The use of a detailed video-based locomotor pattern analysis system to assess the functional reinnervation of denervated hind limb muscles.

BACKGROUND: Spinal cord injuries induce a critical loss of motoneurons followed by irreversible locomotor function impairment. Surgical approaches combined with neuroprotective agents effectively rescue the damaged motoneurons and improve locomotor function. Our aim was to develop a reliable method which is able to provide quantifiable and in-depth data on the locomotor recovery during skeletal muscle reinnervation. NEW METHOD: Sprague-Dawley rats underwent lumbar 4 ventral root avulsion and reimplantation followed by riluzole treatment in order to rescue the injured motoneurons of the damaged pool. Control animals were operated, but received no riluzole treatment. The locomotor pattern of the hind limb was recorded biweekly on a special runway equipped with high resolution and high speed digital cameras producing both lateral and rear views simultaneously. All together 12 parameters of the hind limb movement pattern were evaluated by measuring specific joint angles, footprints and gait parameters in single video frames. Four months after the operation Fast Blue, a fluorescent retrograde tracer was applied to the L4 spinal nerve in order to label the reinnervating motoneurons. RESULTS: Our results confirmed the sensitivity of our arrangement and established strong relationship between the functional improvement and the morphological reinnervation. Moreover, we developed a correction method to make the system tolerant to the differences in the weight, step duration and step length. COMPARISON WITH EXISTING METHODS: There are no commercially available cheap, multi-parametric analysing equipment to characterise the gait in its complexity. CONCLUSIONS: Our system offers a modular, adaptable and expandable analysis on the reinnervation of the limb musculature in rodents.

The Effects of Exergaming on Sensory Reweighting and Mediolateral Stability of Women Aged Over 60: Usability Study.

BACKGROUND: Older adults tend to experience difficulties in switching quickly between various reliable sensory inputs, which ultimately may contribute to an increased risk of falls and injuries. Sideward falls are the most frequent cause of hip fractures among older adults. Recently, exergame programs have been confirmed as beneficial tools for enhancing postural control, which can reduce the risk of falls. However, studies to explore more precisely which mechanism of exergaming directly influences older women's ability to balance are still needed. OBJECTIVE: Our aim was to evaluate, in a single-group pretest/posttest/follow-up usability study, whether Kinect exergame balance training might have a beneficial impact on the sensory reweighting in women aged over 60. METHODS: A total of 14 healthy women (mean age 69.57 [SD 4.66] years, mean body mass index 26.21 [SD 2.6] kg/m2) participated in the study. The volunteers trained with the commercially available games of Kinect for Xbox 360 console 3 times (30 minutes/session) a week over a 6-week period (total of 18 visits). Participants' postural sway in both the anteroposterior (AP) and mediolateral (ML) directions was recorded with NeuroCom Balance Master 6.0. To assess and measure postural sensory reweighting, the Modified Clinical Test of Sensory Interaction in Balance was used, where volunteers were exposed to various changes in visual (eyes open or eyes closed) and surface conditions (firm or foam surface). RESULTS: In the ML direction, the Kinect exergame training caused a significant decrease in the sway path on the firm surface with the eyes open (P<.001) and eyes closed (P=.001), and on the foam surface with the eyes open (P=.001) and eyes closed (P<.001) conditions compared with baseline data. The follow-up measurements when compared with the baseline data showed a significant change in the sway path on the firm surface with the eyes open (P<.001) and eyes closed (P<.001) conditions, as well as on the foam surface with the eyes open (P=.003) and eyes closed (P<.001) conditions. Besides, on the firm surface, there were no significant differences in sway path values in the AP direction between the baseline and the posttraining measurements (eyes open: P=.49; eyes closed: P=.18). Likewise, on the foam surface, there were no significant differences in sway path values in the AP direction under both eyes open (P=.24) and eyes closed (P=.84) conditions. CONCLUSIONS: The improved posturography measurements of the sway path in the ML direction might suggest that the Kinect exergame balance training may have effects on sensory reweighting, and thus on the balance of women aged over 60. Based on these results, Kinect exergaming may provide a safe and potentially useful tool for improving postural stability in the crucial ML direction, and thus it may help reduce the risk of falling.

Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow.

