Is functional mobility associated with quality of sitting in cerebral palsy? A cross-sectional study.

Objectives: A group of neuromuscular system anomalies associated with non-progressive issues in the developing fetal or newborn brain are known as cerebral palsy (CP). These abnormalities are typified by poor posture and motor development, which limits the execution of functional activities. Consequently, to achieve the same goals as peers who are typically developing, children with CP employ a variety of compensatory postures and techniques. Given that both sitting and mobility are essential for functioning, assessing each skill alone and in relation to the other is necessary. This study aims to determine if a child's functional mobility affects their sitting ability. Materials and Methods: Twenty CP (Gross Motor Function Classification System [GMFCS] levels I and II) children, aged 6-12, were enrolled in the research. The level of sitting scale (LSS) and the modified timed up and go (mTUG) test were utilized to evaluate sitting and functional mobility, respectively. Results: The quality of sitting was shown to have a substantial effect on functional mobility, as a significant difference in mTUG durations was established between LSS levels (P < 0.001) and persisted when analyzed within the same GMFCS level (P = 0.007). Conclusion: The importance of trunk control in functional mobility can be inferred from the link between sitting quality and mobility. To improve children with CP's functional mobility, this evidence may be utilized to design a well-informed and specific intervention program incorporating trunk control.

Oblique direction reach test: evaluating psychometric properties in stroke population.

Background: Post-stroke individuals are observed to have reduced limits of stability (LOS) in all directions. Functional activities are rarely performed in pure cardinal planes; instead, they are most likely to be performed in an oblique direction. Existing tools are either expensive or sophisticated to assess the LOS in an oblique direction. Therefore, this study's primary objective is to evaluate the intra-rater, inter-rater reliability, and validity of the oblique direction reach test (ODRT) among stroke subjects. Materials & Methods: A total of 96 first-time stroke patients with age, gender, height, and weight-matched healthy controls aged 18-80 years were recruited for the study. Oblique, forward, and lateral reach distances were assessed using the standard procedure of ODRT, Functional Reach Test (FRT), and Lateral Reach Test (LRT), respectively. Validity was tested by correlating the ODRT distance with the Berg Balance Scale (BBS) Score using Spearman's rank correlation coefficient. Intraclass correlation coefficients (ICCs) and Bland Altman analysis were used to establish inter-rater reliability. ICCs were used to find intra-rater reliability. The Mann-Whitney U test was used to establish the mean difference of the FRT, LRT, and ODRT. Spearman's rank correlation coefficient and linear regression were used to correlate the distance of FRT and LRT with ODRT. Results: A high concurrent validity was found between BBS and ODRT with an r-value of 0.905 (p < 0.001). Inter-rater reliability was high with an ICC of 0.997 (95% CI [0.996-0.998]), and intra-rater reliability was highly significant with an ICC of 0.996 (95% CI [0.994-0.998]). The stroke subjects reached a significantly shorter distance than healthy individuals in FRT, ODRT, and LRT. ODRT was highly correlated with FRT (r = 0.985) and LRT (r = 0.978) (p < 0.001) and had an R2 = 0.987. Conclusion: ODRT is a highly valid and reliable tool that can be used to evaluate balance in stroke patients. Individuals who reached less in the forward and lateral directions showed reduced reach distance in the oblique direction.

Trans-Thoracic Extra-Pleural Percutaneous Spinal Fixation-A Technical Note.

Study Design: Cross-sectional analysis of defined parameters of patients who underwent the presented technique. Patients undergoing thoracic spine fixation for various pathologies. Objective: This technique attempts to limit the incision size in extrapleural thoracotomy for multi-level spinal fixation. Summary of Background Data: Dorsal spine is traditionally approached by either transpleural or extrapleural approach. The extrapleural approach carries a limitation of being restricted in number of levels it can address. By incrementally modifying the present technique, we were able to employ the approach in greater number of levels with lesser morbidities. Method: Classical extrapleural thoracotomy approach is employed with incision size limited to the levels of pathology (~5 cm). Thereafter, proper exposure using Kittner dissection and defining of screw entry points follows. Stab incision is made and screws placed percutaneously through a K-wire-defined trajectory. Results: Eighteen patients underwent fixation through this technique, of which 11 were infectious, four were traumatic, and the rest were neoplastic in pathology. None except three patients had ICU stay of more than 1 day. All patients had a pain score of 6 or lower except for two. Conclusion: Combining the technique of percutaneous screw placement with traditional extrapleural thoracotomy reduces the size of the incision, tissue damage, and morbidity while reducing the cost and duration of hospitalization without comprising the extent of pathology that can be dealt with.

