Failure of explicit movement control in patients with functional motor symptoms

Functional neurological symptoms are one of the most common conditions observed in neurological practice, but understanding of their underlying neurobiology is poor. Historic psychological models, based on the concept of conversion of emotional trauma into physical symptoms, have not been implemented neurobiologically, and are not generally supported by epidemiological studies. In contrast, there are robust clinical procedures that positively distinguish between organic and functional motor signs that rely primarily on distracting attention away from movement or accessing it covertly. We aimed to investigate the neurobiological principles underpinning these techniques and implications for understanding functional symptoms. We assessed 11 patients with functional motor symptoms and 11 healthy controls in three experimental set‐ups, where voluntary movements were made either with full explicit control or could additionally be influenced automatically by factors of which participants were much less aware (one‐back reaching, visuomotor transformation, and precued reaction time with variable predictive value of the precue). Patients specifically failed in those tasks where preplanning of movement could occur and under conditions of increasing certainty regarding the movement to be performed. However, they implicitly learned to adapt to a visuomotor transformation as well as healthy controls. We propose that when the movement to be performed can be preplanned or is highly predicted, patients with functional motor symptoms shift to an explicit attentive mode of processing that impairs kinematics of movement control, but movement becomes normal when such processes cannot be employed (e.g., during unexpected movement or implicit motor adaptation). © 2013 Movement Disorder Society     

Combined use of impella device and intra‐aortic balloon pump to improve survival in a patient in profound cardiogenic shock post cardiac arrest

Patients who suffer cardiogenic shock after cardiac arrest have a very poor prognosis. Left ventricular assist devices have proven to be useful in these patients to improve survival. Recently introduced percutaneous assist devices are easier to use and can be inserted quickly in the catheterization laboratory. We describe a case where intra‐aortic balloon pump by itself was not enough to provide hemodynamic support in a patient with cardiogenic shock after cardiac arrest. The Impella Recover^® LP 2.5 system (ABIOMED, Inc., Danvers, MA) was successfully used along with the balloon pump for hemodynamic support and resulted in dramatic improvement of the patient's condition. © 2009 Wiley‐Liss, Inc.     

A case report of Tubulo-Interstitial Nephritis with Uveitis (TINU syndrome) and follow-up for one year

International Urology and Nephrology -     

Extensive coronary dissection treated with endarterectomy and coronary reconstruction

Acute coronary dissection is an uncommon event, usually not related to typical coronary risk factors, usually in women, and usually diagnosed at autopsy. This report describes a young woman with extensive left anterior descending coronary artery (LAD) dissection, refused for intervention since there was no lesion to angioplasty and no artery to bypass. A long arteriotomy was made, removing under direct vision all of the torn and dissected tissue, just as would be done for extensive LAD endarterectomy. A vein was split and attached to reconstruct the artery. Normal left ventricular function was restored.     

Regeneration of primary sensory axons into the adult rat spinal cord via a peripheral nerve graft bridging the lumbar dorsal roots to the dorsal column

This study investigated the feasibility of using a peripheral nerve autograft (NAG) to promote and guide regeneration of sensory axons from the caudal lumbar dorsal roots to the rostral dorsal column following a lower thoracic cordotomy in adult rats. After a left hemicordotomy at the T13 vertebra level and ipsilateral L3 and L4 rhizotomies, a peripheral NAG (peroneal nerve) was connected to the distal roots stumps, then implanted into the left dorsal column 10 mm rostral to hemicordotomy site (n = 12). After surgery, all animals of the experimental group experienced complete anesthesia in their left hindlimb. Three months later, a slight response to nociceptive stimulation reappeared in L3 and/or L4 dermatomes in 6 of the 12 experimental animals. None of these animals exhibited self-mutilation. Nine months after surgery, we performed retrograde tracing studies by injecting horseradish peroxidase (HRP) into the left dorsal column 30 mm rostral to the NAG implantation site. In eight animals, we found HRP-stained neurons in the left L3 and/or L4 dorsal root ganglia (DRG). The mean number of HRP-stained neurons per DRG was 71 +/- 92 (range 2-259). In control groups, no HRP-stained neurons were found in L3 or L4 DRG. Histological analysis of the NAG showed evidence of axonal regeneration in all 8 animals with positive retrograde labeling of DRG neurons. However, we did not find a statistical correlation between the number of HRP-stained neurons and the degree of sensory recovery. This study demonstrates that an NAG joining dorsal roots to the dorsal column, thus shunting the original CNS-PNS junction, can support regeneration of central axons from DRG primary sensory neurons into the dorsal column over distances of at least 30 mm despite the inhibitory influence of the CNS white matter.     

