A Pearl for Pretibial and Forearm Repair Following Mohs Micrographic Surgery.

Wound repair of the pretibial and forearm regions presents a challenge during dermatologic surgery as these areas are under significant tension and exhibit increased skin fragility. Various methodologies have been proposed for the closure and repair of such wounds, however, the use of the bilayered suture technique may be simpler and more effective than other techniques such as the pinch stitch, pully stitch, slip-knot stitch, pulley set-back dermal suture, horizontal mattress suture, pully stitch, and tandem pulley stitch. Our objective was to describe a novel method for the repair of pretibial and forearm wounds following Mohs micrographic surgery utilizing bilayered closure followed by tissue adhesive application.  J Drugs Dermatol. 2024;23(5):380.     doi:10.36849/JDD.7139  .

Effect of passive leg raising on the cross-sectional area of the right internal jugular vein in patients with obesity: a randomised controlled trial protocol.

BACKGROUND: Venous access in patients with obesity presents significant challenges. The success of central venous catheterisation largely depends on the cross-sectional area (CSA) of the internal jugular vein (IJV). While techniques like the Trendelenburg position have been traditionally used to increase IJV CSA, recent studies suggest its ineffectiveness in patients with obesity. Conversely, the potential of the effect of passive leg raising (PLR) has not been thoroughly investigated in this group of patients. METHODS: This protocol outlines a planned randomised controlled trial to evaluate the effect of PLR on the CSA of the IJV in patients with obesity slated for central venous catheterisation. The protocol involves dividing 40 participants into two groups: one undergoing PLR and another serving as a control group without positional change. The protocol specifies measuring the CSA of the IJV via ultrasound as the primary outcome. Secondary outcomes will include the success rates of right IJV cannulation. The proposed statistical approach includes the use of t-tests to compare the changes in CSA between the two groups, with a significance threshold set at p<0.05. ETHICS APPROVAL: This study has been approved by the Institutional Review Board of Shanghai Tongren Hospital. All the participants will provide informed consent prior to enrolment in the study. Regarding the dissemination of research findings, we plan to share the results through academic conferences and peer-reviewed publications. Additionally, we will communicate our findings to the public and professional communities, including patient advocacy groups. TRIAL REGISTRATION NUMBER: ChiCTR: ChiCTR2400080513.

Long-term monitoring of stimulated lower leg skeletal muscle forces compared with voluntary contractions in myopathy patients - A five-year follow-up report on 5 adults.

OBJECTIVE: Long-term assessments of lower leg muscle forces in ambulant patients with distal myopathies. METHODS AND MATERIALS: Over a five-year period, we measured involuntary, nerve-stimulated, isometric torques of the ankle dorsiflexors in a group of ambulant patients with myopathies and compared results with voluntary Manual Muscle Tests (MMT). RESULTS: From ten recruited patients, five could finish the five-year protocol. Twenty-seven force measurements sessions (one per year; 1,5 hours duration each) were performed. These patients exhibited low, stable torques or increased minimally (0.2 Newtonmeter, versus 0.1 Nm, ns; 0.7 vs. 1.0, ns; 3.4 vs. 3.5, ns; 0.2 vs. 0.1, ns; 0.8 vs. 1.5, P 0.0004 initial values vs. 5-year values, [norm: 3.9-5.7 Nm]). A 6th patient, eliciting low torque values (0.1 Nm) early passed away. Contraction times inversely correlated with MMT. MMT provided similar overall force abilities. CONCLUSIONS: Long-term monitoring of lower leg muscle forces in ambulant patients is limited by the patient's health status. In a small group of patients, stimulated lower leg forces did not worsen over many years relative to their diagnosed myopathies. Tracking involuntary forces, could be a useful monitoring providing phenotypic information, in addition to MMT. Future devices should be small and be simply self-applying, designed for subjects' domestic use and web-based data transfer. CLINICALTRIALS: gov NCT00735384.

Foot and lower leg pain in children and adults with cerebral palsy: a population-based register study on 5,122 individuals.

BACKGROUND: Pain is common in individuals with cerebral palsy (CP) and the most reported pain site is the foot/lower leg. We analyzed the prevalence of pain in the foot/lower leg and the associations with age, sex, gross motor function, and clinical findings in individuals with CP. METHOD: This was a cross-sectional register-study, based on data reported to the Swedish Cerebral Palsy Follow-up Program (CPUP). All participants in CPUP, four years-of-age or older, were included. Pearson chi-square tests and logistic regression were used to analyze the prevalence and degree of pain in the foot/lower leg. RESULTS: In total, 5,122 individuals were included from the CPUP database: 58% were males and 66% were under 18 years-of-age. Overall, 1,077 (21%) reported pain in the foot/lower leg. The odds ratios (ORs) of pain were higher in females (OR 1.31, 95% confidence interval (CI) 1.13-1.53), individuals who could ambulate (Gross Motor Function Classification System Level I (OR 1.84, CI 1.32-2.57) and II (OR 2.01, CI 1.46-2.79) compared to level V), and in individuals with decreased range of motion of the ankle (dorsiflexion 1-10 degrees (OR 1.43, CI 1.13-1.83) and ≤ 0 degrees (OR 1.46, CI 1.10-1.93) compared to ≥ 20 degrees). With increasing age the OR of pain increased (OR 1.02, CI 1.01-1.03) as well as the reported pain intensity (p < 0.001). CONCLUSIONS: Pain in the foot and lower leg appears to be a significant problem in individuals with CP, particularly in those who walk. As with pain in general in this population, both pain intensity and frequency increase with age. The odds of pain in the foot and lower leg were increased in individuals with limited dorsiflexion of the ankle. Given the cross-sectional design causality cannot be inferred and it is unknown if pain causes decreased range of motion of the ankle or if decreased range of motion causes pain. Further research is needed on causal pathways and importantly on prevention.

Measuring Surface Electromyography with Textile Electrodes in a Smart Leg Sleeve.

This paper presents the design, development, and validation of a novel e-textile leg sleeve for non-invasive Surface Electromyography (sEMG) monitoring. This wearable device incorporates e-textile sensors for sEMG signal acquisition from the lower limb muscles, specifically the anterior tibialis and lateral gastrocnemius. Validation was conducted by performing a comparative study with eleven healthy volunteers to evaluate the performance of the e-textile sleeve in acquiring sEMG signals compared to traditional Ag/AgCl electrodes. The results demonstrated strong agreement between the e-textile and conventional methods in measuring descriptive metrics of the signals, including area, power, mean, and root mean square. The paired data t-test did not reveal any statistically significant differences, and the Bland-Altman analysis indicated negligible bias between the measures recorded using the two methods. In addition, this study evaluated the wearability and comfort of the e-textile sleeve using the Comfort Rating Scale (CRS). Overall, the scores confirmed that the proposed device is highly wearable and comfortable, highlighting its suitability for everyday use in patient care.

A case of vitiligo that followed the path of a varicose vein in the lower leg.

Vitiligo is an acquired chronic depigmenting disorder of the skin and is characterized by the destruction of melanocytes. One of the clinical features of vitiligo is that damage to normal skin frequently results in the formation of depigmented macules, which is known as Köebner's phenomenon (KP). Here, we presented a case of vitiligo, in which depigmented macules followed the course of a dilated varicose vein. Dilatation of blood vessels was considered to contribute to the development of the vitiliginous lesions as a trigger for KP. Any kind of skin injury can trigger KP, but this is only the second case in which a dilated blood vessel caused KP in vitiligo. J. Med. Invest. 71 : 177-178, February, 2024.

SurLym trial: study protocol for a multicentre pragmatic randomised controlled trial on the added value of reconstructive lymphatic surgery to decongestive lymphatic therapy for the treatment of lymphoedema.