Effectiveness of structured early mobilization protocol on mobility status of patients in medical intensive care unit.

INTRODUCTION: Patients admitted to the intensive care units (ICU) have limited mobility due to their illness and its management and are at a risk for immobility-related complications. Early mobilization has been suggested to prevent or limit physical dysfunction due to these complications. Effectiveness of early mobilization protocols is studied using various outcomes. OBJECTIVE: To study the effectiveness of an early mobilization protocol on mobility status of patients in Medical ICU. METHODS: Patients admitted to Medical ICU were screened for eligibility and allotted into two groups. Intervention group received mobilization according to a protocol while control group received mobilization as per usual mobilization practices in our ICU. Mobility was assessed using the Perme ICU mobility score on the first day of ICU, first day of rehabilitation and last day of rehabilitation. RESULTS: 63 patients were included in the study. The median difference in the Perme ICU mobility score from first day of rehabilitation to last day of rehabilitation was 9 and 2 in the intervention group and control group respectively. Significant improvements in the mobility scores were not present from first day of ICU to first day of rehabilitation in both, the intervention (p = .069) and control group (p = .124). Improvement in the scores from first day of rehabilitation to last day of rehabilitation was significant within and between both the groups (p < .001). CONCLUSION: Early Mobilization Protocol was effective in improving mobility status of patients in Medical ICU.

Lumbo-peritoneal shunt as treatment modality for visual symptoms in idiopathic intracranial hypertension: A single institution experience / Derivación lumboperitoneal como modalidad terapéutica para los síntomas visuales de la hipertensión intracraneal idiopática: experiencia de una única institución

Objectives To evaluate the efficacy of lumbo-peritoneal shunt (LPS) in patients of idiopathic intracranial hypertension presenting with visual symptoms. Methods Between Apr. 2014 and Mar. 2018, 70 patients of Idiopathic Intracranial Hypertension (IIH) underwent treatment at our institution. Patients were evaluated for neurological and ophthalmological status and were subjected to LPS depending on their symptoms. Results Mean opening pressure was 29.97 ± 5.33 cm of water and mean Body-Mass Index (BMI) was 26.51 ± 3 and the two were significantly correlated (p-value 0.006). All patients with visual symptoms (23) underwent LPS and others (47) were managed medically. All patients with LPS and 25 of medically managed patients improved, while 22 medically-managed patients required LPS due to deterioration in visual symptomatology. The proportion of patients showing complete resolution of features of IIH was significantly different between the three groups. Of the 7 patients with shunt extrusion/migration, only 2 required revision. Conclusion LPS is an equally effective and more technically familiar modality for treatment of IIH for neurosurgeons and should be offered to asymptomatic patients with objective visual signs. Shunt extrusion/migration may not always warrant revision due to “mini-shunt” that drains Cerebro-Spinal Fluid (CSF) through shunt tract even after extrusion (AU)