Postangiographic thrombosis of a spinal arteriovenous malformation: case report

The authors report the case of a 30-year-old man who presented with progressive neurological deficits due to a spinal arteriovenous malformation (AVM). There was sudden increase in his neurological deficits after diagnostic angiography was performed. Repeated magnetic resonance imaging and angiography revealed complete thrombosis of the malformation. Stenosis in the draining vein was the most probable cause of this postangiographic occlusion of the AVM. Contrast injection during angiography may have precipitated the thrombosis.     

Suppressive effect of zinc on antibody response to cholera toxin in children given the killed, B subunit-whole cell, oral cholera vaccine

In a previous study, children aged 2-5 years old in Bangladesh were supplemented orally with a single dose of Vitamin A (200,000 IU) and a placebo for zinc (zinc equivalent to 20 mg of elemental zinc) everyday for 42 days (group A), zinc and a placebo for Vitamin A (group Z), zinc and Vitamin A (group AZ) or both placebos (group P). All children were orally immunised with two doses of the killed cholera vaccine containing whole cells and a recombinant B subunit of cholera toxin (CT). The number of children who responded with > or = 4-fold vibriocidal antibody (a proxy indicator of protection against cholera) was significantly greater among the zinc-supplemented groups than among the non-zinc-supplemented groups, while Vitamin A supplementation did not appear to have any effect. The sera from these children were assayed for antibody to CT. Antibody to CT is known to exert a synergistic protective effect against cholera in animal studies, and offer significantly higher short-term protection against cholera and significant short-term protection against enterotoxigenic Escherichia coli diarrhoea in humans on oral immunisation with the cholera vaccine. Children who received zinc had significantly reduced levels of serum antibodies to CT than children who received placebos only. Factorial analysis showed a trend for zinc showing a reduction in the number of children responding with CT-antibody, while Vitamin A did not appear to have any effect. Thus, zinc enhanced vibriocidal antibody response, but suppressed CT-antibody response, suggesting that zinc supplementation has different modulating effects on vibriocidal antibody response and CT-antibody response.     

Cocoa Flavanols Adjuvant to an Oral Nutritional Supplement Acutely Enhances Nutritive Flow in Skeletal Muscle without Altering Leg Glucose Uptake Kinetics in Older Adults

Ageing is associated with postprandial muscle vascular and metabolic dysfunction, suggesting vascular modifying interventions may be of benefit. Reflecting this, we investigated the impact of acute cocoa flavanol (450–500 mg) intake (versus placebo control) on vascular (via ultrasound) and glucose/insulin metabolic responses (via arterialised/venous blood samples and ELISA) to an oral nutritional supplement (ONS) in twelve healthy older adults (50% male, 72 ± 4 years), in a crossover design study. The cocoa condition displayed significant increases in m. vastus lateralis microvascular blood volume (MBV) in response to feeding at 180 and 240-min after ONS consumption (baseline: 1.00 vs. 180 min: 1.09 ± 0.03, p = 0.05; 240 min: 1.13 ± 0.04, p = 0.002), with MBV at these timepoints significantly higher than in the control condition (p < 0.05). In addition, there was a trend (p = 0.058) for MBV in m. tibialis anterior to increase in response to ONS in the cocoa condition only. Leg blood flow and vascular conductance increased, and vascular resistance decreased in response to ONS (p < 0.05), but these responses were not different between conditions (p > 0.05). Similarly, glucose uptake and insulin increased in response to ONS (p < 0.05) comparably between conditions (p > 0.05). Thus, acute cocoa flavanol supplementation can potentiate oral feeding-induced increases in MBV in older adults, but this improvement does not relay to muscle glucose uptake.