Distal Arm Research Articles

Dialysis-associated steal syndrome as a rare complication of arteriovenous fistula angioplasty

Abstract The angioplasty of arteriovenous fistulas (AVF) has become indispensable in preserving haemodialysis access. Though well-known complications, such as pseudoaneurysm formation and rupture, can occur, the incidence of severe dialysis-associated steal syndrome (DASS) following AVF angioplasty is low. We describe a patient with limited dialysis options who developed significant DASS following angioplasty of his AVF. After excluding flow-limiting causes of DASS, the patient underwent a successful Revision Using Distal Inflow procedure, redirecting blood flow to his distal arm. Subsequently, all ischaemic symptoms resolved. While effective surgical options are available for the management of DASS, preventive measures such as proper angioplasty balloon sizing remain key.

Motor somatotopy impacts imagery strategy success in human intracortical brain-computer interfaces.

The notion of a somatotopically organized motor cortex, with movements of different body parts being controlled by spatially distinct areas of cortex, is well known. However, recent studies have challenged this notion and suggested a more distributed representation of movement control. This shift in perspective has significant implications, particularly when considering the implantation location of electrode arrays for intracortical brain-computer interfaces (iBCIs). We sought to evaluate whether the location of neural recordings from the precentral gyrus, and thus the underlying somatotopy, has any impact on the imagery strategies that can enable successful iBCI control. Three individuals with a spinal cord injury were enrolled in an ongoing clinical trial of an iBCI. Participants had two intracortical microelectrode arrays implanted in the arm and/or hand areas of the precentral gyrus based on presurgical functional imaging. Neural data were recorded while participants attempted to perform movements of the hand, wrist, elbow, and shoulder. We found that electrode arrays that were located more medially recorded significantly more activity during attempted proximal arm movements (elbow, shoulder) than did lateral arrays, which captured more activity related to attempted distal arm movements (hand, wrist). We also evaluated the relative contribution from the two arrays implanted in each participant to decoding accuracy during calibration of an iBCI decoder for translation and grasping tasks. For both task types, imagery strategy (e.g., reaching vs. wrist movements) had a significant impact on the relative contributions of each array to decoding. Overall, we found some evidence of broad tuning to arm and hand movements; however, there was a clear bias in the amount of information accessible about each movement type in spatially distinct areas of cortex. These results demonstrate that classical concepts of somatotopy can have real consequences for iBCI use, and highlight the importance of considering somatotopy when planning iBCI implantation.

Chromosome Xp22.3 deletion syndrome with X-linked ichthyosis, Kallmann syndrome, short stature, generalized epilepsy, hearing loss, attention deficit hyperactivity disorder, and intellectual disability – A rare report with review of literature

Chromosome Xp22.3 deletion syndrome is a very rare contiguous gene deletion syndrome with variable phenotype due to the deletion of genes from the distal short arm of the X chromosome (Xp), including the short-stature homeobox (SHOX), anosmin-1 (ANOS1), arylsulfatase (ARSL), neuroligin-4 (NLGN4), and steroid sulfatase (STS) genes. We have reviewed the available literature on the chromosome Xp22.3 deletion syndrome. A 10-year-old boy presented with global developmental delay, generalized epilepsy, decreased hearing, and hyperactivity. He had no significant family history. Examination revealed microcephaly, short stature, and dry and scaly skin lesions on the trunk. He had thick arched eyebrows, a depressed nasal bridge, a long philtrum, high arched palate, retrognathia, brachytelephalangy, brachymetatarsia, and mild scoliosis. Brainstem-evoked response audiometry testing revealed moderate hearing loss. Magnetic resonance imaging showed cerebellar tonsillar ectopia. Clinical exome sequencing revealed a likely pathogenic contiguous deletion (~8.10 Mb) spanning genomic location chrX:g.(_630898)_(8732037_)del encompassing ANOS1, ARSL, NLGN4X, SHOX, and STS genes. We have reviewed the available literature for reported associations of Chromosome Xp22.3 deletion syndrome and report a novel association of X-linked ichthyosis, Kallmann syndrome, global developmental delay, short stature, bilateral hearing loss, generalized epilepsy, attention deficit hyperactivity disorder, and intellectual disability.

Comparison of supraclavicular block with infraclavicular block for distal arm surgeries: A meta-analysis of randomized controlled studies.

Supraclavicular and infraclavicular nerve block are commonly used for the analgesia of distal arm surgeries, and this meta-analysis aims to compare their analgesic efficacy for distal arm surgeries. We searched several databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and selected the randomized controlled trials exploring the analgesic efficacy of supraclavicular block versus infraclavicular block for distal arm surgeries. This meta-analysis was conducted using the random-effect or fixed-effect model based on the heterogeneity. Six randomized controlled trials were included in this meta-analysis. Compared with infraclavicular nerve block for distal arm surgeries, supraclavicular nerve block was associated with substantially reduced complete sensory block (odds ratio [OR] = 0.41; 95% confidence interval [CI] = 0.19-0.88; P = .02) and block performance time (standard mean difference [SMD] = -3.06; 95% CI = -5.82--0.31; P = .03), but had no effect on duration of analgesia (SMD = -0.15; 95% CI = -0.49-0.18; P = .36), time to sensory block (SMD = -0.41; 95% CI = -2.28-1.47; P = .67), vascular puncture (OR = 1.03; 95% CI = 0.11-10.05; P = .98) or adverse events (OR = 0.70; 95% CI = 0.12-4.04; P = .69). Infraclavicular nerve block may be superior to supraclavicular nerve block for the analgesia of distal arm surgeries but needs increased block performance time.

Distal Versus Proximal Arm Improvement After Paired Vagus Nerve Stimulation Therapy After Chronic Stroke

ObjectiveTo evaluate differences in upper-extremity (UE) segment-specific (proximal or distal segment) recovery after vagus nerve stimulation (VNS) paired with UE rehabilitation (Paired-VNS) compared with rehabilitation with sham-VNS (Control). We also assessed whether gains in specific UE segments predicted clinically meaningful improvement. DesignThis study reports on a secondary analysis of Vagus nerve stimulation paired with rehabilitation for UE motor function after chronic ischemic stroke (VNS-REHAB), a randomized, triple-blinded, sham-controlled pivotal trial. A Rasch latent regression was used to determine differences between Paired-VNS and Controls for distal and proximal UE changes after in-clinic therapy and 3 months later. Subsequently, we ran a random forest model to assess candidate predictors of meaningful improvement. Each item of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Wolf Motor Function Test (WMFT) was evaluated as a predictor of response to treatment. SettingNineteen stroke rehabilitation centers in the USA and UK. ParticipantsDataset included 108 participants (N=108) with chronic ischemic stroke and moderate-to-severe UE impairments. InterventionsNot applicable. Main Outcome MeasuresFMA-UE and WMFT. ResultsDistal UE improvement was significantly greater in the Paired-VNS group than in Controls immediately after therapy (95% confidence interval, 0.27-0.73; P≤.001) and after 3 months (95% confidence interval, 0.16-0.75; P=.003). Both groups showed similar improvement in proximal UE at both time points. A subset of both distal and proximal items from the FMA-UE and WMFT were predictors of meaningful improvement. ConclusionsPaired-VNS improved distal UE impairment in chronic stroke to a greater degree than intensive rehabilitation alone. Proximal improvements were equally responsive to either treatment. Given that meaningful UE recovery is predicted by improvements across both proximal and distal segments, Paired-VNS may facilitate improvement that is otherwise elusive.

A new species of Languidipes Hubbard (Ephemeroptera, Polymitarcyidae) from Borneo.

The genus Languidipes is currently represented by three species distributed in southeastern Asia, India, and Sri Lanka. Languidipes corporaali is the most widely distributed species, and both, male and female imagos, as well as nymphs, are known. In contrast, the other species, L. taprobanes and L. lithophagus, are only known from nymphs. Here, we describe a new species, Languidipes janae sp nov, based on male imagos collected from Borneo, Indonesia. This new species is characterized by the presence of ommation on mesonotum, and penis almost completely divided, with sub-quadrate base and a small outer projection basal to the long and slender distal arms. This constitutes the first record of the genus for Borneo. A cladistic analysis of the subfamily Asthenopodinae supports its taxonomic status.

Prevalence and Incidence of Fractures in Patients With Nonfunctional Adrenal Tumors

It is unclear whether nonfunctional adrenal tumors (NFATs) are associated with fractures. To analyze fracture frequencies in individuals with NFATs. A national retrospective cohort study was conducted in patients with NFATs diagnosed in Sweden between January 1, 2005, and December 31, 2019, and control participants without adrenal tumors followed up until death or the end of 2019. Individuals with a diagnosis of adrenal hormonal excess or previous malignant tumors were excluded. