Outcome measures in pediatric chronic inflammatory demyelinating polyradiculoneuropathy

INTRODUCTION/AIMS

Objective outcome measures in children undergoing treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are lacking. The aim of the study was to record serial grip strength and motor nerve conduction studies to assess interval change.

METHODS

This was a retrospective review of 16 children (8 females and 8 males; median age, 9.7 years; interquartile range, 6-13 years) with CIDP followed at a tertiary children's hospital from 2013 to 2021. Subjects were treated with intravenous immunoglobulin (IVIG). Right and left grip strength measurements were obtained at each clinic visit using a handheld dynamometer. Annual right median motor nerve conduction study data were recorded during the study period.

RESULTS

Mean duration of follow-up was 2.9 years. Grip strength (right: 0.19 kg/month, p < 0.001; left 0.23 kg/month, p < 0.001) and median F-wave latencies (-0.23/month, p = 0.015) showed significant improvement over time. Akaike information criterion showed time + IVIG frequency <21 days as best fit for grip strength and distal compound muscle action potential amplitude.

DISCUSSION

Our study results indicate serial grip strength measurements are a feasible and objective way to assess motor strength improvement in children with CIDP receiving immunotherapy.

Cingulate dynamics track depression recovery with deep brain stimulation

Deep brain stimulation (DBS) of the subcallosal cingulate (SCC) can provide long-term symptom relief for treatment-resistant depression (TRD)1. However, achieving stable recovery is unpredictable2, typically requiring trial-and-error stimulation adjustments due to individual recovery trajectories and subjective symptom reporting3. We currently lack objective brain-based biomarkers to guide clinical decisions by distinguishing natural transient mood fluctuations from situations requiring intervention. To address this gap, we used a new device enabling electrophysiology recording to deliver SCC DBS to ten TRD participants (ClinicalTrials.gov identifier NCT01984710). At the study endpoint of 24 weeks, 90% of participants demonstrated robust clinical response, and 70% achieved remission. Using SCC local field potentials available from six participants, we deployed an explainable artificial intelligence approach to identify SCC local field potential changes indicating the patient's current clinical state. This biomarker is distinct from transient stimulation effects, sensitive to therapeutic adjustments and accurate at capturing individual recovery states. Variable recovery trajectories are predicted by the degree of preoperative damage to the structural integrity and functional connectivity within the targeted white matter treatment network, and are matched by objective facial expression changes detected using data-driven video analysis. Our results demonstrate the utility of objective biomarkers in the management of personalized SCC DBS and provide new insight into the relationship between multifaceted (functional, anatomical and behavioural) features of TRD pathology, motivating further research into causes of variability in depression treatment.

Mitigating Mismatch Compression in Differential Local Field Potentials

Deep brain stimulation (DBS) devices capable of measuring differential local field potentials ( ∂ LFP) enable neural recordings alongside clinical therapy. Efforts to identify oscillatory correlates of various brain disorders, or disease readouts, are growing but must proceed carefully to ensure readouts are not distorted by brain environment. In this report we identified, characterized, and mitigated a major source of distortion in ∂ LFP that we introduce as mismatch compression (MC). Using in vivo, in silico, and in vitro models of MC, we showed that impedance mismatches in the two recording electrodes can yield incomplete rejection of stimulation artifact and subsequent gain compression that distorts oscillatory power. We then developed and validated an opensource mitigation pipeline that mitigates the distortions arising from MC. This work enables more reliable oscillatory readouts for adaptive DBS applications.

Dynamic Oscillations Evoked by Subcallosal Cingulate Deep Brain Stimulation

Deep brain stimulation (DBS) of subcallosal cingulate white matter (SCCwm) alleviates symptoms of depression, but its mechanistic effects on brain dynamics remain unclear. In this study we used novel intracranial recordings (LFP) in n = 6 depressed patients stimulated with DBS around the SCCwm target, observing a novel dynamic oscillation (DOs). We confirm that DOs in the LFP are of neural origin and consistently evoked within certain patients. We then characterize the frequency and dynamics of DOs, observing significant variability in DO behavior across patients. Under the hypothesis that LFP-DOs reflect network engagement, we characterize the white matter tracts associated with LFP-DO observations and report a preliminary observation of DO-like activity measured in a single patient's electroencephalography (dEEG). These results support further study of DOs as an objective signal for mechanistic study and connectomics guided DBS.

Grand challenges in interfacing engineering with life sciences and medicine

This paper summarizes the discussions held during the First IEEE Life Sciences Grand Challenges Conference, held on October 4-5, 2012, at the National Academy of Sciences, Washington, DC, and the grand challenges identified by the conference participants. Despite tremendous efforts to develop the knowledge and ability that are essential in addressing biomedical and health problems using engineering methodologies, the optimization of this approach toward engineering the life sciences and healthcare remains a grand challenge. The conference was aimed at high-level discussions by participants representing various sectors, including academia, government, and industry. Grand challenges were identified by the conference participants in five areas including engineering the brain and nervous system; engineering the cardiovascular system; engineering of cancer diagnostics, therapeutics, and prevention; translation of discoveries to clinical applications; and education and training. A number of these challenges are identified and summarized in this paper.

