British Medical Research Council Research Articles

Acute Flaccid Myelitis: Mid-Term Clinical Course of Knee Extension Paralysis and Outcomes of Nerve Transfer.

Acute flaccid myelitis (AFM) is a rare debilitating poliomyelitis-like illness characterized by the sudden onset of flaccid palsy in the extremities. The purpose of this study was to report the mid-term clinical course of knee extension in AFM and the effect of contralateral obturator nerve-to-femoral nerve transfer (CONFNT) for restoration of knee extension in AFM. Twenty-six patients with lower extremity palsy due to AFM were referred to our clinic for possible surgical reconstruction. Their median age was 4.0 years, and the first evaluation of the palsy was done at a mean of 6 months after paralysis onset. The paralysis ranged from lower limb monoplegia to quadriplegia. The clinical course of knee extension was assessed using the British Medical Research Council (MRC) grading scale and surface electromyography (EMG). Five patients with unilateral paralysis of knee extension underwent CONFNT. The mean follow-up period for 19 limbs with complete paralysis of knee extension (MRC grade M0) in 13 patients who were evaluated for spontaneous recovery was 43 months. No patient who had complete paralysis of knee extension at >6 months and paralysis of the hip adductor muscle had improvement of knee extension to better than M2. Five of the original 26 patients were treated with CONFNT and followed for a mean of 61 months. Two of 5 patients had the CONFNT ≤8 months after paralysis onset and obtained M4 knee extension. Only 1 of the 3 patients with CONFNT performed approximately 12 months after paralysis onset obtained M3 knee extension; the other 2 obtained only M1 or M2 knee extension. The paralysis of the lower extremity in our patients with AFM was similar to that in poliomyelitis. However, in AFM, spontaneous recovery of knee extension was possible if there were signs of recovery from hip adductor paralysis up to 6 months after paralysis onset. CONFNT may enhance the recovery of knee extension and seems to be a reliable reconstruction for restoring knee extension if performed no more than 8 months after paralysis onset. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of reduced quality of life in patients with systemic sclerosis

Predictors of reduced quality of life in patients with systemic sclerosis

Global trends and outcomes of nerve transfers for treatment of adult brachial plexus injuries.

The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/- C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized.Level of evidence: III.

Functional outcomes of different surgical treatments for common peroneal nerve injuries: a retrospective comparative study

BackgroundThis study aims to assess the recovery patterns and factors influencing outcomes in patients with common peroneal nerve (CPN) injury.MethodsThis retrospective study included 45 patients with CPN injuries treated between 2009 and 2019 in Jing’an District Central Hospital. The surgical interventions were categorized into three groups: neurolysis (group A; n = 34 patients), nerve repair (group B; n = 5 patients) and tendon transfer (group C; n = 6 patients). Preoperative and postoperative sensorimotor functions were evaluated using the British Medical Research Council grading system. The outcome of measures included the numeric rating scale, walking ability, numbness and satisfaction. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal time interval between injury and surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function.ResultsSurgical interventions led to improvements in foot dorsiflexion strength in all patient groups, enabling most to regain independent walking ability. Group A (underwent neurolysis) had significant sensory function restoration (P < 0.001), and three patients in Group B (underwent nerve repair) had sensory improvements. ROC analysis revealed that the optimal time interval for achieving M3 foot dorsiflexion recovery was 9.5 months, with an area under the curve (AUC) of 0.871 (95% CI = 0.661–1.000, P = 0.040). For M4 foot dorsiflexion recovery, the optimal cut-off was 5.5 months, with an AUC of 0.785 (95% CI = 0.575–0.995, P = 0.020). When using M3 toe dorsiflexion recovery or S4 sensory function recovery as the gold standard, the optimal cut-off remained at 5.5 months, with AUCs of 0.768 (95% CI = 0.582–0.953, P = 0.025) and 0.853 (95% CI = 0.693–1.000, P = 0.001), respectively.ConclusionsOur study highlights the importance of early surgical intervention in CPN injury recovery, with optimal outcomes achieved when surgery is performed within 5.5 to 9.5 months post-injury. These findings provide guidance for clinicians in tailoring treatment plans to the specific characteristics and requirements of CPN injury patients.

Exploration of biomarkers for efficacy evaluation of traditional Chinese medicine syndromes of acute exacerbation of chronic obstructive pulmonary disease based on metabolomics.