INTRODUCTION: Lymphoedema is a chronic condition caused by lymphatic insufficiency. It leads to swelling of the limb/midline region and an increased risk of infection. Lymphoedema is often associated with mental and physical problems limiting quality of life. The first choice of treatment is a conservative treatment, consisting of exercises, skin care, lymph drainage and compression. Reconstructive lymphatic surgery is also often performed, that is, lymphovenous anastomoses, lymph node transfer or a combination. However, robust evidence on the effectiveness of reconstructive lymphatic surgery is missing. Therefore, the objective of this trial is to investigate the added value of reconstructive lymphatic surgery to the conservative treatment in patients with lymphoedema. METHODS AND ANALYSIS: A multicentre randomised controlled and pragmatic trial was started in March 2022 in three Belgian university hospitals. 90 patients with arm lymphoedema and 90 patients with leg lymphoedema will be included. All patients are randomised between conservative treatment alone (control group) or conservative treatment with reconstructive lymphatic surgery (intervention group). Assessments are performed at baseline and at 1, 3, 6, 12, 18, 24 and 36 months. The primary outcome is lymphoedema-specific quality of life at 18 months. Key secondary outcomes are limb volume and duration of wearing the compression garment at 18 months. The approach of reconstructive lymphatic surgery is based on presurgical investigations including clinical examination, lymphofluoroscopy, lymphoscintigraphy, lymph MRI or CT angiography (if needed). All patients receive conservative treatment during 36 months, which is applied by the patient's own physical therapist and by the patient self. From months 7 to 12, the hours a day of wearing the compression garment are gradually decreased. ETHICS AND DISSEMINATION: The study has been approved by the ethical committees of University Hospitals Leuven, Ghent University Hospital and CHU UCL Namur. Results will be disseminated via peer-reviewed journals and presentations. TRIAL REGISTRATION NUMBER: NCT05064176.

Turkish translation and transcultural validity and reliability of an assessment tool for spasticity: Leg Activity Measure (Leg A).

BACKGROUND: The Leg Activity Measure is the only self-report measure that has been published to date that takes into account both the influence on quality of life and passive and active function in the literature. AIMS: The purpose is to examine the translation, cross-cultural adaptation validity and reliability of the Turkish version of the Leg Activity Measure (Tr-LegA). METHODS: Neurological patients (n = 52) with lower limb spasticity (aged 47.09 ± 14.74 years) were enrolled. The study consisted of two stages. At the first stage, the scale was translated into Turkish and culturally adapted. Validity and reliability analyses were conducted at the second stage. Construct validity was evaluated by exploratory factor analysis (EFA). The Rivermead Mobility Index (RMI), Nottingham Health Profile (NHP), and Functional Independence Measure (FIM) were used for convergent validity. The reproducibility (test-retest reliability) was assessed by the intraclass correlation coefficient (ICC). Furthermore, the standard error of measurement (SEM) was calculated. RESULTS: EFA suggested one factor for the Passive Function and two factors for the Active Function and Impact on Quality of Life Scales (QoL). Tr-LegA Passive and Active Function Scales were correlated with the total RMI, NHP, and FIM (p < 0.05). Tr-LegA Impact on Quality of Life Scale was correlated with the RMI and NHP (p < 0.05). Tr-LegA Passive Function Scale (ICC = 0.997), Tr-LegA Active Function Scale (ICC = 0.996), and Tr-LegA Impact on Quality of Life Scale (ICC = 0.976) had good reliability. Only Passive Function Scale had a significant floor effect (25%). CONCLUSIONS: Tr-LegA is a valid and reliable multidimensional scale for passive and active function and quality of life in patients with lower limb spasticity. THE CLINICAL TRIAL NUMBER: NCT05182411.

The Influence of a Polyphenol-Rich Red Berry Fruit Juice on Recovery Process and Leg Strength Capacity after Six Days of Intensive Endurance Exercise in Recreational Endurance Athletes.