Genetic algorithm for optimization and specification of a neuron model

We present a novel approach for neuron model specification using a Genetic Algorithm (GA) to develop simple firing neuron models consisting of a single compartment with one inward and one outward current. The GA not only chooses the model parameters, but also chooses the formulation of the ionic currents (i.e. single-variable, two-variable, instantaneous, or leak). The fitness function of the GA compares the frequency output of the GA generated models to an I-F curve of a nominal Morris-Lecar (ML) model. Initially, several different classes of models compete among the population. Eventually, the GA converges to a population containing only ML-type firing models with an instantaneous inward and single-variable outward current. Simulations where ML-type models are restricted from the population are also investigated. This GA approach allows the exploration of a universe of feasible model classes that is less constrained by model formulation assumptions than traditional parameter estimation approaches. While we use a simple model, this technique is scalable to much larger and more complex formulations.

Weak phase-resetting in neural oscillators

Phase-resetting experiments have frequently been employed to understand the input/output dynamics of oscillatory physiological systems, such as the respiratory and cardiovascular systems. Analogous techniques based on phase-oscillator models have often been used in computational studies of neuronal networks. These models are often simplified by assuming weak coupling between neurons. This assumption has powerful ramifications for both experimental and theoretical studies, yet it has never been demonstrated in living neurons. Here we examine phase response curves (PRCs) for neurons with different stimulus waveforms. Focusing on amplitude, we show that weak amplitude stimuli create PRCs that scale linearly with amplitude, while strong do not. This is the first step in demonstrating that weak coupling occurs in living neurons. We also show that this notion of weak coupling is more stringent than the geometric classification of weak coupling frequently associated with experimental PRC analysis.

[Guides to chemical risk assessment in the construction industry]

The presence of chemical agents in construction is certainly relevant in terms of quality, quantity and toxicity. Their manipulation can result in potential exposure as inhaled and/or through the skin. It is therefore possible and necessary to identify a list of substances to be considered relevant for the risk assessment and the possible environmental monitoring to verify the adequacy of the estimate made. The many variables inherent in construction make it extremely difficult to apply the usual methods of the industrial hygiene because it would not very significant conclusions in terms of space-time representation. SIMLII in one of its guidelines have proposed a "indexes" method that can provide useful information to the figures of prevention for the actions of their competence. The subsequent introduction of the REACH Regulation and exposure scenarios may help to further sharpening the assessment of chemical hazards in construction.

Holoprosencephaly in clomiphene-induced pregnancy: a possible association? A case report and literature review

Clomiphene is widely used for inducing ovulation. Evidence for congenital abnormalities, in particular central nervous system defects (CNS-D) and in babies born from clomiphene-induced pregnancies is conflicting. The authors report a case of holoprosencephalia (HPE) in a fetus delivered from a mother receiving clomiphene.

Sequential optimal design of neurophysiology experiments

Adaptively optimizing experiments has the potential to significantly reduce the number of trials needed to build parametric statistical models of neural systems. However, application of adaptive methods to neurophysiology has been limited by severe computational challenges. Since most neurons are high-dimensional systems, optimizing neurophysiology experiments requires computing high-dimensional integrations and optimizations in real time. Here we present a fast algorithm for choosing the most informative stimulus by maximizing the mutual information between the data and the unknown parameters of a generalized linear model (GLM) that we want to fit to the neuron's activity. We rely on important log concavity and asymptotic normality properties of the posterior to facilitate the required computations. Our algorithm requires only low-rank matrix manipulations and a two-dimensional search to choose the optimal stimulus. The average running time of these operations scales quadratically with the dimensionality of the GLM, making real-time adaptive experimental design feasible even for high-dimensional stimulus and parameter spaces. For example, we require roughly 10 milliseconds on a desktop computer to optimize a 100-dimensional stimulus. Despite using some approximations to make the algorithm efficient, our algorithm asymptotically decreases the uncertainty about the model parameters at a rate equal to the maximum rate predicted by an asymptotic analysis. Simulation results show that picking stimuli by maximizing the mutual information can speed up convergence to the optimal values of the parameters by an order of magnitude compared to using random (nonadaptive) stimuli. Finally, applying our design procedure to real neurophysiology experiments requires addressing the nonstationarities that we would expect to see in neural responses; our algorithm can efficiently handle both fast adaptation due to spike history effects and slow, nonsystematic drifts in a neuron's activity.

