Abnormal Reflex Research Articles

P.099 A novel electrophysiologic reflex in neurovascular compression syndromes serving as a marker of pain resolution

Background: Radiofrequency rhizotomy is a commonly used percutaneous technique for treatment of trigeminal neuralgia especially in cases not eligible for microvascular decompression. This technique is usually performed with the patient under conscious sedation. We devised a method for performance of this technique under general anesthetic with neurophysiology monitoring. Methods: The patient is put under general anaesthetic and EMG monitoring is set up. Needles are placed in temporalis muscle, masseter and mylohyoid or anterior belly of digastric. Resting activityis monitored. Rhizotomy is then performed under fluoroscopic guidance, with monitoring of EMG potentials pre- and post-lesioning, with specific attention paid to presence of an abnormal electrophysiologic reflex. Results: A total of 38 procedures were performed in 23 patients. Of these, 15 were revision procedures. Patients had improvement from BNI pain scale 3.8 ±0.8 to 1.3 ±1.5, and had a reduction in number of medications from 1.9 ±1.0 to 0.8 ±0.9. Survey results indicate greater practitioner satisfaction with this technique. Conclusions: Radiofrequency rhizotomy can be performed under GA with IONM guidance with good results. We present a novel method for EMG-based monitoring. Further study is required to validate this technique.

The ventilatory component of the muscle metaboreflex is overstimulated in transthyretin cardiac amyloidosis patients with poor aerobic capacity.

Background: The exercise pressor reflex, i.e., metabo- and mechano-reflex, partially regulates the control of ventilation and cardiovascular function during exercise. Abnormal exercise pressor reflex response has been associated with exaggerated ventilatory drive, sympathovagal imbalance and exercise limitation in chronic heart failure patients. Whether metaboreflex is over-activated and participate to poor aerobic capacity in patients with hereditary transthyretin cardiac amyloidosis (CA-TTR) is unknown. Methods: Twenty-two CA-TTR patients (aged 76 ± 7, 68% male) with the V122I (p.Val142Ile) transthyretin underwent a thorough evaluation including heart rate variability metrics, electrochemical skin conductance (ESC), physical function cardiopulmonary exercise testing, and muscle metaboreflex assessment. Eleven control subjects were chosen for muscle metaboreflex assessment. Results: Age-matched controls (n = 11) and CA-TTR patients (n = 22) had similar metaboreflex sensitivity for heart rate, stroke volume, cardiac index and mean systemic arterial pressure. Compared with age-matched controls, metaboreflex sensitivity for systemic vascular resistance (-18.64% ± 6.91% vs 3.14% ± 23.35%) and minute-ventilation responses (-9.65% ± 14.83% vs 11.84% ± 23.1%) was markedly increased in CA-TTR patients. Values of ESC displayed positive correlations with stroke volume (r = 0.53, p = 0.011) and cardiac index (r = 0.51, p = 0.015) components of metaboreflex sensitivity, an inverse correlation with systemic vascular resistance (r = -0.55, p = 0.008) and a trend with mean arterial (r = -0.42, p = 0.052) components of metaboreflex sensitivity. Peak aerobic capacity (peak VO2%) displayed an inverse correlation with the ventilation component of metaboreflex sensitivity (r = -0.62, p = 0.015). Conclusion: Consistent with the "muscle hypothesis" in heart failure, it is proposed that deterioration of skeletal muscle function in hereditary CA-TTR patients may activate muscle metaboreflex, leading to an increase in ventilation and sensation of breathlessness, the perception of fatigue, and overall sympathetic activation.

VIDEO HEAD IMPULSE TEST AND CERVICAL VESTIBULAR EVOKED MYOGENIC POTENTIALS IN PATIENTS WITHMENIERES DISEASE

Menieres disease is a labyrinthine disease that usually presents with episodes of vertigo associated with sensorineural hearing loss, tinnitus and aural fullness. There is no specific Vestibular function test objectively used for diagnosis of the disease. Objective: Here, we compare findings of caloric test, cervical vestibular evoked myogenic potentials (cVEMP) and video-head-impulse test(vHIT) in patients with Menieres disease to assess which one is more sensitive test for diagnosis of Menieres disease. Methods: This study was carried out on two groups of subjects including 20 adult subjects with Menieres disease and 20 normal subjects free from any vestibular symptoms. Results: the most sensitive test was cVEMP (84.6%) followed by vHIT(75%) and then the caloric test(50%).Conclusion: The cVEMP test is the most sensitive test for diagnosing Menieres disease, We also found that the presence of catch–up saccades due to abnormal VOR reflex is an important sign that greatly aids the diagnosis.