Evaluar la eficacia de la derivación lumboperitoneal (DLP) en pacientes con hipertensión intracraneal idiopática con síntomas visuales. Métodos Entre abril de 2014 y marzo de 2018, 70 pacientes con hipertensión intracraneal idiopática (HII) se sometieron a tratamiento en nuestra institución. Los pacientes se evaluaron para determinar el estado neurológico y oftalmológico y se sometieron a DLP en función de sus síntomas. Resultados La presión de apertura media fue de 29,97 ± 5,33 cm de agua y el índice de masa corporal (IMC) medio fue de 26,51 ± 3, y los 2 presentaron una correlación significativa (valor de p = 0,006). Todos los pacientes con síntomas visuales (23) se sometieron a DLP y otros (47) recibieron tratamiento farmacológico. Todos los pacientes con DLP y 23 de los pacientes que recibieron tratamiento farmacológico mejoraron, mientras que 22 pacientes con tratamiento farmacológico precisaron DLP debido al deterioro en la sintomatología visual. La proporción de los pacientes que mostró resolución completa de las características de la HII fue significativamente diferente entre los 3 grupos. De los 7 pacientes con extrusión/migración de la derivación, solo 2 precisaron revisión. Conclusión La DLP es una modalidad igual de eficaz y más familiar desde un punto de vista técnico para los neurocirujanos para el tratamiento de la HII y debe ofrecerse a los pacientes asintomáticos con signos visuales objetivos. La extrusión/migración de la derivación puede no justificar siempre una revisión debido a la «miniderivación» que drena el líquido cefalorraquídeo (LCR) a través del conducto de derivación incluso después de la extrusión (AU)

Lumbo-peritoneal shunt as treatment modality for visual symptoms in idiopathic intracranial hypertension: A single institution experience.

OBJECTIVES: To evaluate the efficacy of lumbo-peritoneal shunt (LPS) in patients of idiopathic intracranial hypertension presenting with visual symptoms. METHODS: Between Apr. 2014 and Mar. 2018, 70 patients of Idiopathic Intracranial Hypertension (IIH) underwent treatment at our institution. Patients were evaluated for neurological and ophthalmological status and were subjected to LPS depending on their symptoms. RESULTS: Mean opening pressure was 29.97±5.33cm of water and mean Body-Mass Index (BMI) was 26.51±3 and the two were significantly correlated (p-value 0.006). All patients with visual symptoms (23) underwent LPS and others (47) were managed medically. All patients with LPS and 25 of medically managed patients improved, while 22 medically-managed patients required LPS due to deterioration in visual symptomatology. The proportion of patients showing complete resolution of features of IIH was significantly different between the three groups. Of the 7 patients with shunt extrusion/migration, only 2 required revision. CONCLUSION: LPS is an equally effective and more technically familiar modality for treatment of IIH for neurosurgeons and should be offered to asymptomatic patients with objective visual signs. Shunt extrusion/migration may not always warrant revision due to "mini-shunt" that drains Cerebro-Spinal Fluid (CSF) through shunt tract even after extrusion.

Comparison of Londrina activities of daily living protocol and Glittre ADL test on cardio-pulmonary response in patients with COPD: a cross-sectional study.

BACKGROUND: In COPD patients it is very important to assess the activities of daily living (ADL) due to an impairment of independence and quality of life. There is a lack of retrievable data regarding the cardio-pulmonary response to Londrina ADL protocol in patients with COPD. The aim of the present study was to assess the cardio-pulmonary response to Londrina ADL protocol in patients with COPD and to compare this with responses to the Glittre ADL test. METHODS: This cross-sectional study was done on 30 COPD subjects. Each subject was taken to perform the Londrina ADL protocol, Glittre ADL test, twice each, on subsequent days. The Londrina ADL protocol comprises 5 activities representing ADL, involving upper limbs, lower limbs, and trunk movements. The Glittre ADL test consists of completing a circuit while carrying a weighted backpack (2.5 kg for women, 5.0 kg for men). The better value of the two was taken into consideration. For the Londrina ADL protocol and Glittre ADL test the outcome of primary interest was time and for the six-minute walk test was the distance walked. The secondary outcomes for all tests were heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, saturation of oxygen in blood and dyspnea. RESULTS: The COPD subjects of age group 63.27±11.07 years took 5.94±0.36 min to complete trial 2 of the Londrina ADL protocol. Significant physiological increases in heart rate (p≤0.01), respiratory rate (p≤0.01), blood pressure (p≤0.01) and severity of dyspnea (p≤0.01) were observed, whereas saturation of oxygen in blood (p≤0.01) was reduced at the end of the Londrina ADL protocol and Glittre ADL test. There was a positive, non-significant correlation between the six-minute walk test distance and the Londrina ADL protocol time (r=0.236) (p=0.209). A positive, not significant correlation was observed between the Glittre ADL test (time) and the Londrina ADL protocol (time) (r=0.194) (p=0.304) and a negative but not significant correlation between the six-minute walk test (distance) and the Glittre ADL test (time) (r= -0.184) (p=0.330). CONCLUSION: The Londrina ADL protocol can be used as an assessment tool for the evaluation of functional performance and activities of daily living in COPD along with other test protocols in pulmonary rehabilitation.