BACKGROUND: Various nutritional strategies are increasingly used in sports to reduce oxidative stress and promote recovery. Chokeberry is rich in polyphenols and can reduce oxidative stress. Consequently, chokeberry juices and mixed juices with chokeberry content are increasingly used in sports. However, the data are very limited. Therefore, this study investigates the effects of the short-term supplementation of a red fruit juice drink with chokeberry content or a placebo on muscle damage, oxidative status, and leg strength during a six-day intense endurance protocol. METHODS: Eighteen recreational endurance athletes participated in a cross-over high intensity interval training (HIIT) design, receiving either juice or a placebo. Baseline and post-exercise assessments included blood samples, anthropometric data, and leg strength measurements. RESULTS: A significant increase was measured in muscle damage following the endurance protocol in all participants (∆ CK juice: 117.12 ± 191.75 U/L, ∆ CK placebo: 164.35 ± 267.00 U/L; p = 0.001, η2 = 0.17). No group effects were detected in exercise-induced muscle damage (p = 0.371, η2 = 0.010) and oxidative status (p = 0.632, η2 = 0.000). The reduction in strength was stronger in the placebo group, but group effects are missing statistical significance (∆ e1RM juice: 1.34 ± 9.26 kg, ∆ e1RM placebo: -3.33 ± 11.49 kg; p = 0.988, η2 = 0.000). CONCLUSION: Although a reduction in strength can be interpreted for the placebo treatment, no statistically significant influence of chokeberry could be determined. It appears that potential effects may only occur with prolonged application and a higher content of polyphenols, but further research is needed to confirm this.

Influence of Magnetic Field Strength on Intravoxel Incoherent Motion Parameters in Diffusion MRI of the Calf.

Background: The purpose of this study was to investigate the dependence of Intravoxel Incoherent Motion (IVIM) parameters measured in the human calf on B0. Methods: Diffusion-weighted image data of eight healthy volunteers were acquired using five b-values (0-600 s/mm2) at rest and after muscle activation at 0.55 and 7 T. The musculus gastrocnemius mediale (GM, activated) was assessed. The perfusion fraction f and diffusion coefficient D were determined using segmented fits. The dependence on field strength was assessed using Student's t-test for paired samples and the Wilcoxon signed-rank test. A biophysical model built on the three non-exchanging compartments of muscle, venous blood, and arterial blood was used to interpret the data using literature relaxation times. Results: The measured perfusion fraction of the GM was significantly lower at 7 T, both for the baseline measurement and after muscle activation. For 0.55 and 7 T, the mean f values were 7.59% and 3.63% at rest, and 14.03% and 6.92% after activation, respectively. The biophysical model estimations for the mean proton-density-weighted perfusion fraction were 3.37% and 6.50% for the non-activated and activated states, respectively. Conclusions: B0 may have a significant effect on the measured IVIM parameters. The blood relaxation times suggest that 7 T IVIM may be arterial-weighted whereas 0.55 T IVIM may exhibit an approximately equal weighting of arterial and venous blood.

Shoe sole impedes leg muscle activation and impairs dynamic balance responding to a standing-slip.

The shoe sole is identified as a fall risk factor since it may impede the afferent information about the outside world collected by the plantar sensory units. However, no study has directly quantified how the shoe sole compromises body balance and increases fall risk. This study aimed to inspect how the sole affects human balance after an unexpected standing-slip. It was hypothesized that individuals wearing the sole, relative to their barefoot counterparts, would exhibit 1) more impaired stability and 2) disrupted lower limb muscle activation following a standing-slip. Twenty young adults were evenly randomized into two groups: soled and barefoot. The soled group wore a pair of customized 10-mm thick soles, while the other group was bare-footed. Full-body kinematics and leg muscle electromyography (EMG) were collected during a standardized and unexpected standing-slip. The EMG electrodes were placed on the tibialis anterior, gastrocnemius, rectus femoris, and biceps femoris bilaterally. Dynamic stability, spatiotemporal gait parameters, and the EMG latency of the leg muscles were compared between groups. The sole impeded the initiation of the recovery step possibly because it interfered with the accurate detection of the external perturbation and subsequently activated the leg muscles later in the soled group than in the barefoot group. As a result, individuals in the soled group experienced a longer slip distance and were more unstable than the barefoot group at the recovery foot liftoff. The findings of this study could augment our understanding of how the shoe sole impairs body balance and increases the fall risk.