Background: Traditional Chinese medicine (TCM) is effective for the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD); however, there is no objective index for the evaluation of TCM syndrome efficacy. This study aimed to screen biomarkers related to the efficacy of TCM syndrome using metabolomics. Methods: We recruited AECOPD patients with phlegm-heat congesting lung (PH)/phlegm-damp amassing lung (PD) syndrome and treated them with Chinese herbal medicine (Qingre Huatan or Zaoshi Huatan granules) in addition to conventional medicine for 7days. Data on clinical symptoms and sign scores, modified British Medical Research Council (mMRC), COPD assessment test (CAT), and inflammation indicators, including white blood cell (WBC) count, percentage of neutrophil count (NEU%), and C-reactive protein (CRP), were collected before and after treatment to evaluate the therapeutic effect. Serum samples were collected before and after treatment for metabolomic analysis to screen differential metabolites. Results: A total of 69 patients with AECOPD were enrolled, including 41 and 28 patients in the PH and PD groups, respectively. The clinical symptoms and sign scores, CAT, mMRC, NEU%, and CRP levels after treatment were lower than those before treatment in both groups (p < 0.05). Serum metabolomics analysis showed that there were 13 differential metabolites in the PH group and 16 differential metabolites in the PD group before and after treatment (p < 0.05, variable importance projection (VIP) ≥ 1.00). In the PH group, lysophosphatidylcholine (LPC) (16:0), LPC (17:1), LPC (18:3), LPC (18:2), and LPC (17:0) negatively correlated with clinical symptoms and sign scores (p < 0.05); LPC (16:0), LPC (17:1), LPC (16:1), and LPC (17:0) negatively correlated with WBC (p < 0.05) and NEU% (p < 0.05); and LPC (16:0) negatively correlated with CRP levels. In the PD group, L-phenylalanine positively correlated with CRP levels (p < 0.05), and 2-methylbutyroylcarnitine positively correlated with clinical symptoms and sign (p < 0.05) and CAT scores (p < 0.05). DL-carnitine positively correlated with clinical symptoms and sign scores (p < 0.05). Conclusion: Serum metabolites may be potential indicators to objectively evaluate the efficacy of TCM syndromes; however, further large controlled trials are required to verify these findings.

Development of a complex Interdisciplinary Nurse-coordinated SELf-MAnagement (INSELMA) intervention for patients with inflammatory arthritis

BackgroundApart from a consistent focus on treating inflammation, patients with inflammatory arthritis (IA) report a range of unmet needs. Many experience not only residual symptoms but also various other physical, psychological, and social effects. Therefore, this study aimed to develop a complex Interdisciplinary Nurse-coordinated self-management (INSELMA) intervention for patients with IA, as an add-on treatment to usual outpatient care for those with substantial disease impact.MethodsThis study followed the British Medical Research Council’s updated framework for developing complex interventions. The process encompassed the following steps: (1) The evidence base was identified; (2) workshops were held, involving 38 relevant stakeholders (managers, physicians, nurses, physiotherapists, occupational therapists, social workers, psychologists from hospitals and municipalities, and two patient research partners), to discuss and further develop the preliminary ideas; (3) relevant theories were identified (i.e., self-efficacy, acceptance and commitment therapy, and health literacy); (4) the intervention was modeled and remodeled and (5) the results, describing the final INSELMA intervention and outcomes.ResultsThe INSELMA intervention encompasses an initial biopsychosocial assessment, which is performed by a rheumatology nurse. Then, activities that the participant wishes to improve are identified and goals are set. The nurse refers the participant to a multidisciplinary team and coordinates their support and relevant services in the participant’s municipality. In addition, the health professionals have the opportunity to hold two interdisciplinary conferences during the intervention period. The participant and the health professionals work to achieve the set goals during a 6-month period, which ends with a status assessment and a discussion of further needs. The INSELMA intervention aims to increase self-management, reduce the impact of IA (e.g., pain, fatigue, sleep problems, and absenteeism), and increase self-efficacy, quality of life, mental well-being, work ability, and physical activity.ConclusionsThe development of the INSELMA intervention involved stakeholders from two Danish rheumatology outpatient clinics, patient research partners and municipalities. We believe that we have identified important mechanisms to increase the self-management and quality of life of people with IA and to decrease the disease impact in those who are substantially affected. The health professionals involved have developed competences in delivering the intervention and it is ready to be tested in a feasibility study.