Association of thoraco-lumbar fascia length in individuals with non-specific low back pain - an observational study.

OBJECTIVE: The purpose of the study was to assess the length of TLF and to evaluate the strength of muscles attached to it in subjects with and without nonspecific low back pain (NSLBP). METHODS: 31 patients with NSLBP and 31 healthy individuals were included in the study. In each subject the TLF length was assessed by quantifying lumbar rotation using Back range of motion (BROM-II) instrument. The endurance of transverses abdominis was assessed using the pressure biofeedback unit while the strength of Latissimus dorsi, internal and external oblique's were assessed using MMT. Outcome measure such as Range of Motion (ROM) was compared across the group using independent sample T-test. While the muscle strength of Latissimus dorsi and oblique's were compared across the group using Man-whitney U- test. Transverse abdominis endurance was tested using chi-square test. RESULTS: There was statistically significant difference in the length of TLF of subjects with NSLBP when compared with subjects without NSLBP. When the strength of Latissimus dorsi muscle, transverses abdominis muscle and internal and external oblique's muscle was assessed no significant (p value > 0.05) difference was found in either group. CONCLUSIONS: There was statistically significant reduction in length of TLF but there was no difference in the strength of Latissimus dorsi, internal and external oblique's or endurance of transverses abdominus attached to the TLF in individuals with NSLBP and without low back pain. This study will help in determining the inclusion of TLF and the associated structures in evaluation and management of subjects with NSLBP.

Clinical practice guidelines 2019: Indian consensus-based recommendations on influenza vaccination in adults.

Influenza, a common cause of acute respiratory infections, is an important health problem worldwide, including in India. Influenza is associated with several complications; people with comorbidities and the elderly are at a higher risk for such complications. Moreover, the influenza virus constantly changes genetically, thereby worsening therapeutic outcomes. Vaccination is an effective measure for the prevention of influenza. Despite the availability of global guidelines on influenza vaccination in adults, country-specific guidelines based on regional variation in disease burden are required for better disease management in India. With this aim, the Indian Chest Society and National College of Chest Physicians of India jointly conducted an expert meeting in January 2019. The discussion was aimed at delineating evidence-based recommendations on adult influenza vaccination in India. The present article discusses expert recommendations on clinical practice guidelines to be followed in India for adult influenza vaccination, for better management of the disease burden.

Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults.

Similar to the global scenario, pneumococcal diseases are a significant health concern in India. Pneumococcal diseases occur frequently among adults and are largely preventable through vaccines. Globally, several guidelines and recommendations are available for pneumococcal vaccination in adults. However, owing to wide variations in the disease burden, regulatory landscape, and health-care system in India, such global guidelines cannot be unconditionally implemented throughout the country. To address these gaps, the Indian Chest Society and National College of Chest Physicians of India jointly conducted an expert meeting in January 2019. The aim of the discussion was to lay down specific evidence-based recommendations on adult pneumococcal vaccination for the country, with a view to further ameliorate the disease burden in the country. This article presents an overview of the closed-door discussion by the expert members on clinical practice guidelines to be followed for adult pneumococcal vaccination in India.

Reference value for the six-minute peg board and ring test. A cross sectional study.

