Neoadjuvant chemoradiation treatment followed by surgery for esophageal cancer: there is much more than the mandard tumor regression score.

OBJECTIVE: Tumor regression grading (TRG) systems categorize residual tumor volume on the primary tumor after neoadjuvant treatment. Aim was to evaluate the impact of Mandard TRG, residual tumor depth (ypT) and residual lymph node status (ypN) and extent (ELNI) i.e. intracapsular versus extracapsular involvement on overall (OS) and disease-free survival (DFS) in esophageal carcinoma. METHODS: Between 2005 and 2014, 344 patients receiving R0-esophagectomy after neoadjuvant chemoradiation therapy (nCRT) were selected. Mandard TRG, ypTN and ELNI were prospectively recorded. RESULTS: Mandard TRG1 was found in 110 (32%); TRG2 in 120 (35%); TRG3 in 53 (15%); TRG4 in 54 (16%) and TRG5 in 7 (2%) patients. Both OS and DFS showed no significant difference between TRG1 and 2 (p = 0.059 and 0.105, respectively). Therefore, TRG1/2 was classified together as 'major response', TRG3/4 as 'minor response' and TRG5 as 'no response'. Multivariate analysis showed two independent prognosticators for OS (tumor regression response (TRR) and number of positive lymph nodes) and three independent prognosticators for DFS (TRR, ypT and ELNI). CONCLUSION: After nCRT followed by surgery for esophageal carcinoma, number of residual positive lymph nodes as well as TRR are prognosticators for OS. Minor TRR, ypT and extracapsular lymph node invasion are prognosticators for recurrence.

Development and validation of a motor function classification in patients with neuromuscular disease: the NM-score.

OBJECTIVE: To develop a classification for neuromuscular disease patients in each of the three motor function domains (D1: standing and transfers; D2: axial and proximal function; D3: distal function). MATERIALS AND METHODS: A draft classification was developed by a study group and then improved by qualitative validation studies (according to the Delphi method) and quantitative validation studies (content validity, criterion validity and inter-rater reliability). A total of 448 patients with genetic neuromuscular diseases participated in the studies. RESULTS: On average, it took 6.3minutes to rate a patient. The inter-rater agreement was good when the classification was based on patient observation or an interview with the patient (Cohen's kappa=0.770, 0.690 and 0.642 for NM-Score D1, D2 and D3 domains, respectively). Stronger correlations (according to Spearman's coefficient) with the respective "gold standard" classifications were found for NM-Score D1 (0.86 vs. the Vignos Scale and -0.88 vs. the Motor Function Measure [MFM]-D1) and NM-Score D2 (-0.7 vs. the Brooke Scale and 0.64 vs. MFM D2) than for NM-Score D3 (0.49 vs. the Brooke scale and -0.49 vs. MFM D3). DISCUSSION/CONCLUSIONS: The NM-Score is a reliable, reproducible outcome measure with value in clinical practice and in clinical research for the description of patients and the constitution of uniform patient groups (in terms of motor function).

Relationships between motor impairments and activity limitations in patients with neuromuscular disorders.

AIM: The strength and nature of the relationships between motor impairments and activity limitations assessed by the ACTIVLIM questionnaire were investigated in 245 patients with neuromuscular disorders. METHODS: Measures of motor impairments consisted of: (1) a grip strength test using a Jamar dynamometer, (2) a Manual Muscle Testing bilaterally performed in 18 muscle groups and (3) a gait speed spontaneously adopted by the patients using the 10 m timed walking test. RESULTS: Activity limitations were poorly correlated with grip strength in both hands (r = 0.3 and 0.36) and moderately correlated with gait speed (r = 0.53). Spearman's coefficients of correlation between the manual muscle testing and activity limitations were moderate to very poor (rho = 0.5 to 0.17). CONCLUSION: The relationships between motor impairments and activity limitations are not straightforward in patients with neuromuscular disorders, indicating that the activity limitations should be separately assessed and cannot be simply inferred from motor impairment measures.

Botulinum toxin and short-term electrical stimulation in the treatment of equinus in cerebral palsy.

Intramuscular botulinum toxin type A (BT-A) has been shown to reduce spasticity and to improve gait in children with cerebral palsy. To determine whether the efficacy of BT-A may be enhanced by electrical stimulation, as suggested in focal dystonia or in adult spastic patients, 12 children with dynamic foot equinus deformity were randomly assigned to two groups in a blinded, clinically controlled trial. Intramuscular BT-A into calf muscles was followed by adjuvant electrical stimulation in Group A (n = 6) but not in Group B (n = 6). Clinical assessment and instrumented gait analysis were performed before and 1, 3, and 6 months after treatment. The combined treatment of BT-A and electrical stimulation was not superior to BT-A alone. For all patients, improvement of the clinical and gait variables occurred at 1 and 3 months after BT-A injection.