INTRODUCTION: Pulled elbow (PE) is one of the most common injury in children under the age of five years. Diagnosis of PE is usually based on the typical anamnesis and clinical symptoms. A simple reduction maneuver without the need of any imaging modality can eliminate the problem. Certain fractures however can mimic the physical findings of PE and in this cases reduction should not be attempted. The aim of our prospective diagnostic study was to evaluate the accuracy of a sonographic testing method in the differential diagnosis of PE. METHODS: 205 children aged 0-5 with clinical suspicion for PE were enrolled in our study. Inclusion criteria were the typical clinical sign of PE: painful, motionless, extended or slightly flexed and pronated arm following a traumatic event under the age of five. We excluded older children and patients with pronounced elbow swelling and initially flexed and supinated upper arm position. A two plane point of care sonographic examination was carried out at each patient immediately after history taking and primary physical survey. Presence of the elevated dorsal sonographic fat pad sign(FPS) and the synovial fringe enlargement (SFE) were examined from dorsal and ventral longitudinal planes. Children with FPS positivity and/or unsuccessful reduction were x-rayed. Suspected occult fractures with persistent complains were also x-rayed on the 3rd week. Sonographic pictures and x-rays were analyzed and compared to clinical findings. RESULTS: The diagnosis of PE was confirmed in 196 cases. (95.6%). 9 children had type I. supracondylar humerus fractures. (4.39%) Out of these 2 proved to be occult fractures.(0.97%). SFE positivity was detected only in the PE group (156 cases, 76%) fractures have not shown this sign. Elevated FPS was negative in all but one PE cases, while all fractures showed FPS positivity without exception. Evaluating the two parameters together both sensitivity, specificity, negative and positive predictive value were 100%. CONCLUSIONS: The two plane sonographic point of care method is an effective tool for confirming the diagnosis of PE and excluding the presence of fractures. It is an easy, standard and objective procedure which can be used as a fast diagnostic test before reduction attempts.

Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency.

INTRODUCTION: Positive role of ultrasound in the diagnosis of pediatric elbow injuries were confirmed by many papers but no comprehensive, standardized method has been developed for daily clinical practice. The aim of our prospective diagnostic study was to prove the efficacy of a five point sonographic point of care method for detecting different pediatric elbow fractures or dislocations. METHODS: Between 2016 January and 2017 March 365 children (age 1-14) with suspected closed elbow injury were enrolled in our study. Sonographic point of care examination was carried out by a properly trained resident and two orthopedic surgeons immediately after physical survey. We used a standardized five point sonographic examination. Two plane x-rays were made following sonography according to protocol. Utility of sonographic pictures were analyzed by a radiologist. Cases with images which have not met with standard requirements were excluded. In those cases when primary x-rays were negative and/or any of the ultrasound planes showed positive findings, radiography was repeated after 4 weeks of injury. If we detected callus formation the fracture was considered occult. Cases with images which have not met with standard requirements were excluded. Ultrasonic pictures, evaluation sheets and x-ray results were compared. RESULTS: Out of the 365 cases we identified 165 with positive findings (45, 2%) by primary x-rays. Distribution of the different injuries were the following: Radial condylar fractures, (n = 29) supracondylar humeral fractures (n = 84 proximal radial fractures, (n = 19) proximal ulnar fractures, (n = 7) fractures with joint dislocations (n = 3) joint dislocations without fractures, n = 2 medial epicondyle fractures (n = 14) fracture combinations (n = 7) We did not find injuries in this series that we could not categorize into these groups. Evaluating the abnormal sonographic dorsal fat pad sign (FPS) as a sole parameter for fracture detection we found sensitivity: 0, 97, specificity: 0,97, positive predictive value: 0,97, negative predictive value: 0,97 Evaluating the effectivity of the four cortical planes we calculated sensitivity 0, 85 specificity 0.96 positive predictive value: 0. 95 negative predictive value 0.87. The overall values of the five planes were the following: specificity0.97 sensitivity 1, positive predictive value 0.97 negative predictive value: 1 Interrater agreements on the cortical plane abnormality were considered good at two examiners and very good at one examiner. (Kappa = 0.79, 0, 81, 0, 79) Agreements on differentiation of elevated, normal fat pad) or lipohaemarthrosis in sonographic pictures were very good in all cases. (Kappa = 0,83, 0,86,0,82) While identification of any displacement or dislocation was possible in 96%, of all cases(n = 59)the exact determination of the type of the injury was possible in only 70,3% (n = 116) CONCLUSIONS: Using the five point ultrasonic examination provides enough information for excluding or confirming the presence of any pediatric elbow fractures or dislocations. The method is quick, simple and can help in the immediate differentiation of the severity of injuries. Sonographic lipohaemarthrosis seems to be more sensitive than elevated fat pad sign for the detection of potential occult fractures. Positive cases should be cleared by x-rays because the exact nature of the fractures are not identifiable only by ultrasound.