INTRODUCTION: In our daily life, arm activities, whether supported or unsupported play a major role. Both simple and complex activities require the muscles, namely trapezius, pectoralis minor, scalene, and intercostals, to participate in arm positioning. These muscles also enact as the accessory respiratory muscles. Therefore, arm elevation increases the load on these muscles and they fail to perform dual activities, resulting in arm fatigue and a feeling of dyspnoea in healthy individuals as well as in chronic obstructive pulmonary disease patients. Various upper limb exercise tests were designed to measure this impairment, one of them being the six-minute peg board and ring test. The aim of the study is to derive a reference value for the six-minute peg board and ring test among healthy Indian population (Mangalore) from the age of 20-70 years of either gender. Also, to find a correlation among the number of rings and body mass index, arm length, arm and forearm circumference, the strength of shoulder and elbow flexors-extensors, grip strength of both sides and level of physical activity. METHODS: Participants performed two tests, thirty minutes apart. They were asked to load as many rings as possible in 6 minutes. Arm length, arm and forearm circumference were measured with a measuring tape. Shoulder and elbow flexors-extensors were assessed using a handheld push-pull dynamometer. Grip strength was measured with the Jamar hand-held dynamometer. Level of physical activity was assessed using International Physical Activity Questionnairelong form. RESULTS: The samples consisted of 450 healthy individuals between the age of 20-70 years. Reference values for each age group for both genders were reported. We found that age was correlated with the six-minute peg board and ring test score (p<0.05). We also found a correlation between the strength variables and the test results (p=0.001). However, no correlation was found between the arm length, arm and forearm circumference and the level of physical activity with the number of rings. CONCLUSION: In this study, we derived a reference value for the six-minute peg board and ring test. There was a correlation among age, strength variables and the number of rings.

Normative Values for Londrina ADL Protocol in Healthy Individuals in Age Group of 40-60 Years among Indian Population: A Cross-Sectional Study.

Background: Due to increase in the life expectancy and changes related to aging, it is important to assess ADL (activities of daily living) in older adults. However, there is no standardized protocol available to assess ADLs. Considering the limitations of the available tools, a new protocol named Londrina ADL protocol was developed for which normative values are unavailable in different ethnic groups. Objective: To develop the normative value and reference equation for the Londrina ADL protocol on the basis of anthropometric and demographic variables in healthy individuals in the age group of 40-60 years among the Indian population. Methods: This cross-sectional study was conducted with 282 healthy individuals of both the genders between the age group of 40 and 60 and they were divided into 2 groups: 40-49 and 50-60. Each subject was made to perform the Londrina ADL protocol twice with a 30 min interval between the two protocols. The protocol is composed of 5 activities and the best out of the 2 performances were recorded. Results: The mean time taken among 40-49 years by females is 3.50 ± 0.50 min and by males is 3.73 ± 0.43 min. The mean time taken among 50-60 years by females is 4.25 ± 0.20 min and by males is 4.36 ± 0.18 min. The reference equation to predict reference values for the Londrina ADL protocol was as follows: equation (1): Londrina ADL predicted = 1.205 + (0.054 × age (years)) + (0.001 × height (cm)); equation (2): Londrina ADL predicted = 1.374 + (0.054 × age (years)) + (-0.003 × BMI). Conclusion: The reference equation for the time to complete the Londrina ADL protocol was based on age and BMI as independent variables and can be useful for predicting the performance of healthy individuals.

Bone Sandwich Closure Technique for Posterior Fossa Craniectomy.

Background Surgery of posterior fossa including cerebellopontine (CP) angle involves either craniectomy or craniotomy. While there has been precedence of craniotomy in recent practice, the preferred access in resource-strapped centers still remains been craniectomy. Although the latter offers an excellent exposure, it is believed to carry increased risk of postoperative pseudomeningocoele and cerebrospinal fluid (CSF) leak compared with craniotomy. Methods We have suggested a technique by which after standard craniectomy for the posterior fossa surgeries the bony defect is covered by Gelfoam bone sandwich (GBS) technique. We studied this technique over a period of 25.6 years in 1,028 patients. Results and Conclusion We analyze the risk of pseudomeningocoele and CSF leak in our patients using GBS technique and reviewed literature to compare our outcomes with standard craniotomy and craniectomy procedures.

A system of radiological criteria for grading and prognosticating temporal lobe contusions.