Reduced cardiovagal baroreflex sensitivity is associated with postural orthostatic tachycardia syndrome (POTS) and pain chronification in patients with headache.

Non-cephalgic symptoms including orthostatic intolerance, fatigue, and cognitive impairment, are common in patients with chronic headache disorders and may result from alterations in the autonomic nervous system. However, little is known about the function of autonomic reflexes, which regulate cardiovascular homeostasis and cerebral perfusion in patients with headache. Autonomic function testing data from patients with headache collected between January 2018 and April 2022 was retrospectively analyzed. Through review of EMR we determined headache pain chronicity and patient self-report of orthostatic intolerance, fatigue, and cognitive impairment. Composite Autonomic Severity Score (CASS), CASS subscale scores, and cardiovagal and adrenergic baroreflex sensitivities were used to quantify autonomic reflex dysfunction. Descriptive analyses (Mann-Whitney-U or χ2, as appropriate) determined associations between autonomic reflex dysfunction and POTS as well as chronic headache. Binomial logistic regression adjusted for age and sex. Spearman's rank correlation determined the association between the total CASS score and the number of painless symptoms reported by each participant. We identified 34 patients meeting inclusion criteria, of whom there were 16 (47.0%) with orthostatic intolerance, 17 (50.0%) with fatigue, 11 (32.4%) with cognitive complaints, and 11 (32.4%) with Postural Orthostatic Tachycardia Syndrome (POTS). The majority of participants had migraine (n = 24, 70.6%), were female (n = 23, 67.6%) and had a chronic (>15 headache days in a month) headache disorder (n = 26, 76.5%). Reduced cardiovagal baroreflex sensitivity (BRS-V) independently predicted chronic headache [aOR: 18.59 (1.16, 297.05), p = 0.039] and POTS [aOR: 5.78 (1.0, 32.5), p = 0.047]. The total CASS was correlated with the total number of non-painful features in the expected direction (r = 0.46, p = 0.007). Abnormal autonomic reflexes may play an important role in pain chronification and the development of POTS in patients with headache.

Facial onset sensory and motor neuronopathy (FOSMN syndrome): Cases series and systematic review.

To provide new and comprehensive evidence for diagnosis and management of FOSMN syndrome. We reviewed our database to identify patients with FOSMN syndrome. Online database including PubMed, EMBASE, and OVID were also searched for relevant cases. We identified a total of 71 cases, including 4 cases from our database and 67 ones from online searching. A predominance of male was observed [44 (62.0%)] with median onset age of 53 (range: 7-75) years old. The median (range) disease duration was 60 (3-552) months at the time of the visit. The initial symptoms could be sensory deficits in face (80.3%) or oral cavity (4.2%), bulbar paralysis (7.0%), dysosmia (1.4%), dysgeusia (4.2%), weakness or numbness of upper limbs (5.6%), or lower limbs (1.4%). Abnormal blink reflex was presented in 64 (90.1%) patients. CSF tests showed elevated protein level in 5 (7.0%) patients. Six (8.5%) patients had MND-related gene mutation. Five (7.0%) patients showed transient responsiveness to immunosuppressive therapy, then deteriorated relentlessly. Fourteen (19.7%) patients died, with an average survival time of around 4years. Among them, five patients died of respiratory insufficiency. The age of onset, progress of disease course, and prognosis of FOSMN syndrome could be varied significantly. The prerequisites of diagnosis were progressive and asymmetric lower motor neuron dysfunction, with sensory dysfunction which usually showed in face at the onset. Immunosuppressive therapy could be tried in some patients with suspected inflammatory clues. In general, FOSMN syndrome tended to be motor neuron disease with sensory involvement.

