Building a Multidisciplinary Clinic Dedicated to Upper-Extremity Limb Loss.

Complete care of the patient with upper limb loss mandates a long-term, multifaceted approach. Increased functionality and quality of life require collaborative efforts between the patient's surgeon, prosthetist, hand therapists, mental health professionals, and peers. An individual surgeon may find that initiating and maintaining a practice offering total integrated treatment for upper-extremity amputees is a formidable task, but with specific, actionable recommendations, the process can be demystified. The upper-extremity surgeon must be facile with operative techniques such as targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI), and soft tissue reconstruction and focus on team recruitment strategy and promotion of the clinic within the community. Consistent communication and team decision-making shape each patient's preoperative and postoperative course. We aim to relay effective interventions at each step of recovery from each clinic member and describe clinic workflow designed to reinforce holistic care. We present a blueprint for creating a functional and comprehensive multidisciplinary center for patients with upper-extremity limb loss for those providers interested in providing care, but who are missing the logistical roadmap for how to do so.

Radial astrocyte synchronization modulates the visual system during behavioral-state transitions.

Glial cells support the function of neurons. Recent evidence shows that astrocytes are also involved in brain computations. To explore whether and how their excitable nature affects brain computations and motor behaviors, we used two-photon Ca2+ imaging of zebrafish larvae expressing GCaMP in both neurons and radial astrocytes (RAs). We found that in the optic tectum, RAs synchronize their Ca2+ transients immediately after the end of an escape behavior. Using optogenetics, ablations, and a genetically encoded norepinephrine sensor, we observed that RA synchronous Ca2+ events are mediated by the locus coeruleus (LC)-norepinephrine circuit. RA synchronization did not induce direct excitation or inhibition of tectal neurons. Nevertheless, it modulated the direction selectivity and the long-distance functional correlations among neurons. This mechanism supports freezing behavior following a switch to an alerted state. These results show that LC-mediated neuro-glial interactions modulate the visual system during transitions between behavioral states.

An electrophysiological and kinematic model of Paramecium, the "swimming neuron".

Paramecium is a large unicellular organism that swims in fresh water using cilia. When stimulated by various means (mechanically, chemically, optically, thermally), it often swims backward then turns and swims forward again in a new direction: this is called the avoiding reaction. This reaction is triggered by a calcium-based action potential. For this reason, several authors have called Paramecium the "swimming neuron". Here we present an empirically constrained model of its action potential based on electrophysiology experiments on live immobilized paramecia, together with simultaneous measurement of ciliary beating using particle image velocimetry. Using these measurements and additional behavioral measurements of free swimming, we extend the electrophysiological model by coupling calcium concentration to kinematic parameters, turning it into a swimming model. In this way, we obtain a model of autonomously behaving Paramecium. Finally, we demonstrate how the modeled organism interacts with an environment, can follow gradients and display collective behavior. This work provides a modeling basis for investigating the physiological basis of autonomous behavior of Paramecium in ecological environments.

Tendon Transfer to Treat Radial Nerve Palsy Following COVID-19 Infection.

Multiple manifestations have been associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Among them are mononeuritis multiplex (MNM) and other neurological complications, whose connection to coronavirus disease 2019 (COVID-19) is still unclear. One of the most common sites of nerve injury is the radial nerve, which can be treated with both nerve or tendon transfer. In this case report, a patient who was afflicted with severe COVID-19 infection and developed mono neuritis multiplex after prolonged mechanical ventilation with radial nerve palsy was treated with multiple tendon transfers. This is a way to use an established mechanism of resolving the manifestations of radial nerve palsy to aid in the recovery of COVID-19-related mononeuritis multiplex.

Comparing Bridging Thrombolysis with Direct Thrombectomy in Stroke due to Large Vessel Occlusion- Indian Experience (LVO-Direct).

Objectives: Intravenous thrombolysis alone has poor recanalization rates in large vessel occlusion strokes. Bridging thrombolysis has evolved as a standard treatment approach in emergent large vessel occlusions. Patients who undergo thrombectomy have a higher probability of favorable outcomes irrespective of the use of prior intravenous thrombolysis. Our aim was to compare bridging thrombolysis with direct thrombectomy in ischemic stroke due to large vessel occlusion. Methods: We included patients from our stroke registry, with large vessel occlusion strokes, presenting <4.5 hr from onset. Bridging thrombolysis was the standard approach. Direct thrombectomy was done in patients with contraindications to intravenous thrombolysis. The primary outcome was the modified Rankin scale at 3 months. Secondary outcomes were National Institute of Health Stroke Scale at 24 hr post-procedure, door to puncture time, puncture to recanalization time, the extent of recanalization, and the number of passes required. Safety outcomes were any occurrence of intracranial hemorrhage or other complications related to procedure or death. Logistic regression analysis was used to find the factors affecting the outcome. Results: Total 76 patients were included, 29 underwent bridging thrombolysis and 47 underwent direct thrombectomy. A favorable outcome (mRS 0-2) was achieved in 19 (65.5%) patients in the bridging group and 25 (58.1%) patients in the direct group (P = 0.4, Chi-square test). There was no significant difference in any of the secondary outcomes as well. Symptomatic intracranial hemorrhage occurred in 2 (2.6%) patients and a total of 10 (13.9%) were dead at 3-month follow-up, comparable in both groups. Conclusion: Direct thrombectomy has comparable outcomes to bridging thrombolysis in emergent large vessel occlusions.

