Self-rehabilitation combined with botulinum toxin to improve arm function in people with chronic stroke. A randomized controlled trial

BackgroundBotulinum toxin injection (BTI) reduces muscle hyperactivity, but its effect on active upper-limb function is limited. Intensive rehabilitation could optimize the effects; however, outpatient post-stroke rehabilitation is usually not intensive. One solution could be self-rehabilitation.ObjectivesThe aim of this randomized controlled trial was to determine the effect of a self-rehabilitation program combined with BTI on upper-limb function in individuals with chronic hemiparesis.MethodsIn total, 33 outpatients were randomly allocated to receive BTI + self-rehabilitation (R group: n = 17) or BTI alone (C group: n = 16). Outcomes evaluated just before the BTI and 4 weeks later included the Wolf Motor Function Test (WMFT time: primary outcome), Action Research Arm Test, fatigue and quality of life.ResultsChange in WMFT did not differ between groups at 4 weeks (WMFT time: ?14% for R group, ?4% for C group. WFMT score: +12% for R group, 0% in C group). WFMT time and score improved significantly in the R group only (?14%, P = 0.01, and +12%, P = 0.02). In addition, the proportion of patients with improved WMFT time and score was higher in the R than C group (R group: 71% improved score, 77% improved time; C group: 43% improved score, 50% improved time). Also, passive range of shoulder flexion (P = 0.03) and wrist extension (P = 0.01) improved only in the R group. No other variables changed significantly. Compliance was excellent; average daily training time was greater than that prescribed.ConclusionsThe addition of a self-rehabilitation program to BTI did not significantly improve functional outcomes more than BTI alone; however, movement quality and speed improved only in the self-rehabilitation group. Participants in the self-rehabilitation group trained more than they were asked to, which suggests that they found the program worthwhile. These clinically relevant findings justify larger-scale studies of the effects of self-rehabilitation to enhance the effects of BTI. Clinical trial: NCT02699762.     

Finite element analysis to determine stress fields at the apex of V-Y flaps

After performing a V-Y advancement flap, we observed an unusually shaped necrosis, resembling a keyhole at the apex of the flap. As high closing tensions are an accepted cause of skin necrosis, we developed a mathematical model based on the finite element analysis in order to determine the stress field by simulating the mechanical behavior of human skin during suture and to explain this particular shape of necrosis. For the modeling, a planar nonlinear two-dimensional finite element model was used. The numerical simulation was carried out with Ansys® v12 software. Results are expressed in numerical and graphic form. The shape of the vertical iso-stress line for a stress equal to 18.8 kPa was similar to the necrosis observed in our clinical case. Similarities between the shape of necrosis and the calculated stress field at the apex of the V-Y advancement flap indicate the major role of skin tension in this necrosis. Finite element analysis is an original approach for describing the particular shape of a necrosis. Although many factors can be implicated in skin necrosis, the modeling confirms the role of tension in the necrosis of this particular case. Level of Evidence: Level V, risk/prognostic study     

Annoyance Caused by Exposure to Road Traffic Noise: An Update

This paper addresses the negative effects resulting from the exposure to road traffic noise on people's well being with a focus on annoyance. Following the observations that noise exposures engender physiological reactions typical of stress, the non-auditory effects of noise on humans are generally viewed as being stress-related, and annoyance is one of the first and most direct reactions to environmental noise. In general terms, it is found that the continuous exposure of people to road traffic noise leads to suffering from various kinds of discomfort thus reducing appreciably the number of their well being elements. However drawing such a conclusion is hindered by difficulties when non-acoustical factors like sensitivity, socio-economic situation and age are also taken into account along with the usual acoustical factors of road traffic noise. The results of several decades of research on this topic have permitted lately to establish a quantitative relationship between the objective quantities characterising road traffic noise, namely the day to night noise level, and the human subjective reaction to it as expressed by the percentage of highly annoyed people. These findings are important at both the society and the individual level in as much as they may help in regulating in a more efficient way the planning of road traffic activity in order to secure minimum comfort to the affected population.     

Long-term kidney graft survival across a positive historic but negative current sensitized cross-match

BACKGROUND: The sensitive cross-match (XM) techniques that have been introduced for clinical transplantation can detect anti-donor immune reactivity despite a negative standard National Institute of Health (NIH) cross-match. One of them uses anti-kappa human light chain globulins (AHG). But there is some discussion about the clinical consequences of a positive AHG-XM in the historical sera that became negative in the sera collected just before the transplantation (pretransplant sera). This study was intended to assess the risk of kidney graft failure associated with a positive historic but negative pretransplant AHG-XM in allosensitized patients having a negative historic NIH-XM. METHODS: This retrospective study includes 90 consecutive renal transplants in immunized patients performed at one center between 1985 and 1991. All of the patients had negative historical and pretransplant standard NIH lymphocytotoxic cross-matches and received the same immunosuppressive regimen. The AHG-XMs were done retrospectively using peak historic and sera collected on the day of the transplantation. RESULTS: The AHG cross-match (AHG-XM) was positive in 17 patients, although the standard NIH cross-match was negative. Fourteen of them had a positive historical but negative pretransplant AHG-XM. The actuarial graft survival in this group of 14 patients was 100% at 1 year and 78% at 9 years compared with 90 and 67%, respectively, in patients with negative historical AHG-XM. In addition, the number of rejection episodes per patient as well as renal function at 1, 2, and 5 years were similar in the two groups. IgG anti-donor HLA class I accounted for the XM positivity in 12 of the 14 patients; most rapidly lost all antibody reactivity by NIH technique in an average time of 8 months before the transplantation. In conclusion, this study suggests that transplant patients having a negative historic NIH-XM but a positive historic AHG-XM may not be at high risk of graft failure especially if there is a well-documented sera history showing a marked decrease in PRA level before transplantation and a negative pretransplant AHG-XM.     