The effect of a home exercise program on visio-vestibular function in concussed pediatric patients.

A visio-vestibular home exercise program (VV-HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. The effects of a VV-HEP on improving concussion symptoms and visio-vestibular function are unclear. Determine the effect of VV-HEP on symptoms and visio-vestibular function in concussed pediatric patients. This study included 527 patients [294 female (55.8%); age = 14.4 ± 2.1 years] reporting to a specialty care concussion center within 28 days of injury and for a first follow-up within 60 days of injury. Patients completed the Post-Concussion Symptom Inventory (PCSI) and Visio-Vestibular Examination (VVE). Patients were prescribed the VV-HEP at initial visit, with exercises including saccades, gaze stability, convergence, and balance, and instructed to complete these 1-2 times/day. At follow-up, patients self-reported their VV-HEP progress as (1) has not done, (2) in progress, or (3) completed. Primary outcomes included VV-HEP progress at follow-up, PCSI endorsement and severity, VVE subtests (normal/abnormal), and total VVE score (abnormal = 2 + abnormal subtests). Kruskal-Wallis tests and chi-square were used to determine if concussion symptoms or the proportion of abnormal VVE outcomes, respectively, were associated with VV-HEP status. Post-hoc pairwise comparisons with Bonferonni corrections were used to determine concussion symptom (α = 0.017 a priori) and VVE (α = 0.005 a priori) differences in VV-HEP status. At follow-up, patients who had completed the VV-HEP reported lower symptom endorsement (median = 1, IQR = 0-3) and lower symptom severity (median = 1, IQR = 0-4) relative to patients who had not started the VV-HEP (endorsement median = 7, IQR = 1-13, p < 0.0001; severity median = 15.5, IQR = 2-32.5, p < 0.0001) and those in progress (endorsement median = 8, IQR = 3-14, p < 0.0001; severity median = 15, IQR = 4-30, p < 0.0001). A lower proportion of patients who completed the VV-HEP reported with abnormal vestibular-ocular reflex (22.2%), tandem gait (0%), and total VVE score (22.2%) relative to those who had not started or those in progress (p < 0.005). Our findings indicate that patients who completed the VV-HEP had lower symptom burden and improved visio-vestibular function relative to those who did not start or were in progress. This suggests that a VV-HEP can effectively reduce visio-vestibular dysfunction following concussion and may serve as a means to minimize inequities in access to care.

Neoplastic Disorders of Visual Apparatus: Advances and Management

Purpose: Ocular neoplasms, both primary and metastatic, may present with visual disturbance or vision loss and often are asymptomatic. Clinical examination may demonstrate leukocoria, abnormal pupillary light reflex, or a mass lesion with or without retinal detachment or hemorrhage. Retinoblastoma in children and uveal melanoma and ocular metastases in adults are the most important ocular malignant neoplasms referred for imaging to aid with diagnosis and staging. Familiarity with their common imaging appearances, the common patterns of spread, and the diagnostic findings of greatest concern to the optometrist or ocular oncologist will enhance accuracy of imaging interpretation.&#x0D; Methodology: Clinical examination and imaging using B-scan ultrasound, A-scan ultrasound, fluorescein angiography, computed tomography and magnetic resonance imaging have complementary roles in ocular tumor staging and treatment assessment.&#x0D; Findings: Ocular neoplasm tumors are relatively rare but require unique diagnostic and treatment considerations given the functional importance of the eye and periocular structures and their unique metastatic behavior. In the following paper, a major malignant tumor of the ocular adnexa including the eyelid, conjunctiva and orbit will be reviewed. Frozen section control of the margins and, in selected cases, Mohs microsurgery have decreased the recurrence rate in malignant eyelid tumors. Intraoperative cryotherapy and postoperative topical mitomycin C have similarly contributed to better surgical outcomes in conjunctival malignant tumors including squamous cell carcinoma and malignant melanoma. Immunotherapy with CD20 antibodies is a developing treatment in Ocular neoplasm lymphomas.&#x0D; Unique Contribution to Theory, Practice and Policy: Optometrists by the new advances in clinical optometry training/research, and specialists in occuloplasty/ocularistry form part of the team for a multidisciplinary approach in the clinical management of neoplastic disorders of visual apparatus.

Health Conditions Associated with Alzheimer's Disease and Vascular Dementia.

We examined medical records to determine health conditions associated with dementia at varied intervals prior to dementia diagnosis in participants from the Baltimore Longitudinal Study of Aging (BLSA). Data were available for 347 Alzheimer's disease (AD), 76 vascular dementia (VaD), and 811 control participants without dementia. Logistic regressions were performed associating International Classification of Diseases, 9th Revision (ICD-9) health codes with dementia status across all time points, at 5 and 1 year(s) prior to dementia diagnosis, and at the year of diagnosis, controlling for age, sex, and follow-up length of the medical record. In AD, the earliest and most consistent associations across all time points included depression, erectile dysfunction, gait abnormalities, hearing loss, and nervous and musculoskeletal symptoms. Cardiomegaly, urinary incontinence, non-epithelial skin cancer, and pneumonia were not significant until 1 year before dementia diagnosis. In VaD, the earliest and most consistent associations across all time points included abnormal electrocardiogram (EKG), cardiac dysrhythmias, cerebrovascular disease, non-epithelial skin cancer, depression, and hearing loss. Atrial fibrillation, occlusion of cerebral arteries, essential tremor, and abnormal reflexes were not significant until 1 year before dementia diagnosis. These findings suggest that some health conditions are associated with future dementia beginning at least 5 years before dementia diagnosis and are consistently seen over time, while others only reach significance closer to the date of diagnosis. These results also show that there are both shared and distinctive health conditions associated with AD and VaD. These results reinforce the need for medical intervention and treatment to lessen the impact of health comorbidities in the aging population. ANN NEUROL 2023;93:805-818.

Motor rehabilitation of aphasic stroke patient: the possibility of Rood's approach.

Motor rehabilitation of aphasic stroke patient: the possibility of Rood's approach.

A Review on Some Associated Disorders with Chorea Based on a Neurobiochemical Perspective

Chorea which is characterized by random, brief, irregular and arrhythmic movements which would start from a body part and go to another one, in most of the cases has association with various secondary features like parakinesis, athetosis, ballism, partial suppressibility, motor impersistence, gait and deep tendon reflex abnormalities. The movements in chorea have low amplitude in general and all of the muscles can be engaged in such unpredictable movements. There are some disorders which have association with chorea. This brief review tries to point to some disorders which have association with chorea from a Neurobiochemical perspective.

Comparative Analysis of Pupillometry in Idiopathic Rapid Eye Movement Sleep Behavior Disorder and Parkinson’s Disease

Background and Objective Pupillary light reflex (PLR) abnormalities have been reported in patients with Parkinson’s disease (PD). However, few studies have been conducted on the abnormality of PLR in patients with idiopathic rapid eye movement sleep behavior disorder (iRBD), which is a prodromal stage of α-synucleinopathy. We herein quantitatively analyzed the PLR of iRBD using an automated pupillometer, and compared the results with those of PD.Methods In this cross-sectional study, we prospectively enrolled 27 patients with polysomnography-confirmed iRBD, and 23 patients with PD. Pupillometry was performed three times in each eye, alternating left and right. We compared seven pupillometric parameters between the iRBD and PD patients.Results Maximum and minimum pupil diameters were significantly larger in PD patients than in iRBD patients. However, the other pupillometric parameters, such as mean constriction velocity, maximum constriction velocity, reflex amplitude, latency, and mean dilation velocity, did not differ between the two groups. Among iRBD patients, the pupillometric parameters were not correlated with any clinical characteristics related to autonomic dysfunction or neurodegeneration.Conclusions We found that the pupillary constriction and dilation in response to light of iRBD were not different from those of PD. These findings suggest that autonomic pupillary dysfunction already existed in the prodromal stage of α-synucleinopathy to a degree comparable to that in PD. Larger pupil diameters in PD than in iRBD may reflect the pharmacological effect of dopaminergic medications. Future studies are needed to elucidate the association between the PLR abnormalities and the risk of phenoconversion in iRBD.