Mechanical Thrombectomy: Review.

Large vessel occlusion stroke contributes to disability and mortality out of proportion to its incidence. Over time it was noted that intravenous thrombolysis alone was not sufficient for this stroke type. Slowly, endovascular approach and mechanical clot retrieval have come out to be the biggest advances in the field of neurology as well as modern medicine. Although the careful selection of patients is needed as standardized by landmark trials. At the same time, thrombectomy is now being studied in patients excluded by previous trials and is seemingly coming out be effective in the vast majority of patients with large vessel occlusions. Further, techniques and devices are getting refined day by day to achieve the maximum possible benefit.

Reliability of Instant Messaging-Based Evaluation of Brain Imaging in Acute Stroke.

BACKGROUND: The use of instant messenger applications among physicians has become common in acute stroke management, especially in developing countries. Photos or video sequences of brain computed tomography (CT) scans are being sent to receive real-time support in assessing radiological findings. We analyzed whether instant messaging-based evaluation is precise enough to extract relevant information from the images. METHODS: In this prospective study, anonymized videos and photos of CT and CT angiography scans of patients with symptoms of acute stroke were recorded from the diagnostic monitor using a smartphone. Two neurologists and 2 neuroradiologists performed evaluation of the images using WhatsApp. The gold standard was set by 2 experienced neuroradiologists who evaluated the CT images with their full radiological equipment. Statistical analysis included the calculation of Cohen kappa (κ). RESULTS: A total of 104 brain images (derived from 81 patients) were included. All 4 raters performed with a perfect (κ=1) interobserver reliability in diagnosing intracerebral hemorrhage. For subarachnoid hemorrhage, interobserver reliability was slightly lower (raters 1, 2, and 3, κ=1; rater 4, κ=0.88). For diagnosing stroke mimics, interobserver reliability showed considerable variations (κ between 0.32 and 1). Alberta Stroke Program Early CT Score differences overall were comparable between raters and did not exceed 3 to 4 points without noticeable outliers. All raters performed with a moderate-to-substantial interobserver reliability for detecting large vessel occlusions (κ=0.48 in rater 1, κ=0.62 in rater 2, and κ=0.63 in raters 3 and 4). CONCLUSIONS: Stroke neurologists can reliably extract information on intracerebral hemorrhage from CT images recorded via smartphone and sent through instant messaging tools. Remote diagnosis of early infarct signs and stroke mimics was less reliable. We developed a standard for the acquisition of images, taking data protection into account.

Effect of visual input on syllable parsing in a computational model of a neural microcircuit for speech processing.

Objective.Seeing a person talking can help us understand them, particularly in a noisy environment. However, how the brain integrates the visual information with the auditory signal to enhance speech comprehension remains poorly understood.Approach.Here we address this question in a computational model of a cortical microcircuit for speech processing. The model consists of an excitatory and an inhibitory neural population that together create oscillations in the theta frequency range. When stimulated with speech, the theta rhythm becomes entrained to the onsets of syllables, such that the onsets can be inferred from the network activity. We investigate how well the obtained syllable parsing performs when different types of visual stimuli are added. In particular, we consider currents related to the rate of syllables as well as currents related to the mouth-opening area of the talking faces.Main results.We find that currents that target the excitatory neuronal population can influence speech comprehension, both boosting it or impeding it, depending on the temporal delay and on whether the currents are excitatory or inhibitory. In contrast, currents that act on the inhibitory neurons do not impact speech comprehension significantly.Significance.Our results suggest neural mechanisms for the integration of visual information with the acoustic information in speech and make experimentally-testable predictions.

Synchronization, Stochasticity, and Phase Waves in Neuronal Networks With Spatially-Structured Connectivity.