Efficient model-based design of neurophysiological experiments

We apply an adaptive approach to optimal experimental design in the context of estimating the unknown parameters of a model of a neuron's response. We present an algorithm to choose the optimal (most informative) stimulus on each trial; this algorithm can be implemented efficiently even for high-dimensional stimulus and parameter spaces (in particular, no high-dimensional numerical optimizations or integrations are required). Our simulation results show that model parameters can be estimated much more efficiently using this adaptive algorithm rather than random sampling. We also show that this adaptive approach leads to superior performance in the case that the model parameters are nonstationary, as would be expected in real experiments.

Bursting Without Slow Kinetics: A Role for a Small World?

Bursting, a dynamical phenomenon whereby episodes of neural action potentials are punctuated by periodic episodes of inactivity, is ubiquitous in neural systems. Examples include components of the respiratory rhythm generating circuitry in the brain stem, spontaneous activity in the neonatal rat spinal cord, and developing neural networks in the retina of the immature ferret. Bursting can also manifest itself in single neurons. Bursting dynamics require one or more kinetic processes slower than the timescale of the action potentials. Such processes usually manifest themselves in intrinsic ion channel properties, such as slow voltage-dependent gating or calcium-dependent processes, or synaptic mechanisms, such as synaptic depression. In this note, we show rhythmic bursting in a simulated neural network where no such slow processes exist at the cellular or synaptic level. Rather, the existence of rhythmic bursting is critically dependent on the connectivity of the network and manifests itself only when connectivity is characterized as small world. The slow process underlying the timescale of bursting manifests itself as a progressive synchronization of the network within each burst.

Web-based antidotes management: evaluation of an Italian experience

Antidotes (ANT) are lifesaving drugs that must be timely administered in case of poisoning, but their availability when and where needed is often a problem. The experience of setting up a web-based national network aimed at sharing ANT availability information is described, together with the steps followed to make it be an effective solution.

Carbon monoxide cardiotoxicity

Cardiac dysfunction including arrhythmias and myocardial ischemia have often been reported in carbon monoxide poisoning; scattered punctiform hemorrhages throughout the heart have been documented in autopsy samples. An appropriate diagnostic approach is crucial to assess carbon monoxide cardiac damage. This evaluation may be confounded by several factors, including the absence of overt symptoms and of specific ischemic changes in the electrocardiogram. In experimental studies, laboratory animals can develop cardiac changes similar to those seen in humans and therefore proved to be useful models to study the effects and the mechanisms of cardiac damage due to carbon monoxide. These investigations, as well as others performed in vitro, provide support for a direct action of carbon monoxide on the heart, in addition to systemic hypoxia produced by carboxyhemoglobin formation. This review focuses on the diagnostic aspects of carbon monoxide cardiotoxicity. Experimental results obtained in animals and in vitro models are also discussed.

Cardiac damage in pediatric carbon monoxide poisoning

BACKGROUND

Cardiovascular disorders including myocardial ischemia and heart failure have been described in both laboratory animals and humans following carbon monoxide poisoning. Carbon monoxide cardiotoxicity may be clinically occult and often remains undiagnosed because of the lack of overt symptoms and specific ischemic changes in the electrocardiogram. Routine myocardial necrosis markers have low diagnostic efficiency, particularly in patients with concomitant skeletal muscle necrosis or multiple organ failure complicating carbon monoxide poisoning. Carbon monoxide-induced cardiotoxicity has been investigated rarely in children.

CASE REPORT

This paper describes carbon monoxide poisoning in a 12-year-old child who suffered from occult cardiac damage despite mild symptoms and low carboxy hemoglobin concentrations. Myocardial and mitral valve dysfunctions were observed, suggesting an ischemia-like syndrome. Cardiac damage was completely reversible within 1 month.

CONCLUSION

This case report supports that a prolonged carbon monoxide exposure can cause cardiac damage in children even in the absence of specific symptoms, cerebral failure and high carboxyhemoglobin concentrations.

Mild ciguatera poisoning: Case reports with neurophysiological evaluations

Ciguatera poisoning causes mainly gastrointestinal and neurological effects of variable severity. However, symptoms of peripheral neuropathy with paresthesias and paradoxical disturbance of thermal sensation are the hallmark. Electrophysiological studies are often normal, except in severe cases. We report four people who developed mild ciguatera poisoning after barracuda ingestion. Electrophysiological studies documented normocalcemic latent tetany. These findings are consistent with ciguatoxin's mechanism of toxicity, which involves inactivation of voltage-gated Na(+) channels and eventually increases nerve membrane excitability.