Exploring the association between canine perineal hernia and neurological, orthopedic, and gastrointestinal diseases

BackgroundPerineal hernia (PH) is a relatively common condition in intact male dogs, but the etiology remains unclear. The objective of this study was to assess the contribution of gastrointestinal (GI), neurological, and orthopedic conditions to the development of PH in male dogs. Patient history with a focus on chronic GI disease was assessed using an owner questionnaire. Neurological conditions were explored, applying neurological, electromyographic (EMG), and motor nerve conduction velocity (MNCV) examinations and combining these with computed tomography (CT) imaging. To exclude possible orthopedic diseases, an orthopedic examination was conducted together with CT analysis. The chi-squared test was used to assess the associations between categorical variables.ResultsAltogether, 66 male dogs with diagnosed PH were recruited for this study. The frequency of neurological, orthopedic, and GI diseases was low in dogs with PH. No signs of generalized neuro- or myopathies were detected. Still, perineal and bulbourethral reflexes were decreased or missing in 44.6% (29/65) and 40.0% (26/65) of dogs, respectively. Mild or moderate occlusion of the intervertebral foramen at the lumbosacral (LS) junction occurred in 18.5% (12/65) of dogs and was caused by spondylosis deformans in 83.3% (10/12). Moderate disc protrusion was evident in 9.2% (6/65) of dogs.ConclusionNo evidence was found that PH is caused by gastrointestinal, orthopedic, or neurological conditions. Abnormalities in perineal and bulbourethral reflexes are most likely secondary to PH.

Quantitative gastrointestinal function and corresponding symptom profiles in autonomic neuropathy.

Peripheral neuropathies with autonomic nervous system involvement are a recognized cause of gastrointestinal dysmotility for a wide spectrum of diseases. Recent advances in wireless motility capsule testing allow improved sampling of regional and whole gut motility to aid in the diagnosis of gastrointestinal motility disorders and may provide additional insight into segment-specific enteric involvement of peripheral neuropathies affecting autonomic nervous system function. We utilized standardized autonomic nervous system (ANS) reflex assessment and wireless motility capsule testing to evaluate 20 individuals with idiopathic autonomic neuropathy and unexplained gastrointestinal symptoms. Additionally, we examined the relationship between quantifiable autonomic neuropathy and gastrointestinal dysmotility at specific neuroanatomical levels. Symptom profiles were evaluated using the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS-31) and compared to wireless motility capsule data. We found that transit times were predominately abnormal (delayed) in the foregut (10 of 20; 50%), while contractility abnormalities were far more prominent in the hindgut (17 of 20; 85%), and that motility and symptom patterns, as assessed by the COMPASS-31 GI domain items, generally corresponded. Finally, we also found that there was neuroanatomical overlap in the presence of autonomic reflex abnormalities and WMC-based transit and/or contractility abnormalities. We found that transit times were predominately abnormal in the foregut and midgut, while contractility abnormalities were far more prominent in the hindgut in individuals with idiopathic autonomic neuropathy. There was a high rate of agreement in segmental wireless motility capsule data with neuroanatomically corresponding standardized ANS function measures (e.g., cardiovagal, sudomotor, adrenergic). Expanded sudomotor testing, including additional neuroanatomical segments, could provide additional indirect assessment of visceral involvement in ANS dysfunction.

Mystery of changing choroidal thickness.

Mystery of changing choroidal thickness.