Oscillations in the beta/low gamma range (10-45 Hz) are recorded in diverse neural structures. They have successfully been modeled as sparsely synchronized oscillations arising from reciprocal interactions between randomly connected excitatory (E) pyramidal cells and local interneurons (I). The synchronization of spatially distant oscillatory spiking E-I modules has been well-studied in the rate model framework but less so for modules of spiking neurons. Here, we first show that previously proposed modifications of rate models provide a quantitative description of spiking E-I modules of Exponential Integrate-and-Fire (EIF) neurons. This allows us to analyze the dynamical regimes of sparsely synchronized oscillatory E-I modules connected by long-range excitatory interactions, for two modules, as well as for a chain of such modules. For modules with a large number of neurons (> 105), we obtain results similar to previously obtained ones based on the classic deterministic Wilson-Cowan rate model, with the added bonus that the results quantitatively describe simulations of spiking EIF neurons. However, for modules with a moderate (~ 104) number of neurons, stochastic variations in the spike emission of neurons are important and need to be taken into account. On the one hand, they modify the oscillations in a way that tends to promote synchronization between different modules. On the other hand, independent fluctuations on different modules tend to disrupt synchronization. The correlations between distant oscillatory modules can be described by stochastic equations for the oscillator phases that have been intensely studied in other contexts. On shorter distances, we develop a description that also takes into account amplitude modes and that quantitatively accounts for our simulation data. Stochastic dephasing of neighboring modules produces transient phase gradients and the transient appearance of phase waves. We propose that these stochastically-induced phase waves provide an explanative framework for the observations of traveling waves in the cortex during beta oscillations.

A simple device to immobilize protists for electrophysiology and microinjection.

We present a simple device to mechanically immobilize motile cells such as ciliates. It can be used in particular for intracellular electrophysiology and microinjection. A transparent filter with holes smaller than the specimen is stretched over an outlet. A flow is induced by either a peristaltic pump or a depressurized tank, mechanically entraining cells to the bottom, where they are immobilized against the filter. The cells start swimming again as soon as the flow is stopped. We demonstrate the device by recording action potentials in Paramecium and injecting a fluorescent dye into the cytosol.

Sustained Rhythmic Brain Activity Underlies Visual Motion Perception in Zebrafish.

Following moving visual stimuli (conditioning stimuli, CS), many organisms perceive, in the absence of physical stimuli, illusory motion in the opposite direction. This phenomenon is known as the motion aftereffect (MAE). Here, we use MAE as a tool to study the neuronal basis of visual motion perception in zebrafish larvae. Using zebrafish eye movements as an indicator of visual motion perception, we find that larvae perceive MAE. Blocking eye movements using optogenetics during CS presentation did not affect MAE, but tectal ablation significantly weakened it. Using two-photon calcium imaging of behaving GCaMP3 larvae, we find post-stimulation sustained rhythmic activity among direction-selective tectal neurons associated with the perception of MAE. In addition, tectal neurons tuned to the CS direction habituated, but neurons in the retina did not. Finally, a model based on competition between direction-selective neurons reproduced MAE, suggesting a neuronal circuit capable of generating perception of visual motion.

Evaluation of microvascular density in Barrett's associated neoplasia.

Angiogenesis has an important role in the carcinogenesis of esophageal adenocarcinoma, however, the diagnostic and prognostic utility of microvascular density counts have not been clinically established. The aim of this study is to assess the correlation between microvascular density and disease progression of non-dysplastic Barrett's esophagus, low-grade dysplasia, high-grade dysplasia and invasive carcinoma in the superficial aspects of the tissue. Archival histological specimens from two referral centers for Barrett's esophagus and esophageal cancer were selected for review. A total of 160 regions marked according to histological grade were assessed with digitally interactive software to measure microvascular density. This was quantified in three levels: 0-50, 50-100 and 100-150 µm. In the areas of gastric cardia, Barrett's esophagus, low-grade dysplasia, high-grade dysplasia and cancer, microvascular density was significantly different (P<0.0001) among the five groups in the most superficial 150 µm of the mucosa. Furthermore, when examining the pairwise difference between the groups, there was a significant difference between cancer and each of the lower grades of histology (P<0.05) and between high-grade dysplasia and each of the lower grades of histology (P<0.05). These statistically significant differences were preserved in examining the depth at the most superficial 50 µm. We have used digital pathology to demonstrate a significant and stepwise increase in microvascular density, which supports the hypothesis that angiogenesis has a key role in Barrett's carcinogenesis. Furthermore, the differences in the most superficial mucosal layers are consistent with findings of increased vascularity by depth-restricted imaging modalities.

The effects of chemokine, adhesion and extracellular matrix molecules on binding of mesenchymal stromal cells to poly(l-lactic acid).