The usage of a modified straight-leg raise neurodynamic test and hamstring flexibility for diagnosis of non-specific low back pain: A cross-sectional study.

OBJECTIVES: The main purpose of this research study was to compare mean modified straight-leg raise test (mSLR) and hamstring muscle length (HL) between chronic non-specific low back pain (LBP) and healthy subjects to understand the possibility of neuropathic causes in LBP population as it may impact the diagnosis and treatment of LBP. Another purpose was to compare mean mSLR between those with lumbar nerve root impingement and those without as determine by magnetic resonance imaging (MRI). METHODS: The design of the study is cross sectional and included 32 subjects with ages ranging from 18-50 years old. Clinical exam objective measures were collected such as patient questionnaires, somatosensory tests, HL range of motion, and a mSLR test, and were compared to the findings from a structural lumbar spine MRI. RESULTS: There were no significant differences in mean HL angulation and mSLR angulation between LBP and healthy subjects (p>0.05). There was no significant difference in mean HL by impingement by versus no impingement (38.3±15.6 versus 44.8±9.4, p = 0.08, Cohen's d = 0.50). On the other hand, there was a significant difference in mean mSLR angulation by impingement (57.6.3±8.7 versus 63.8±11.6, p = 0.05, Cohen's d = 0.60). CONCLUSIONS: The mSLR test was found to be associated with lumbar nerve root compression, regardless of the existence of radiating leg symptoms, and showed no association solely with the report of LBP. The findings highlight the diagnostic dilemma facing clinicians in patients with chronic nonspecific LBP with uncorrelated neuroanatomical image findings. Clinically, it may be necessary to reevaluate the common practice of exclusively using the mSLR test for patients with leg symptoms. This study may impact the way chronic LBP and neuropathic symptoms are diagnosed, potentially improving treatment methods, reducing persistent symptoms, and ultimately improving disabling effects.

The effect of forward postural lean on running economy, kinematics, and muscle activation.

BACKGROUND: Running economy, commonly defined as the metabolic energy demand for a given submaximal running speed, is strongly associated with distance running performance. It is commonly believed among running coaches and runners that running with increased forward postural lean either from the ankle or waist improves running economy. However, recent biomechanical research suggests using a large forward postural lean during running may impair running economy due to increased demand on the leg muscles. PURPOSE: This study tests the effect of altering forward postural lean and lean strategy on running economy, kinematics, and muscle activity. METHODS: 16 healthy young adult runners (23±5 years, 8M/8F) ran on a motorized treadmill at 3.58m/s using three postural lean angles [upright, moderate lean (50% of maximal lean angle), and maximal lean] and two strategies (lean from ankle and lean from waist [trunk lean]). Metabolic energy consumption, leg kinematics, and muscle activation data were recorded for all trials. RESULTS: Regardless of lean strategy, running with an increased forward postural lean (up to 8±2 degrees) increased metabolic cost (worsened economy) by 8% (p < .001), increased hip flexion (p < .001), and increased gluteus maximus (p = .016) and biceps femoris (p = .02) muscle activation during the stance phase. This relation between running economy and postural lean angle was similar between the ankle and trunk lean strategies (p = .743). CONCLUSION: Running with a large forward postural lean reduced running economy and increased reliance on less efficient extensor leg muscles. In contrast, running with a more upright or moderate forward postural lean may be more energetically optimal, and lead to improved running performance.

Limb and joint kinetics during walking in individuals with Mild-Moderate Parkinson's disease.