Facial nerve and branch dysfunction in leprosy - a study from India

Objective Involvement of the facial nerve in leprosy can result in debilitating features, including blindness. Electrophysiological studies addressing abnormalities in the facial nerve along with its branches are limited. This study was designed to assess the prevalence and pattern of clinical and subclinical involvement of the facial nerve and its branches in patients with active disease. Methods A hospital-based cross-sectional study was done in 75 patients who had leprosy. The facial nerve and branches were examined clinically and assessed electro-physiologically with nerve conduction studies (NCS), F wave, blink reflex and synkinesis. Results 64/75 (85%) patients had facial nerve involvement, of whom 58 had subclinical involvement. detected by electrophysiology and 6 had facial nerve palsy. 83% of patients had subclinical involvement and belonged to the borderline spectrum (27-BL, 21-BT), and 23 (48%) were in reactional states (T2R-12, T1R-11). Patients with facial lesions and reactional states showed significant association (p = 0.035) with clinical or subclinical facial nerve involvement. The marginal mandibular branch was the most commonly affected (50%) in those with subclinical involvement while in those with facial nerve palsy, the facial nerve trunk was most affected (50%). 12/58 (21%) with subclinical involvement and 5/6 patients with facial nerve palsy had an abnormal blink reflex. Abnormal F wave was observed in 7/42 (17%), (4 subclinical/3 facial nerve palsy). Conclusion Electrophysiological changes in the facial nerve, without clinical signs are common among patients in the borderline spectrum with about half being in reactional states. We know that many institutions may not have the equipment to conduct nerve studies, but the higher incidence of subclinical facial nerve involvement underscores the need to monitor facial and autonomic functions closely.

Commentary: Dysthyroid optic neuropathy: A lurking danger in thyroid eye disease.

Poonam et al., in their retrospective study, highlighted male gender, hyperthyroidism, and smoking as risk factors of developing dysthyroid optic neuropathy (DON) over four years. They highlighted the potential of recurrence of DON in patients with diabetes.[1] DON is the most dreaded complication of thyroid eye disease (TED), warranting an urgent intervention. Fortunately, the occurrence of DON is noted only in 5%–7% of TED cases.[2] The diagnosis of established DON is majorly clinical, but the diagnosis of subclinical DON may need detailed ophthalmic examination and imaging. Patients with subclinical DON may not experience a sudden diminution of vision, abnormal pupillary reflexes, and features of orbital inflammation—classical of severe TED.[2] The risk factors for clinical and subclinical DON include older age, male gender, smoking, diabetes (controlled or uncontrolled), radioisotope therapy, hyperthyroidism or Grave’s ophthalmopathy, and high level of thyroid autoantibodies.[12] The pathogenesis of DON involves mechanical, inflammatory, and vascular factors causing damage to the nerve cells and axons of the optic nerve.[2] TED patients can be classified as type I (predominantly fat enlargement) or type II disease (predominantly extraocular muscle enlargement). In type II TED, the mechanical compression of optic nerve blood supply and axonal flow at the crowded orbital apex occurs due to enlarged extraocular muscles. The reduced arterial supply to the optic nerve and sluggish outflow of the blood from the superior ophthalmic vein comprises of major vascular insults contributing to the DON.[2] Moreover, these phenomena occurring at the orbital apex do not contribute much to clinical proptosis; hence many remain underdiagnosed. In ophthalmic examination, relative afferent pupillary defect (RAPD), blue-yellow (Tritan) color deficiency, and reduced contrast sensitivity in patients of TED are sensitive parameters for detecting DON. Clinical examination of the optic disc and optic disc imaging are important for the monitoring of DON.[2] Orbital magnetic resonance imaging with or without contrast may provide sufficient details about the extraocular muscles, orbital fat, optic nerve, orbital apex, superior ophthalmic vein, and other essential orbital structures. Apparent diffusion coefficient readings from magnetic resonance imaging (MRI) may provide the activity details in the extraocular muscles. Barrett’s muscle index of >60% is considered highly sensitive and specific for DON.[3] It is calculated on coronal computed tomography (CT) or MRI at a mid-point between the posterior globe and the orbital apex. Barrett’s index includes two indices, horizontal and vertical, and the larger of the two is taken as significant. Other parameters are extraocular muscle volume/orbital volume (MV/OV) and crowding index (CI) are considered reliable indicators of DON. The 3D MRI-based volumetric analysis showed the larger extraocular muscle volume as the most relevant factor in DON.[4] Optical coherence tomography angiography (OCTA) has been used to measure retinal nerve fiber layer thickness and peripapillary capillary vessel density (whole image and radial vessel density) as DON parameters. The patients with subclinical DON have shown significantly lower vessel densities as compared to normal individuals.[25] Intravenous steroids and orbital decompression surgery remain the mainstay of treatment in DON patients. The best outcomes for DON patients are provided by combined intravenous methylprednisolone and 3-wall orbital decompression, as vision is successfully preserved in most cases with a reduction in proptosis.[6] The advent of teprotumumab, a targeted insulin-like growth factor 1 (IGF-1) receptor-based therapy, is slowly establishing itself as “medical orbital decompression” therapy. It reduces the levels of thyroid stimulating hormone (TSH) receptors and IGF-1 receptors on fibroblasts and reduces the release of pro-inflammatory cytokines like interleukin (IL)-6, IL-8, and tumor necrosis factor alpha (TNF-α) responsible for severe TED.[26] Hence, an ophthalmologist should be aware of the clinical features of subclinical DON and maintain a low threshold for aggressive treatment. For the holistic management of DON, a multidisciplinary team involving an ophthalmologist, endocrinologist, and otolaryngologist should be working in coordination to avoid blindness.