Is Kinect Training Superior to Conventional Balance Training for Healthy Older Adults to Improve Postural Control?

OBJECTIVE: To investigate the effects of balance training to improve postural control in adults older than 60. Our aim was to find out if Kinect training is superior to the conventional balance training in aspects of functional balance tests and posturography measurements testing postural stability through visual feedback. MATERIALS AND METHODS: Thirty subjects participated in the Kinect training group (29 women and 1 man), practiced Kinect Adventures and Sports, 23 volunteers (22 women and 1 man) attended the conventional balance training, and 22 participants (18 women and 4 men) were allocated to the no-intervention control group. Both interventions lasted for 6 weeks, three times a week, and 30 minutes per session. The Four-Square Step Test, Functional Reach Test, Timed Up and Go test, Timed Up and Go cognitive dual-task test were measured, and for the assessment of the limit of stability (LOS), we used computerized posturography. Measurements were taken before the training at baseline and 6 weeks after (follow-up) the interventions. Statistical analysis was done through two-factor mixed analysis of variance and Newman-Keuls post hoc test. RESULTS: Both training groups showed progress in the follow-up measurements; however, more statistically significant improvements were found in favor of the Kinect balance training group (Timed Up and Go test [P < 0.05], Timed Up and Go cognitive dual-task test [P < 0.05], Four-Square Step Test [P < 0.05], Functional Reach Test [P < 0.05], LOS movement velocity [P < 0.05]). CONCLUSION: Our results suggest that Kinect balance training may be a preferable and safe method for the healthy older adults to improve postural control and reduce the possibility of falling.

Intraoperative sonography may reduce the risk of extensor pollicis longus tendon injury during dorsal entry elastic intramedullary nailing of the radius in children.

Extensor pollicis longus tendon (EPL) injury is a potential complication of dorsal entry radial elastic nailing technique in children. The aim of this study was to investigate if intraoperative ultrasonographic guidance can reduce the risk of (EPL) injury.Correlation between sonographic and operative findings were examined first in 6 adult cadavers. Position of Lister's tubercle, EPL, and extraosseal end of the elastic nail were detected by ultrasound imaging during a minimally invasive dorsal entry nailing. Radial slope of Lister's eminence was determined as a safe and easily identifiable entry point for opening the medullary canal. Extraosseal ends of the nails were bended in a slight radial direction and cut immediately beneath the skin in a maximally palmar-flexed wrist position. Cadaveric dissections followed our procedures all correlated with ultrasonographic findings, we have not seen tendon damage, obstruction or friction by the implant's end.After cadaveric experiments, we began using intraoperative sonography for monitoring elastic nail insertion in pediatric radial fractures.Between January 2015 and November 2016, 77 pediatric closed diaphyseal radial fractures were operated by dorsal approach ESIN under intraoperative sonographic checking.Procedures were executed by 2 orthopedic surgeons experienced in ESIN technique with basic musculoskeletal ultrasonographic qualifications.Sonographic identification of EPL and Lister's tubercle in the transverse view was possible in all cases. Determination of the position of the nail end to EPL was also possible in all cases. Mean distance of the transverse view center of the EPL and nail was 0.49 cm (range 0.3-0.62 cm, SD = 0.66). Based on the sonographic transverse view, the operator decided repositioning the nails by 2 patients.We have not found EPL injury postoperatively. All patients were followed for at least 12 months after operations. Nails were removed in all children without further complications.Intraoperative sonography helps determining optimal insertion point and the risk of EPL injury may be reduced during dorsal entry approach.Although the procedure is relatively easy, authors take note that surgical and sonoanatomic knowledge, basic sonographic skills and experience in the ESIN technique are equally necessary for its successful application. A greater number of cases is necessary to confirm our initial promising experiences.

Delayed Spinal Cord-Brachial Plexus Reconnection after C7 Ventral Root Avulsion: The Effect of Reinnervating Motoneurons Rescued by Riluzole Treatment.

