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years. Each patient underwent a multidimensional evaluation capable of identifying the deficient domains, defining the presence of frailty, and the different degrees of severity. All patients underwent a project and rehabilitation program according to the literature protocol.

RESULTS

The average age of the enrolled patients was 73.2 ± 5.6, 38.6% were over 75 years of age, mostly females (58.9%). The prevalence of frailty increased with age, and cognitive functions were associated with both the frailty measured with the Rockwood and Lacks scales. The recovery of Barthel and Tinetti scores correlates to the level of fragility.

CONCLUSION

The approach based on the diagnosis and treatment of the individual disease should be radically changed to a culture and an assessment capacity of elderly persons that take into account the indicators which characterize it as comorbidity, psychological, cultural factors, and environmental health status. Frailty is the sum of these conditions, and it is the most impacting variable in the recovery of autonomy.

CLINICAL REHABILITATION IMPACT

The approach based on the diagnosis and treatment of the individual disease should include comorbidity, psychological condition, cultural factors, and environmental health status.

[Check-list for inspection in banks]

We suggest a checklist for inspection in banks. The checklist is composed of 14 schedules where information on bank clerks and buildings is collected. Principle risk factors are analysed (workplaces, lighting and noise, air quality, emergency management). The critical points are observed and the times of intervention are established. Then follows data processing and the reports are transmitted to the employer. The checklist, tested on 250 workplaces, allows us to identify the interventions having priority to be realized through appropriate planning. A quantitative evaluation of the risk is matched with immediate and brief operative indications. The situations to improve are: cleanliness of workplaces, thermal comfort, electricity/telephone wires. The checklist seems to be a valid instrument for the evaluation of risk factors, their management and times of intervention. Such instrument simplifies, moreover, the employer choices of intervention.