Brain plasticity and age after restoring elbow flexion with distal nerve transfers in neonatal brachial plexus palsy and nonneonatal traumatic brachial plexus injury using the plasticity grading scale.

Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown. Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences. In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (β = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups. The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.

Predictors of 2-Year Mortality in Patients Receiving Long-Term Oxygen Therapy: A Prospective Observational Study.

Background: Patients receiving long-term oxygen therapy are in a state of progressive respiratory dysfunction and have high mortality. However, the predictors of mortality in these patients have not yet been established. Objectives: This prospective observational study aimed to identify the predictors of two-year mortality in patients receiving long-term oxygen therapy. Design, Setting/Subjects: This two-year prospective observational study included 96 patients who received long-term oxygen therapy in the outpatient department of the National Hospital Organization Nishiniigata Chuo Hospital in Japan. Measurements: The updated Charlson Comorbidity Index, body mass index, handgrip strength, modified British Medical Research Council scale (mMRC), Barthel Index (BI), and Montreal Cognitive Assessment (MoCA) were collected in 2019 as a baseline. Outcome was defined as mortality due to chronic respiratory disease during the two-year follow-up period, and predictors were estimated using age- and sex-adjusted Cox proportional hazards model. Results: The 83 patients that were followed up, 30 (36%) died. The Cox proportional hazards model estimated handgrip strength (adjusted hazard ratio [HR]: 0.89; 95% confidence interval [CI]: 0.84-0.94; p < 0.01; Wald: 14.38.), mMRC (adjusted HR: 1.96; 95% CI: 1.36-2.83; p < 0.01; Wald: 13.16.), BI (adjusted HR: 0.95; 95% CI: 0.93-0.98; p < 0.01; Wald: 17.07.), and MoCA (adjusted HR: 2.17; 95% CI: 1.31-3.59; p < 0.01; Wald: 9.06) as predictors. Conclusions: This study indicated that handgrip strength, dyspnea, activities of daily living, and cognitive function were predictors of two-year mortality in patients receiving long-term oxygen therapy.

Respiratory symptoms and pulmonary function impairment among textile industry workers in Alexandria, Egypt.

Occupational exposure to cotton dust is still an important cause of respiratory problems in textile workers particularly in less developed countries like Egypt. Evaluate respiratory symptoms and diseases, and pulmonary function pattern among Egyptian textile workers. Cross sectional comparative study was conducted from December 2019 to September 2020 in a textile factory in Egypt; 364 male workers (184 cotton dust exposed workers, and 180 unexposed workers) were included. Participants were subjected to an interviewing questionnaire, British Medical Research Council questionnaire, anthropometric measurements, pulmonary function tests, and byssinosis grading format. Descriptive and analytic statistics were conducted. Chronic cough, phlegm production, and shortness of breath grade I, II and III were more reported in cotton dust exposed workers than unexposed workers (P#x003C;0.01, P#x003C;0.01, and P=0.02, respectively). Prevalence of chronic bronchitis was significantly higher among cotton dust exposed workers (12%) than unexposed workers (3.9%) (P#x003C;0.01). The mean percent predicted values of lung function indices reflecting large-1irway function (VC, FVC, FEV1, FEV1%, PEFR, and FEF75) were significantly lower in cotton dust exposed workers (P#x003C;0.01). Prevalence of byssinosis was 22.8%. Workers with byssinosis had significantly higher prevalence of respiratory symptoms, chronic bronchitis, cross-shift reduction in PEFR and significant decrease in mean percent predicted values of FVC, FEV1, PEFR, FEF75, and FEF50 than workers without byssinosis. This study revealed a substantial association between cotton dust exposure at work and respiratory symptoms and morbidity. Regular measurement of cross shift change in PEFR is recommended among exposed workers for early diagnosis of byssinosis.