How to tailor A "pi" graft for complex myocardial revascularization: a variant of the mammary loop technique

We present a new pattern for tailoring the “π” graft that uses the advantages of the mammary loop technique. The two internal thoracic mammary arteries are skeletonized. The free right mammary artery is anastomosed end-to-side to the proximal part of the in situ left mammary artery to make a “Y” graft. The distal end of the left mammary artery is anastomosed end-to-side to the middle portion of the right one to form a loop with the two arteries. The loop is severed at the appropriate level at the time of the coronary anastomosis to form a “π” graft. This technique allows a more rational use of the length of the two mammary arteries, because the branch leading to the left anterior descending artery is measured and cut precisely at the time of the anastomosis.     

Clinical applications of neuroimaging with susceptibility-weighted imaging

Susceptibility-weighted imaging (SWI) consists of using both magnitude and phase images from a high-resolution, three-dimensional, fully velocity compensated gradient-echo sequence. Postprocessing is applied to the magnitude image by means of a phase mask to increase the conspicuity of the veins and other sources of susceptibility effects. This article gives a background of the SWI technique and describes its role in clinical neuroimaging. SWI is currently being tested in a number of centers worldwide as an emerging technique to improve the diagnosis of neurological trauma, brain neoplasms, and neurovascular diseases because of its ability to reveal vascular abnormalities and microbleeds.     

Recurrence of aneurysmal bone cysts in young children: a multicentre study

Some authors have reported that the clinical and pathologic behaviour of aneurysmal bone cysts (ABCs) is more aggressive in younger patients and that younger patients have more tumour recurrence. The authors carried out a retrospective, multicentred paediatric population-based analysis of 21 patients (14 boys and seven girls), 5 years of age or younger, with primary ABCs. Only patients with a minimum follow-up of 2 years were included. The most common operation was curettage (14 cases). Methylprednisolone acetate injection was used in two cases (failure in the initial diagnosis before biopsy) with negative results. An Ethibloc (Ethnor Laboratories/Ethicon, Norderstedt, Germany) injection was employed in four cases. There were five recurrences. Three lesions recurred once, one lesion recurred three times and one recurred six times. These recurrences occurred in two cases after methylprednisolone acetate injection, after Ethibloc (Ethnor Laboratories/Ethicon) injection (one case) and, after curettage (two cases). ABCs in children, 5 years of age or younger, do not seem to be more aggressive than in older children. Curettage is a surgical procedure that can be used even in young children. Of course, recurrence is always possible but the recurrence rate is not unacceptable. More aggressive operative intervention does not appear to be indicated.     

Deactivation of alveolar macrophages in septic neutropenic ARDS

STUDY OBJECTIVES: Neutrophils often have been involved in the pathophysiology of ARDS. However, authentic ARDS has been described in patients with severe neutropenia, suggesting the presence of other potential mechanisms that are responsible of this syndrome. Alveolar macrophages (AMs) could be involved in the development of ARDS, and so we decided to study AM activation in neutropenic patients. PATIENTS: We designed a prospective study and enrolled two subgroups of consecutive patients (group A, 18 patients; group B, 22 patients) with septic ARDS. In the first period, 7 of 18 patients were neutropenic, and in the second period 10 of 22 patients were neutropenic. All neutropenic patients were treated with granulocyte colony-stimulating factor (G-CSF). Measurements and results: In group A, BAL fluid samples were analyzed for differential and total cell counts, and alveolar activation marker expression (ie, human leukocyte antigen [HLA]-DR locus) was determined. Basal and lipopolysaccharide (LPS)-stimulated production of tumor necrosis factor, interleukin (IL)-1 beta, IL-6, and IL-10 was evaluated in group B. In neutropenic patients, the BAL fluid total cell count and the neutrophil absolute count was significantly lower compared to those in nonneutropenic patients (p = 0.029 and p = 0.046, respectively). HLA-DR expression on AMs was significantly decreased (p = 0.016), and the percentage of AMs expressing HLA-DR was also significantly lower (p = 0.041). In neutropenic patients, the mean percentage of AMs expressing HLA-DR was significantly lower in deceased patients compared to survivors (30 +/- 7 vs 43 +/- 1, respectively; p = 0.047). Basal AMs released cytokines was comparable between the two groups; however, LPS stimulation yielded a deactivation of AMs in neutropenic patients. CONCLUSION: These results suggest a deactivation and/or hypoactivation of AMs in septic ARDS patients. This deactivation/hypoactivation could be linked to the use of G-CSF as this molecule has been shown to generate a down-regulation of HLA-DR expression.