Ventral root avulsion induces dramatic loss of the affected spinal cord motoneurons. The neuroprotective effect of riluzole has been previously proven on the injured motoneurons: the vast majority of them can be rescued even when they have no possibility to regenerate their axons. In this study the number of injured motoneurons rescued by riluzole treatment and their capacity to reinnervate the denervated forelimb muscles was investigated. Surgical reconnection with a peripheral nerve graft between the affected spinal cord segment and the C7 spinal nerve was established immediately or with 1- and 3-week delay after avulsion. Avulsion and immediate reconnection of the motoneuron pool to the spinal nerve resulted in moderate reinnervation of the spinal nerve (281 ± 23 standard error of mean [SEM] retrogradely labeled motoneurons), whereas treatment of the injured motoneurons with riluzole yielded considerably higher numbers of reinnervating motoneurons (548 ± 18 SEM). Reconnection of the motor pool with the C7 spinal nerve with 1-week delay allowed fewer motor axons to reinnervate their targets in control and riluzole-treated animals (159 ± 21 vs. 395 ± 16 SEM). A clinically relevant 3-week delay in reconnection further reduced the number of reinnervating motoneurons (76 ± 22 SEM), but riluzole pre-treatment still enabled a significant number of rescued motoneurons (396 ± 17 SEM) to regenerate their axons into the C7 spinal nerve. These results show that those injured adult motoneurons that are rescued by riluzole treatment started immediately after the avulsion injury are able to reinnervate their targets even if they are provided with a conduit several weeks after the primary injury. This finding suggests that partial rescue of injured motoneurons with riluzole in patients who suffered a brachial plexus avulsion injury may provide an available pool of surviving motoneurons for late reconnection/reimplantation surgeries.

Pulmonary epithelioid haemangioendothelioma studies in vitro and in vivo: new diagnostic and treatment methods.

BACKGROUND: Pulmonary epithelioid haemangioendothelioma is a rare endothelial tumour without standard treatment. For this reason, our aim is to present contemporary research outlining new therapeutic possibilities; thus in vitro and in vivo methods were combined. PATIENTS AND METHODS: Pulmonary epithelioid haemangioendothelioma was diagnosed in a 49-year-old female patient. A bronchial excision was obtained from a parenchymal lesion, and the excised sample was manipulated with in vitro-standardized experiments to support the diagnostic and therapeutic procedures. RESULTS: according to in vitro examination of tumour pulmonum and metastases from bone, carboplatin, docetaxel and pharmarubicin was the most effecient treatment modality. CONCLUSION: Currently, pulmonary epithelioid haemangioendothelioma does not have any standard treatment; the most efficient therapeutic regimen was gradually developed by combining in vitro and in vivo methods, which proved to be an efficient therapeutic modality hitherto.

Granulomatous Propionibacterium acnes infection after trauma surgery.

We report here a rare case of infection caused by Propionibacterium acnes following trauma surgery: a 36-year-old male, accident victim was admitted to the hospital because of polytrauma. He underwent a long-drawn-out surgical intervention and after a free-muscle transfer using the rectus femoris muscle, signs of inflammation were detected in the affected area. Microbiological examination of the wound revealed the presence of P. acnes as the only etiological agent of this infection. Adequate antibiotic treatment with penicillin had been started right after the positive microbiological result. Our data confirm the pathogenic potential of P. acnes in late post-surgical infections, and suggest a proper therapeutic approach with intravenous antibiotics and surgical removal of the infected tissue.

Increased survival and reinnervation of cervical motoneurons by riluzole after avulsion of the C7 ventral root.

Although adult motoneurons do not die if their axons are injured at some distance from the cell body, they are unable to survive injury caused by ventral root avulsion. Some of the injured motoneurons can be rescued if the ventral root is re-inserted into the spinal cord. Brachial plexus injuries that involve the complete or partial avulsion of one or more cervical ventral roots can be treated successfully only if satisfactory numbers of motoneurons remain alive following such an injury at the time of reconstructive surgery. Here we investigated the various strategies that could be used to rescue injured rat cervical motoneurons. The seventh cervical ventral root (C7) was avulsed and various therapeutic approaches were applied to induce motoneuronal survival and regeneration. Avulsion of the root without reimplantation resulted in very low numbers of surviving motoneurons (65 ± 8 SEM), while treatment of the injured motoneurons with riluzole resulted in high numbers of surviving motoneurons (637 ± 26 SEM). When the C7 ventral root was reimplanted or a peripheral nerve implant was used to guide the regenerating axons to a muscle, considerable numbers of motoneurons regenerated their axons (211 ± 15 SEM and 274 ± 28 SEM, respectively). Much greater numbers of axons regenerated when reimplantation was followed by riluzole treatment (573 ± 9 SEM). These results show that injured adult motoneurons can be rescued by riluzole treatment, even if they cannot regenerate their axons. Reinnervation of the peripheral targets can also be further improved with riluzole treatment.