Efficacy and safety of Kangxian Huanji Granule as adjunctive treatment in acute exacerbation of idiopathic pulmonary fibrosis: An exploratory randomized controlled trial

BackgroundAcute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is an important occurrence in the natural history of idiopathic pulmonary fibrosis (IPF), associated with high hospitalization rates, high mortality and poor prognosis. At present, there is no effective treatment for AE-IPF. Chinese herbal medicine has some advantages in treating IPF, but its utility in AE-IPF is unclear. ObjectiveThe treatment of AE-IPF with Kangxian Huanji Granule (KXHJ), a compound Chinese herbal medicine, lacks an evidence-based justification. This study explores the efficacy and safety of KXHJ in patients with AE-IPF. Design, setting, participants and interventionsWe designed a randomized, double-blind, placebo-controlled, exploratory clinical trial. A total of 80 participants diagnosed with AE-IPF were randomly assigned to receive KXHJ or a matching placebo; the treatment included a 10 g dose, administered twice daily for 4 weeks, in addition to conventional treatment. Participants were followed up for 12 weeks after the treatment. Main outcome measuresThe primary endpoints were treatment failure rate and all-cause mortality. Secondary endpoints included the length of hospitalization, overall survival, acute exacerbation rate, intubation rate, the modified British Medical Research Council (mMRC) score, and the St George’s Respiratory Questionnaire for IPF (SGRQ-I) score. ResultsThe rate of treatment failure at 4 weeks was lower in the intervention group compared to the control group (risk ratio [RR]: 0.22; 95% confidence interval [CI]: 0.051 to 0.965, P = 0.023). There was no significant difference in all-cause mortality at 16 weeks (RR: 0.75; 95% CI: 0.179 to 3.138; P > 0.999) or in the acute exacerbation rate during the 12-week follow-up period (RR: 0.69; 95% CI: 0.334 to 1.434; P = 0.317). The intervention group had a shorter length of hospitalization than the control group (mean difference [MD]: –3.30 days; 95% CI, –6.300 to –0.300; P = 0.032). Significant differences in the mean change from baseline in the mMRC (between-group difference: –0.67; 95% CI: –0.89 to –0.44; P < 0.001) and SGRQ-I score (between-group difference: –10.36; 95% CI: –16.483 to –4.228; P = 0.001) were observed after 4 weeks, and also in the mMRC (between-group difference: –0.67; 95% CI: –0.91 to –0.43; P < 0.001) and SGRQ-I (between-group difference: –10.28; 95% CI, –15.838 to –4.718; P < 0.001) at 16 weeks. The difference in the adverse events was not significant. ConclusionKXHJ appears to be effective and safe for AE-IPF and can be considered a complementary treatment in patients with AE-IPF. As a preliminary exploratory study, our results provide a basis for further clinical research. Trial registrationChinese Clinical Trial Registry (ChiCTR1900026289).Please cite this article as: Li JS, Zhang HL, Guo W, Wang L, Zhang D, Zhao LM, Zhou M. Efficacy and safety of Kangxian Huanji Granule as adjunctive treatment in acute exacerbation of idiopathic pulmonary fibrosis: an exploratory randomized controlled trial. J Integr Med. 2023; Epub ahead of print.

Clinical effect of aerobic exercise training in chronic obstructive pulmonary disease: A retrospective study.

Aerobic exercise training is a kind of pulmonary rehabilitation for lung diseases. This was a retrospective study to assess the efficacy of aerobic exercise training in chronic obstructive pulmonary disease (COPD) at a stable stage. A total of one hundred and fifty-six stable COPD patients who had accepted self-education only or self-education combined with an aerobic exercise training between January 2017 to January 2019 were reviewed retrospectively. A total of 79 patients who had received self-education combined with an aerobic exercise training schedule comprised the aerobic exercise training group (AET group) and 77 patients who had received self-education only were regarded as the education group (EDU group). The acute incidence rate in AET group was 7.6% better than that in EDU group 20.7% (P < .05). The AET group patients expressed higher levels of 6 minutes walking distance (6MWD) (P < .05) and better evaluations of both lung function (P < .05) and T lymphocyte immune response (P < .05), as well as significantly decreased chronic obstructive pulmonary disease assessment test (CAT) scores and modified British medical research council (mMRC) grades (P < .05). Patients in EDU group did not report any changes in any of these characteristics. The aerobic exercise training intervention contributed to an increasing in 6MWD and decrease in CAT scores and mMRC grades, as well as improving the T lymphocyte immune response in stable COPD patients.

Versatility of the double fascicular transfer in reconstruction of elbow flexion paralysis: Intermediate term follow-up and patient-related outcome measures

The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up. All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA. In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores. This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject.