BACKGROUND AIMS: Mesenchymal stromal cells (MSC) are pluripotent adult stem cells capable of osteogenesis and chondrogenesis to form bone and cartilage. This characteristic gives them the potential for bone and cartilage regeneration. Synthetic polymers have been studied to examine whether they could be used as a scaffold for tissue engineering. In the current study a two-dimensional (2-D) poly(l-lactic acid) (PLLA) scaffold was treated with chemokine, adhesion and extracellular matrix molecules with the aim of using biologic molecules to improve the attachment of human MSC. METHODS: MSC were isolated from human bone marrow and applied to a 2-D PLLA scaffold. Chemokines ligand (CXCL12 and CXCL13), adhesion molecules [P-selectin, vascular cell adhesion molecule (VCAM)-1 and heparin] and extracellular matrix molecules (fibronectin and type IV collagen) were coated on the scaffold and their effects on the number of MSC that adhered were recorded. RESULTS: When used alone CXCL12 and CXCL13 enhanced MSC adhesion, as did VCAM-1, P-selectin, fibronectin and collagen, but not heparin. The effects of VCAM-1, P-selectin and heparin were enhanced by the addition of CXCL12. Incubation of MSC with antibodies to integrins α4 and α5ß1 inhibited their adhesion to VCAM-1 and fibronectin-treated PLLA respectively, suggesting that these integrins were involved in the MSC interactions. CONCLUSIONS: The use of certain chemokines and adhesion and extracellular matrix molecules, alone or in combination, is beneficial for the attachment of MSC to PLLA, and may be helpful as natural molecules in scaffolds for regenerative medicine.

Pediatric spinal schwannomas: An institutional study.

OBJECTIVE: The objective was to analyze the demography, clinical presentation, and management of spinal intradural schwannomas in pediatric population. MATERIALS AND METHODS: This retrospective study includes 21 pediatric patients (under 18 years of age) who underwent surgery for spinal intradural schwannomas from January 1998 to April 2008. The medical records were reviewed retrospectively and the information regarding clinical presentation, tumor location, operative findings, and postoperative status and functional outcome were analyzed. RESULTS: A total of 21 patients (14 females and 7 males) were operated for spinal schwannomas. Six patients had associated neurofibromatosis (five were NF I and one was NF II) at presentation. The most common presenting symptom was progressive myelopathy (86%). The tumor location was either cervical or dorsal in 18 cases. All patients underwent surgery. Gross total excision was achieved in 20 cases. The median follow-up was 38 months. All the patients had neurological improvement in both power and bladder symptoms. CONCLUSION: Pediatric spinal neurofibromas/schwannomas are an uncommon but completely treatable group of tumors. Complete surgical excision gives excellent outcome.

Successful management of multi-focal hepatic infantile hemangioendothelioma using TACE/surgery followed by maintenance metronomic therapy.

Infantile hepatic hemangioendothelioma (IHE) is a rare angiogenic tumour with diverse clinical presentations and varied course ranging from spontaneous regression to life-threatening complications. The authors report a 2-year boy who presented with respiratory distress and was identified as a case of inoperable multi-focal hepatic IHE. He showed a transient response to trans-arterial-chemo-embolisation and liver resection but had progressive disease despite chemotherapy (prednisolone/vicristine/ifosfamide/cisplatin). Thereafter, he was successfully managed with metronomic therapy using cyclophosphamide and tamoxifen.

American ginseng suppresses Western diet-promoted tumorigenesis in model of inflammation-associated colon cancer: role of EGFR.

BACKGROUND: Western diets increase colon cancer risk. Epidemiological evidence and experimental studies suggest that ginseng can inhibit colon cancer development. In this study we asked if ginseng could inhibit Western diet (20% fat) promoted colonic tumorigenesis and if compound K, a microbial metabolite of ginseng could suppress colon cancer xenograft growth. METHODS: Mice were initiated with azoxymethane (AOM) and, two weeks later fed a Western diet (WD, 20% fat) alone, or WD supplemented with 250-ppm ginseng. After 1 wk, mice received 2.5% dextran sulfate sodium (DSS) for 5 days and were sacrificed 12 wks after AOM. Tumors were harvested and cell proliferation measured by Ki67 staining and apoptosis by TUNEL assay. Levels of EGF-related signaling molecules and apoptosis regulators were determined by Western blotting. Anti-tumor effects of intraperitoneal compound K were examined using a tumor xenograft model and compound K absorption measured following oral ginseng gavage by UPLC-mass spectrometry. Effects of dietary ginseng on microbial diversity were measured by analysis of bacterial 16S rRNA. RESULTS: Ginseng significantly inhibited colonic inflammation and tumorigenesis and concomitantly reduced proliferation and increased apoptosis. The EGFR cascade was up-regulated in colonic tumors and ginseng significantly reduced EGFR and ErbB2 activation and Cox-2 expression. Dietary ginseng altered colonic microbial diversity, and bacterial suppression with metronidazole reduced serum compound K following ginseng gavage. Furthermore, compound K significantly inhibited tumor xenograft growth. CONCLUSIONS: Ginseng inhibited colonic inflammation and tumorigenesis promoted by Western diet. We speculate that the ginseng metabolite compound K contributes to the chemopreventive effects of this agent in colonic tumorigenesis.