Usefulness of gait analysis combined with motor point block in a stroke patient.

This clinical note describes a typical case of dynamic varus deformity of the rear foot in a stroke patient. An overactive Tibialis Posterior muscle seemed mainly responsible for the varus deformity. However, this hypothesis was not confirmed by a motor point block of this muscle. It appeared that the Tibialis Posterior and Extensor Hallucis Longus muscles were both involved in the varus deformity. A double motor point block of both the Tibialis Posterior and Extensor Hallucis Longus muscles was performed. Kinematic and kinetic data showed improvement. This case report illustrates the usefulness of gait analysis combined with motor point block in the diagnosis and management of gait disturbance.

[Contribution of electromyographic analysis of the walking habits of children with spastic foot in cerebral palsy: a preliminary study]. / L'apport de l'analyse électromyographique de la marche dans l'étude du pied spastique de l'infirme moteur d'origine cérébrale: étude préliminaire.

PURPOSE OF THE STUDY: This preliminary study describes the methodology and the results of gait analysis in cases of equinus and equino-varus deformity of the foot in cerebral palsy children. The ultimate goal was to establish an aid to decision in spastic foot surgical management. MATERIAL: A prospective series of 12 walking children (16 feet) with cerebral palsy has been evaluated prior to surgical correction of equinus or equino-varus deformity of the foot. The mean age was 8 years (range 4 to 11 years of age). METHOD: The pattern of muscle activity during gait cycle has been recorded by surface electrodes for the tibialis anterior, the triceps and the peroneae and by implanted electrodes for the tibialis posterior. Foot switches have been used to differentiate swing and stance gait phases. The results were compared with these of a series of normal children previously published. RESULTS: In four cases, the dynamic equinus was due to an extended or continuous contraction of the triceps surae. The varus deformity appeared to originate from two muscles: the tibialis posterior in 9 cases and the tibialis anterior in 1 case. Both muscles were responsible for the deformity in 2 cases. Two muscular activation patterns were observed in the tibialis posterior: inverted (2 feet) or permanent (9 feet). From the main muscle which was responsible for deformity, we have determined the surgical technique which was most appropriate to restore the muscular balance. DISCUSSION: Our observations confirm Perry's hypothesis, namely that selective and phasic control during the walking cycle does not occur for patients suffering from cerebral palsy. Different surgical procedures were chosen according to the literature on this subject. In the treatment of equinus deformity, lengthening of the Achilles tendon is a satisfactory technique for hemiplegic patients. But we prefer gastrocnemius recession described by Vulpius in spastic diplegia in order to avoid over-lengthening or calcanal gait. If it can be shown that posterior tibial muscle overactivity is the cause of equinovarus, we perform a posterior tibial tendon lengthening, as proposed by Ruda and Frost, or a split posterior tibial tendon transfer as developed by Green. If the posterior tibial muscle is active only during the swing phase, we accomplish a split posterior tibial tendon transfer through the interosseus membrane as advocated by Saji. If the anterior tibial muscle is continuously active, a split anterior tibial tendon transfer to the cuboid described by Hoffer is performed. If the activity is continuous in both the tibial posterior and the tibial anterior muscles, we add a posterior tibial myotendinous lengthening to the split anterior tibial tendon transfer. CONCLUSION: Since 1992, we have developed in our institution a gait analysis laboratory in order to bring objective data in the process of decision making for tendon transfer surgery. With 4 years experience, this objective support now seems to us compulsory in decision of type of transfer. The goal of this preliminary study was to explain how we use the data and match these to our experience and literature.

[Chromoblastomycosis in Gabon. Study of 64 cases]. / La chromoblastomycose au Gabon. Etude de 64 cas.

During the last 25 years, 64 cases of chromoblastomycosis were diagnosed in Gabon. They came from the entire territory, where living in rural zones men as well as women were affected. The evolution of the disease has lasted for more than 10 years for the majority of the cases. The preferential location is the lower limb for 78.5% of the patients, with a double localization for one case and an exceptional malignant transformation for another case. Two clinical aspects emerged, despite an apparent polymorphism: extensive patches and warty nodules, spread apart from or adjacent to the others. The histological images were classical and the fumagoid cells, sometimes budding and filamentous, were easily detected during examination of the squama and scabs. Fonsecaea pedrosoï was the only identified species. The 5-fluorocytosine treatment constantly led to an improvement of the lesions. The major problem for these destitute patients is economic, concerning the cost of the therapy.