Improving Red Reflex Screening in a Level III NICU Through a Quality Improvement-based Approach.

Red reflex is a routine part of newborn examination in most high-income countries. It is an inexpensive, noninvasive method of detecting serious ocular abnormalities like cataracts, retinoblastoma, vitreous masses, etc. The American Academy of Pediatrics recommends red reflex examination before discharge from newborn nursery. However, the current rate of red reflex examination in the NICUs in the United States is unknown. We noted a low rate of documentation (19%) in our level III NICU, prompting us to initiate this quality improvement project to improve this rate. We created a key-driver diagram and summarized possible interventions to achieve our aim to increase the documentation rate to >80%. We implemented various interventions over 4 plan-do-study-act cycles. Over 19 months, we educated the nurses and the providers regarding the importance of red reflex assessment, placed visual reminders to check red reflex, implemented discharge checklist for the residents, and improved the accessibility to ophthalmoscope. Infants discharged from our NICU during a 25-month period included 1168 infants who an ophthalmologist did not formally examine. The rate of red reflex documentation improved significantly from a baseline of 19% (6 months before the first plan-do-study-act cycle) to 89.5% (during the 19-month intervention period). One abnormal red reflex was detected during this study. Implementation of this project has led to a culture change at our institution, which will help prevent us from missing the diagnosis of serious visual abnormalities in the future.

Relationship between Severity of Lumbar Spinal Stenosis and Ligamentum Flavum Hypertrophy and Serum Inflammatory Factors.

Objective This study is aimed at investigating the correlation between lumbar spinal stenosis (LSS) severity, ligamentum flavum hypertrophy, and the upregulation of inflammatory markers. Methods From March 2019 and May 2022, eighty-five inpatients with LSS were enlisted as the study's research group, while sixty-five patients hospitalized for lumbar intervertebral disc herniation over the same time period served as the study's control group. Moreover, mild, moderate, and severe subgroups of patients were created within the research population based on their LSS severity. The ligamentum flavum thickness and the positive expression rates of TNF-α, TGF-β1, and IL-1α were compared between the study group and the control group. The levels of TNF-α, TGF-β1, and IL-1α that were found to be positively expressed were compared between the mild, moderate, and severe groups. Patients with LSS had their ligamentum flavum thickness and their positive expression rates of TNF-α, TGF-β1, and IL-1α analyzed using Spearman correlation analysis. We evaluated the diagnostic utility of the positive expression rates of IL-α1, TGF-β1, and TNF-α and ligamentum flavum thickness in distinguishing the severity of LSS using a receiver operating characteristic (ROC) curve. Results The rates of both lower limb pain (40.00%) and intermittent claudication (80.00%) in the LSS group were higher than those in the lumbar disc herniation group (15.38%, 12.31%), with statistical significance (P < 0.05). However, no substantial disparity was observed in left lower limb pain, right lower limb pain, low back pain, lower limb sensation, muscle strength, and reflex abnormalities between the two groups (P > 0.05). Positive expressions of TGF-β1, TNF-α, and IL-1α and thicker ligamentum flavum were more prevalent in the LSS group than in the lumbar intervertebral disc herniation group. All indexes were significantly (P < 0.05) higher in the moderate stenosis group than in the severe stenosis group. Additionally, the thickness of the ligamentum flavum and the positive expression rates of TNF-α, TGF-β1, and IL-1α were higher in the mild and moderate stenosis groups than in the severe stenosis group. The expression levels of TNF-α, TGF-β1, and IL-1α were favorably linked with ligamentum flavum thickness (P < 0.05). ROC curve analysis showed that the thickness of ligamentum flavum, the expression of IL-1α, the expression of TGF-β1, and the expression of TNF-α could effectively diagnose mild, moderate, and severe LSS (P < 0.05). Conclusion Ligamentum flavum hypertrophy and positive expression rates of IL-1α, TGF-β1, and TNF-α are closely linked to LSS, which can effectively identify mild, moderate, and severe LSS.