Does obstetric brachial plexus injury influence speech dominance?

OBJECTIVE: Right-handedness and left-sided language lateralization is an unresolved mystery with unknown cause/effect relations. Most studies suggest that the language lateralization is related to a fundamental brain asymmetry: right-handedness may be secondary. We analyzed the possibility of an opposite cause/effect relation: whether asymmetric hand usage (as a cause) can influence language lateralization (as a consequence). METHODS: We determined language lateralization by functional magnetic resonance imaging in 15 subjects whose upper limb (UL) had been injured at birth because of unilateral damage of the brachial plexus. These subjects were able to use only one (the noninjured) UL perfectly. RESULTS: We found correlation between the severity of right-sided UL injuries and hand usage dysfunction and the degree of left-to-right shift of language lateralization. There was, however, not a complete switch of language lateralization. INTERPRETATION: Right-sided UL injury can induce a left-to-right shift in language lateralization, suggesting that hand usage can influence language lateralization. These findings may contradict the broadly accepted theory that right-handedness is a secondary phenomenon caused by left-sided hemispheric language lateralization. However, the cause/effect problem between asymmetric hand usage and language lateralization is not resolved in this study. Our findings may support the theory that gestures had a crucial role in human language evolution and is a part of the language system even today.

Regeneration of reinnervated rat soleus muscle is accompanied by fiber transition toward a faster phenotype.

The functional recovery of skeletal muscles after peripheral nerve transection and microsurgical repair is generally incomplete. Several reinnervation abnormalities have been described even after nerve reconstruction surgery. Less is known, however, about the regenerative capacity of reinnervated muscles. Previously, we detected remarkable morphological and motor endplate alterations after inducing muscle necrosis and subsequent regeneration in the reinnervated rat soleus muscle. In the present study, we comparatively analyzed the morphometric properties of different fiber populations, as well as the expression pattern of myosin heavy chain isoforms at both immunohistochemical and mRNA levels in reinnervated versus reinnervated-regenerated muscles. A dramatic slow-to-fast fiber type transition was found in reinnervated soleus, and a further change toward the fast phenotype was observed in reinnervated-regenerated muscles. These findings suggest that the (fast) pattern of reinnervation plays a dominant role in the specification of fiber phenotype during regeneration, which can contribute to the long-lasting functional impairment of the reinnervated muscle. Moreover, because the fast II fibers (and selectively, a certain population of the fast IIB fibers) showed better recovery than did the slow type I fibers, the faster phenotype of the reinnervated-regenerated muscle seems to be actively maintained by selective yet undefined cues.

Incidence and outcome of congenital cytomegalovirus infection in selected groups of preterm and full-term neonates under intensive care.

Congenital cytomegalovirus (CMV) infection is the leading cause of mental retardation and hearing impairment. Examination for the presence of CMV infection was carried out in a selected population of 70 neonates. Urine samples were tested for CMV by means of a nested polymerase chain reaction. CMV was detected in 6 (16.7%) of the 36 preterm newborns and in 5 (14.7%) of the 34 full-term newborns. One preterm neonate died and the remaining 10 newborns were followed up. Two children born at full-term did not excrete CMV at 2 years of age and were symptom-free. Of 8 CMV-excreting children (5 preterm and 3 full-term), 2 were symptom-free (1 preterm and 1 term). Symptomatic CMV disease developed in 6 children (4 preterm and 2 full-term), with mental retardation (n=4), hearing loss (n=1), strabismus (n=2) or bronchial asthma (n=1). Screening of such neonates is important; those identified as congenitally CMV-infected can be monitored to correct any sequelae immediately.

Neural impacts on the regeneration of skeletal muscles.

The regeneration of skeletal muscles is a suitable model to study the development and differentiation of contractile tissues. Neural effects are one of the key factors in the regulation of this process. In the present work, effects of different reinnervation protocols (suture or grafting) were studied upon the regenerative capacity of rat soleus muscles treated with the venom of the Australian tiger snake, notexin, which is known to induce complete necrosis and subsequent regeneration of muscles. Morphological and motor endplate analysis indicated that the regenerative capacity of denervated, and thereafter surgically reinnervated muscles remains impaired compared to that of normally innervated muscles, showing differences in the muscle size, fiber type pattern and motor endplate structure, even 35 days after the notexin injection. A lack or deficiency of secreted neural factors, deterioration of satellite cells and/or incomplete recovery of the sutured or grafted nerves may be the cause of these discrepancies in the regeneration process.