Given the known deficits in spatiotemporal aspects of gait for people with Parkinson's disease (PD), we sought to determine the underlying gait abnormalities in limb and joint kinetics, and examine how deficits in push-off and leg swing might contribute to the shortened step lengths for people with PD. Ten participants with PD and 11 age-matched control participants walked overground and on an instrumented treadmill. Participants with PD then walked on the treadmill with a posteriorly directed restraining force applied to 1) the pelvis to challenge push-off and 2) the ankles to challenge leg swing. Spatiotemporal, kinematic, and force data were collected and compared between groups and conditions. Despite group differences in spatiotemporal measures during overground walking, we did not observe these differences when the groups walked on a treadmill at comparable speeds. Nevertheless, the hip extension impulse appeared smaller in the PD group during their typical walking. When challenging limb propulsion, participants in the PD group maintained step lengths by increasing the propulsive impulse. Participants with PD were also able to maintain their typical step length against resistance intended to impede swing limb advancement, and even increased step lengths with cuing. The presence of reduced hip extension torque might be an early indicator of gait deterioration in this neurodegenerative disease. Our participants with PD were able to increase hip extension torque in response to needed demands. Additionally, participants with PD were able to increase limb propulsion and leg swing against resistance, suggesting a reserve in limb mechanics.

The relationship between joint kinematic patterns during single-leg drop landing and perceived instability in individuals with chronic ankle instability.

BACKGROUND: Perceived instability is a primary symptom among individuals with chronic ankle instability. However, the relationship between joint kinematics during landing remains unclear. Therefore, we investigated the relationships between landing kinematics and perceived instability in individuals with chronic ankle instability. METHODS: In 32 individuals with chronic ankle instability, we recorded ankle, knee, and hip joint angles during a single-leg drop landing. Joint angle waveforms during 200 ms before and after initial contact were summarized into single values using two methods: peak joint angles and principal component scores via principal component analysis. Using Spearman's rank correlation coefficient (ρ), we examined the relationships of peak joint angles and principal component scores with the Cumberland Ankle Instability Tool score, with a lower score indicating a greater perceived instability (α = 0.05). FINDINGS: The second principal component scores of ankle angle in the horizontal and sagittal planes significantly correlated with the Cumberland Ankle Instability Tool score (Horizontal: ρ = 0.507, P = 0.003; Sagittal: ρ = -0.359, P = 0.044). These scores indicated the differences in the magnitude of angles before and after landing. Significant correlations indicated a greater perceived instability correlated with smaller internal rotation and plantarflexion before landing and smaller external rotation and dorsiflexion after landing. In contrast, no peak joint angles correlated with the Cumberland Ankle Instability Tool score (P > 0.05). INTERPRETATION: In individuals with chronic ankle instability, ankle movements during landing associated with perceived instability may be a protective strategy before landing and potentially cause ankle instability after landing.

Inter-leg systolic blood pressure difference has been associated with all-cause and cardiovascular mortality: analysis of NHANES 1999-2004.

BACKGROUND: Inter-leg systolic blood pressure difference (ILSBPD) has emerged as a novel cardiovascular risk factor. This study aims to investigate the predictive value of ILSBPD on all-cause and cardiovascular mortality in general population. METHODS: We combined three cycles (1999-2004) of the National Health and Nutrition Examination Survey (NHANES) data. Levels of ILSBPD were calculated and divided into four groups based on three cut-off values of 5, 10 and 15mmHg. Time-to-event curves were estimated with the use of the Kaplan-Meier method, and two multivariable Cox proportional hazards regression models were conducted to assess the hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause and cardiovascular mortality associated with ILSBPD. RESULTS: A total of 6 842 subjects were included, with the mean (SD) age of 59.5 (12.8) years. By December 31, 2019, 2 544 and 648 participants were identified all-cause and cardiovascular mortality respectively during a median follow-up of 16.6 years. Time-to-event analyses suggested that higher ILSBPD was associated with increased all-cause and cardiovascular mortality (logrank, p < 0.001). Every 5mmHg increment of ILSBPD brings about 5% and 7% increased risk of all-cause and cardiovascular mortality, and individuals with an ILSBPD ≥ 15mmHg were significantly associated with higher incidence of all-cause mortality (HR 1.43, 95%CI 1.18-1.52, p < 0.001) and cardiovascular mortality (HR 1.73, 95%CI 1.36-2.20, p < 0.001) when multiple confounding factors were adjusted. Subgroup and sensitivity analysis confirmed the relationship. CONCLUSIONS: Our findings suggest that the increment of ILSBPD was significantly associated with higher risk of all-cause and cardiovascular mortality in general population.