Patterns of facial and blink reflex abnormalities in type 2 diabetes mellitus patients with short disease duration: a clue to subclinical cranial neuropathy

Abstract Background Cranial neuropathies occur in 3 to 14% of diabetic patients. Motor conduction study of the facial nerve and blink reflex study are electrophysiologic techniques used to assess the facio-trigeminal pathway in diabetic patients. The patterns of facial and blink reflex abnormalities are inconsistent among studies. This study aimed to assess the subclinical facial nerve and blink reflex abnormalities patterns in short-duration type 2 diabetes mellitus patients. This cross-sectional study included 30 type 2 diabetic patients with disease duration ≤ 5 years. We included only patients with the Toronto clinical neuropathy score ≤ 5. We enrolled 30 age- and sex-matched healthy subjects as a control group. We performed facial nerve motor conduction and blink reflex studies. Patients with prior history of cranial nerve lesions, stroke, or any other disease-causing polyneuropathy or drug-induced neuropathy were excluded from the study. Results Thirty diabetic patients were included, 20 females (66.7%) and ten males (33.3%). Their mean age was 52.63 ± 8.94 years. None of the patients had clinical evidence of neuropathy. There were significant differences between patients and controls in the distal latencies and amplitudes of facial nerve compound muscle action potentials and contralateral R2 late response latencies of the blink reflex. We detected subclinical cranial abnormalities in 6 diabetic patients (20%). One of them (3.3%) had facial nerve conduction abnormalities, four of them (13.4%) had blink reflex abnormalities, and one of them (3.3%) had both facial nerve and blink reflex abnormalities. Conclusion Subclinical cranial neuropathy can occur in short-duration type 2 diabetes mellitus patients. We detected different blink reflex patterns and facial conduction study abnormalities. We recommend blink reflex and facial nerve conduction studies as simple tests for the early evaluation of neurological subclinical affection in patients with short disease duration of T2DM as they may appear in the absence of peripheral neuropathy.

Foot Drop In A Performing Arts Dance Girl

HISTORY: A 12-year-old performing arts dance girl with history of cerebral cavernous malformations (CCM) presents with pain in left leg and suddenly foot drop. She is involved in a strict strength and conditioning program and her mom referred symptoms began two days after a dance session. PHYSICAL EXAMINATION: examination revealed stepagge gait with an ample sustentation base, left ankle with no active range of motion with stiffness at passive range of motion, strength of tibialis anterior muscle 0/5 in Lovett scale, extensor digitorum longus and extensor hallucis longus muscle 3/5 in Lovett scale. Pain with the manipulation of proximal tibiofibular joint, positive Tinel test and muscle atrophy in calf zone, no abnormal reflexes, no overlying erythema or skin changes were noted. Neurodynamic testing for peroneal nerve reproduced tingle and pain. DIFFERENTIAL DIAGNOSIS:1. Vasculitis 2. Peroneal stress fracture 3. L5 radiculopathy TEST AND RESULTS: laboratory and immunological test results were normal. Brain MRI showed the CCM and knee MRI showed increased intensity and thickness of common peroneal nerve and edema of the tibialis anterior, peroneous longus and extensor digitorum longus suggestive of edema. FINAL WORKING DIAGNOSIS: traction peroneal neuropathy TREATMENT AND OUTCOMES: 1. Splint immobilization at night. 2. Physical therapy with progressive neurodynamic peroneal nerve glide exercises and manual therapy in ankle joint.3. Proprioception exercises. 4. Range of motion and ankle strengthening exercises started 2 weeks post injury. 5. Return to sports 4 months post injury with total resolution of symptomatology.