Correlation between pulmonary quantitative CT measurement indicators and respiratory symptoms in patients with chronic obstructive pulmonary disease in stable stage

Objective: To explore the correlation between pulmonary quantitative CT measurement indicators and respiratory symptoms in patients with stable chronic obstructive pulmonary disease (COPD). Methods: A total of 186 patients with COPD in stable stage who visited in the outpatient department of Beijing Hospital from March 2021 to February 2022 were prospectively included. Demographic data, respiratory symptoms and lung function were collected. The original DICOM data of high-resolution CT (HRCT) were processed using the FACT medical imaging information system and the pulmonary emphysema index pixel index-950 (PI-950) and the airway wall thickness (4-6 T) and the percentage of airway area (4-6 WA%) of the 4-6 generation bronchi which represent the segmental and subsegmental bronchi were measured automatically. According to the modified British medical research council dyspnea scale (mMRC, 0-1 point for low score group, 2-4 points for high score group), chronic obstructive pulmonary disease assessment test (CAT, score<10 points for low score group,≥10 points for high score group), cough, expectoration and wheezing (asymptomatic group and symptomatic group), they were divided into two groups as dependent variables. The relationship between imaging parameters and the above symptoms was evaluated using a logistic regression model. Results: The study ultimately included 186 patients who met the inclusion criteria, including 162 males and 24 females, aged (68.9±9.3) years old. There were 83 patients in the high mMRC group, 120 patients in the high CAT group, 146 patients in the cough group, 154 patients in the expectoration group, and 65 patients in the wheezing group. The age and emphysema parameter PI-950 in the high score group of mMRC were higher than those in the low score group, while the percentage of the forced expiratory volume in 1 second (FEV1) predicted value (FEV1 pred) after medication, the percentage of carbon monoxide diffusion volume (DLCO) predicted value (DLCO pred), and the percentage of the maximum midexpiratory flow (MMEF) predicted value (MMEF pred) after medication were lower than those in the low score group (all P<0.05). The age of the high CAT group was higher than that of the low score group, while FEV1 pred and MMEF pred after medication were lower than those of the low score group (all P<0.05). The proportion of males, patients with smoking history, and smoking index in the cough group were higher than those in the non cough group, while the 4 WA% was lower than that in the non cough group (all P<0.05). The proportion of males, patients with smoking history, smoking index, and PI-950 in the expectoration group were higher than those in the non expectoration group, while FEV1 pred after medication and 4 WA% were lower than those in the non expectoration group (all P<0.05). The 5 WA% and 6 WA% of the wheezing group were higher than those of the non wheezing group, while MMEF pred after medication was lower than that of the non wheezing group (all P<0.05). Multivariate logistic regression analysis showed that after adjusting for demographic characteristics, smoking, combined diseases, lung function and other confounding factors, for every 10% increase in PI-950, the likelihood of developing more severe dyspnea for the patients (high score group according to mMRC) increased by 67.3% (OR=1.673, 95%CI: 1.052-2.658); Every 10% increase in 6WA% increased the likelihood of wheezing by 3.189 times (OR=4.189, 95%CI: 1.070-16.395). No correlation was found between various imaging indicators and cough, expectoration, and CAT scores (P>0.05). Conclusion: Quantitative CT measurement indicators in stable COPD patients can explain the presence and severity of respiratory symptoms, the pulmonary emphysema indicator is associated with dyspnea, and the percentage of proximal airway wall area is associated with wheezing.

Preconditioning of the motor network with repetitive navigated transcranial magnetic stimulation (rnTMS) to improve oncological and functional outcome in brain tumor surgery: a study protocol for a randomized, sham-controlled, triple-blind clinical trial

BackgroundThe extent of resection of glioma is one of the most important predictors of the survival duration of patients after surgery. The presence of eloquent areas within or near a tumor often limits resection, as resection of these areas would result in functional loss and reduced quality of life. The aim of this randomized, triple-blind, sham-controlled study is to investigate the capability of repetitive navigated transcranial magnetic stimulation (rnTMS) over the primary motor cortex to facilitate the functional reorganization of the motor network.MethodsOne hundred forty-eight patients with tumors in movement-relevant areas will be included in this randomized, sham-controlled, bicentric, triple-blind clinical trial. Patients considered at high risk for postoperative motor deficits according to an initial nTMS assessment will receive inhibitory rnTMS at 1 Hz for 30 min followed by a short motor training of 10 min. Stimulation will be applied to the fiber endings of the corticospinal tract closest to the tumor based on individualized tractography. Stimulation will be performed twice daily for each 30 min for 5–28 days depending on the individually available time between study inclusion and surgery. The intervention is controlled by a sham stimulation group (1:1 randomization), where a plastic adapter will be placed on the coil. We expect a comparable or better motor status 3 months postoperatively as measured by the British Medical Research Council (BMRC) score for the affected upper extremity (non-inferiority) and a higher rate of gross total resections (superiority) in the rnTMS compared to the sham group.DiscussionThe generated reorganization of the brain’s areas for motor function should allow a more extensive and safer removal of the tumor while preserving neurological and motor function. This would improve both survival and quality of life of our patients.Trial registrationDRKS.de DRKS00017232. Registered on 28 January 2020.

Bridging Inequity Gaps in Healthcare Systems While Educating Future Healthcare Professionals-The Social Health Bridge-Building Programme.

Social inequity in healthcare persists even in countries with universal healthcare. The Social Health Bridge-Building Programme aims to reduce healthcare inequities. This paper provides a detailed description of the programme. The Template for Intervention Description and Replication (TIDieR) was used to structure the description. The programme theory was outlined using elements from the British Medical Research Council's framework, including identifying barriers to healthcare, synthesising evidence, describing the theoretical framework, creating a logic model, and engaging stakeholders. In the Social Health Bridge-Building Programme, student volunteers accompany individuals to healthcare appointments and provide social support before, during, and after the visit. The programme is rooted in a recovery-oriented approach, emphasising personal resources and hope. The programme finds support in constructs within the health literacy framework. Student volunteers serve as health literacy mediators, supporting individuals in navigating the healthcare system while gaining knowledge and skills. This equips students for their forthcoming roles as healthcare professionals, and potentially empowers them to develop and implement egalitarian initiatives within the healthcare system, including initiatives that promote organisational health literacy responsiveness. The Social Health Bridge-Building Programme is a promising initiative that aims to improve equity in healthcare by addressing individual, social, and systemic barriers to healthcare. The programme's description will guide forthcoming evaluations of its impact.

The Clinical Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Through a Posterior Approach.

Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance. This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets. A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°. Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.

Outcomes of radiocarpal pinning to facilitate nerve repair in wrist level ulnar nerve injuries with defect.

The ideal scenario for ulnar nerve repair is primary end-to-end neurorrhaphy in a tension-free environment. However, this could be complicated by soft tissue loss, scarring and neuroma formation in a delayed injury, creating a nerve defect. With a wrist level nerve defect, a flexion position can help shorten the nerve gap. However, maintaining the position can be challenging intraoperatively and postoperatively. We proposed our method previously of using a 1.6mm K wire for radio-lunate-capitate pinning of the wrist in flexion to minimize the nerve gap, thereby facilitating neuroma excision and end-to-end neurorrhaphy in delayed ulnar nerve injury. In this study, we elaborate our method and present our case series. From October 2018 to July 2020, 5 patients (mean age: 48.2 years; mean delay from injury to surgery: 84.6 days; mean follow-up: 17.5 months) were retrospectively reviewed. The mean flexion fixation angle was 52 degrees and the K wire was removed at an average of 5.1 weeks postoperatively. All patients were followed-up for a minimum of 12 months. All patients achieved M4 and S3 or S3+ neurologically (according to the criteria of the Nerve Injuries Committee of the British Medical Research Council). The mean Disabilities Arm Hand and Shoulder score was 14.1. The mean grasp and pinch strengths were, respectively, 76.8% and 63.6% of the contralateral hand. All wrist range-of-motion returned to normal within 12 weeks. No complications were noted intraoperatively or postoperatively. Our study showed that radiocarpal pinning of the wrist in flexion was safe and convenient to minimize the nerve gap and to facilitate end-to-end neurorrhaphy in limited-sized wrist-level ulnar nerve defects.