INTRODUCTION: Temporal contusions are common in patients with head injuries and require close monitoring due to the propensity of these patients to deteriorate rapidly and fatally. This study attempts to introduce a radiological grading system for temporal lobe contusions and analyse its prognostic value so as to better identify patients at risk of deterioration. METHODS: The study was conducted as a cross-sectional observational study from April 2011-March 2017 on 42 patients with temporal lobe contusion. Each patients was graded according to the proposed system from a minimum of four to a maximum of 13 and then further grouped in three grades - grade 1 (score = 4), grade 2 (score 5-7) and grade 3 (score > 7) - and their clinical course was closely observed. RESULTS: The minimum and maximum scores observed were four and 11 respectively. The proposed grading system has statistically significant correlation to the Glasgow Coma Scale (p-value < 0.05). All patients in grade 1 (17) could be managed conservatively, while all those in grade 3 (five) needed immediate surgical intervention. Of 20 patients in grade 2, 11 had a score of 5-6 and did not require surgery, whereas nine patients had a score of seven and of these eight required delayed surgical intervention. This correlation was statistically significant (p-value < 0.05). CONCLUSION: The proposed temporal lobe contusion grading system is a good radiological tool to predict the clinical course of patients and thereby identify patients at higher risk of delayed deterioration.

Airway Stenosis Related to Foreign Body Aspiration: An Under-recognized Long term Complication.

INTRODUCTION: Sequelae of chronic foreign body aspiration include occlusive granulation tissue formation, which can cause delayed fixed airway stenosis. The aim of this study is to highlight this complication, which should be diagnosed early and treated proactively. METHODS: We present a case series of areca nut aspiration, an organic foreign body commonly chewed in Southeast Asia, complicated by delayed airway stenosis and examine the peculiar nature of areca nut that predisposes to this complication. RESULTS: Long-term sequelae of areca nut aspiration are granulation tissue formation, potentially complicated by airway stenosis due to the mechanical and chemical irritant nature of areca nut. DISCUSSION: Organic impacted foreign bodies such as areca nut can cause delayed complications of airway stenosis. Both the sharp edges of the areca nut and chemical irritation caused by alkaloids released by the nut in constant contact with the airway mucosa can predispose to this long-term complication. Early diagnosis and appropriate therapeutic interventions such as balloon bronchoplasty can help restore airway patency and prevent lung damage.

Prospective isolation of nonhematopoietic cells of the niche and their differential molecular interactions with HSCs.

A major limitation preventing in vivo modulation of hematopoietic stem cells (HSCs) is the incomplete understanding of the cellular and molecular support of the microenvironment in regulating HSC fate decisions. Consequently, murine HSCs cannot be generated, maintained, or expanded in culture over extended periods of time. A significantly improved understanding of the bone marrow niche environment and its molecular interactions with HSCs is pivotal to overcoming this challenge. We here prospectively isolated all major nonhematopoietic cellular niche components and cross-correlate them in detail with niche cells defined by lineage marking or tracing. Compiling an extensive database of soluble and membrane-bound ligand-receptor interactions, we developed a computational method to infer potential cell-to-cell interactions based on transcriptome data of sorter-purified niche cells and hematopoietic stem and progenitor cell subpopulations. Thus, we establish a compendium of the molecular communication between defined niche components and HSCs. Our analysis suggests an important role for cytokine antagonists in the regulation of HSC functions.

Forty years of clinical excellence at the Dr A Lakshmipathi Neurosurgical Centre and Post-Graduate Institute of Neurological Surgery, Voluntary Health Services (VHS) Hospital.

The Achanta Lakshmipathi Neurosurgical Center (ALNC) and Post Graduate Institute of Neurological Surgery is a private teaching neurosurgical institution located in the VHS (Voluntary Health Services) Hospital Chennai. It has been a leader and trendsetter among the private academic neurosurgical training institutions, and because of its unique legacy, has influenced the progress of Neurosurgery in India. The center was the second neurosurgical Institute to be created by Prof. B Ramamurthi and has trained neurosurgeons in the unique ALNC school of Neurosurgery. The Institute has grown to become a centre of excellence in microsurgery, and spinal surgery and has become a training centre for neurosurgery since 1985. The unique humanitarian aspects of the Voluntary Health Services Hospital helped in bringing the best of Neurosurgery to all strata of society. Forty years after its inception, the ALNC continues its delivery of excellence in clinical neurosurgery and academics.