[Occupational poisoning with psychiatric manifestations]

Numerous occupational intoxications (acute, chronic and their sequelae) may affect the central nervous system and result in a wide variety of neuropsychiatric effects, ranging from subtle behavioural disturbances to overt psychosis. Chemicals causing such manifestations include many metals and organometals (Hg, Mn, Pb, Al, Sn), pesticides (organophosphates), compounds utilised in the industrial setting as solvents or intermediates (carbon disulfide, hydrocarbons and their halogenated derivatives), and combustion products (carbon monoxide). Some types of toxic insults may not be reflected in any clinical manifestation. However, this type of damage may render the brain more vulnerable to additional insult or accelerate physiological loss of neurones with ageing. Thus, occupational exposures to chemicals (Al, Pb, organic solvents) might be involved in the causation of neurodegenerative diseases--such as Alzheimer's disease--which are usually labelled as "idiopathic". A careful occupational anamnesis is crucial to diagnose work-related psychiatric manifestations and--consequently--to interrupt the toxic exposure, to start therapy, and to promote insurance compensation.

[Telematics equipment for poison control surveillance. Its applications in the health management of relevant chemical incidents]

Health management of major chemical incidents requires a close collaboration between rescuers (on the disaster site and in the emergency department) and the poison center. The study tested telematic technologies allowing telepresence and teleconsulting, a real time and continuous connection among health care personnel and toxicologists involved in the management of the emergency. The link between the poison center (PC) and the emergency department in the local hospital is provided by a ISDN operating video conferencing system, while the data transmission from the site of the accident to the PC is achieved with a personal computer and GSM cellular data transmission. Toxicological databases and risk assessment software are integrated in the system, to support information sharing. To test such instruments in operative nearly realistic conditions, the main phase of the study has implemented simulated chemical disasters in different locations in Italy. Instruments for telepresence and teleconsulting have been effectively utilized to evaluate from a remote location the scenario and the severity of the accident, by inspecting either specific details or the whole scene, to enable PC guiding the triage of the victims before and after hospitalization, to utilize and share data, such as intervention protocols or patient records, and to document all the activities. In summary, this experience shows that the telematic link allows the toxicologists of the poison center to rapidly understand the situation, and to correctly learn about the conditions of patients with the help of images. The results of this study indicate the valuable benefits of telematic instruments for the health care in case of major chemical disasters occurring in a remote geographical location or in an area which lacks local toxicological experts, where specialized expertise can be achieved by the use of telematic technologies.

Early complications and value of initial clinical and paraclinical observations in victims of smoke inhalation without burns

OBJECTIVE

To evaluate the incidence of early pulmonary complications and the value of initial clinical signs and paraclinical investigations in victims of smoke inhalation not suffering from burns following structural fires.

DESIGN

Retrospective chart review.

SETTING

Thirteen-bed ICU.

PATIENTS

Sixty-four victims of smoke inhalation following household fires were admitted to the ICU between January 1987 and December 1992. Exclusion criteria from the study were patients with cutaneous burns or multiple trauma or blast injury, and patients found in cardiac arrest.

METHODS

Clinical, biological, and radiologic parameters were collected over a 5-day period.

RESULTS

The mortality rate in relation to progressive respiratory failure was 3.1%. Mean ICU stay was 5.8 days (range, 1 to 33 days), and was longer in the patients presenting with soot deposits in the oropharynx (p = 0.02), dysphonia (D) (p = 0.05), or ronchi (R) (p = 0.0004) at the first examination, and in those having a positive sputum bacteriologic analysis (p = 0.003) or requiring parenteral bronchodilator agents for more than 24 h (p = 0.04). Thirty-five patients underwent mechanical ventilation (MV) for a mean of 101.2 h (range, 8 to 648 h). Mean MV duration was higher in the patients presenting initially with R (p = 0.003), high carbon monoxide (but not cyanide) levels (p = 0.02), or a positive bacteriologic sample (p = 0.0001). Positive bacteriologic sampling correlated with the presence of D (p = 0.02) or R (p = 0.04) and with immediate intubation (p = 0.0003). No correlation was found with chest radiograph.

CONCLUSIONS

In this selected series of fire victims without cutaneous burns, respiratory injury was frequent. The initial clinical signs may be helpful to predict pulmonary complications.

Radioimmuno-guided endoscopy (RIGE) in the detection of primary and recurrent rectal tumor

The usefulness of radioimmunoguided endoscopy in the detection of primary and recurrent rectal cancer was investigated. Of the 15 patients included in our study, 4 with suspected primary rectal cancer were examined preoperatively, while the remaining 11 were studied after radical resection of rectal carcinoma with the aim of detecting local recurrence. Radioimmunoguided endoscopy was performed employing a hand-held gamma-detecting probe (mod. 2 Oris, France), after the administration of a 111In labeled monoclonal antibody to CEA. Radioimmuno-guided endoscopy results detected the presence of primary or recurrent periluminal cancer in seven cases. In four it modified the preoperative stage based on the findings of conventional investigation and it influenced the surgical decision in five cases. No toxicity was noted and none of the patients developed HAMAs.