Ulnar nerve anteposition with adipofascial flap, an alternative treatment for severe cubital syndrome

BackgroundUlnar nerve entrapment at the elbow is the second most common cause of nerve entrapment in the upper limb. Surgical techniques mainly include simple decompression, decompression with anterior transposition and medial epicondylectomy.MethodsWe performed decompression with anterior transposition and protected ulnar nerve by adipofascial flap (a random flap with radial based vascularization, harvested through the avascular plane of Scarpa’s fascia. We analyzed patients who underwent ulnar nerve ante-position from 2015 to 2022 according to inclusion and exclusion criteria for a total of 57 patients. All patients included were graded on the McGowan's classification Messina criteria and the British Medical Research Council modified by Mackinnon and Dellon.ResultsThe average McGowan’s score was 2.4 (± 0.6), Messina’s criteria 91.2% indicated a satisfactory or excellent result, sensibility at 6 months was 98.5% S3 or more. A preferential technique has not yet been defined.ConclusionsThe adipofascial flap offers numerous advantages in providing a pliable, vascular fat envelope, which mimics the natural fatty environment of peripheral nerves and creates favorable micro-environmental conditions to contribute to neural regeneration via axon outgrowth.

Post-COVID-19 syndrome in a cohort of hospitalized COVID-19 patients.

The study aimed to investigate the frequency of post-COVID-19 syndrome and associated factors in patients who visited the post-COVID-19 outpatient clinic after hospital discharge in the first, third, and sixth months of the first year of the pandemic. The study was a clinical cohort study of patients hospitalized due to COVID-19. The modified British Medical Research Council (mMRC) Dyspnea Scale, the Clinical Frailty Scale (CFS), the Mini Nutritional Assessment short-form (MNA-SF), and the Malnutrition Universal Screening Tool (MUST) were evaluated using a standard form and symptom interview by a specialist physician. Of the 254 patients in the study group, 50.4% were women, and their ages ranged from 18 to 85 years, with a mean (SD) of 55.3±11.5. Post-COVID-19 syndrome was diagnosed in 57.5% of the patients. It was found that the frequency of some of the symptoms persisted and increased in the first month, decreased significantly in the third month, and did not differ between the third and sixth months. Body mass index (BMI), MNA-SF, MUST, and CFS improved over time. Multiple logistic regression analysis showed that the risk of the post-COVID-19 syndrome was 1.91- and 1.40-fold higher in patients with severe COVID-19 and patients with more symptoms in the first month, respectively. COVID-19 is not a short-term infectious disease but an infectious disease with long-term effects. Cohorts of patients who are still symptomatic at the end of the first month after severe COVID-19 should be followed up for a longer period and their clinical outcomes monitored.

The Effectiveness of Home-Based Inspiratory Muscle Training on Small Airway Function and Disease-Associated Symptoms in Patients with Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitations, occurring mainly in the small airways. Weakness in the respiratory muscles contributes to dyspnea and a decreased exercise capacity in COPD patients. This study aimed to investigate the effectiveness of home-based inspiratory muscle training (IMT) on small airway function and symptoms in COPD patients. This research adopted a non-randomized controlled-study quasi-experimental design. The IMT program consisted of two 15 min sessions·d-1, 5 d·wk-1, with 40% of the maximal inspiratory pressure (PImax) on each participant's assessment results and lasted for 12 weeks. Small airway function was assessed using plethysmography at baseline and after 12 weeks. The modified British Medical Research Council (mMRC), COPD assessment test (CAT), PImax, and 6 min walking distance (6MWD) were recorded at baseline as well as four, eight, and twelve weeks. Twenty-three participants with at least moderate COPD were enrolled in IMT (n = 16) or in the control group (n = 7) in this study. The study participants were mostly male (82.6%), and the average age was 68.29 ± 10.87 years, with a mean body mass index (BMI) of 23.54 ± 4.79. After 12 weeks, the ratios of the first second of forced expiration to the forced vital capacity (FEV1/FVC%) (B coefficient [95% Wald confidence interval] of 5.21 [0.46 to 9.96], p = 0.032), forced expiratory flow (FEF25-75%) (0.20 [0.04 to 0.35] L/s, p = 0.012), and FEF50% (0.26 [0.08 to 0.43] L/s, p = 0.004) in the IMT group were significantly better than in the control group. The IMT group showed significantly lower CAT scores at week 8 (-5.50 [-10.31 to -0.695] scores, p = 0.025) than the control group. The mMRC grade, CAT score, PImax, and 6MWD were significantly improved compared to their values at baseline in the IMT group. Home-based IMT effectively improved post-bronchodilator small airway function and disease-associated symptoms in COPD patients.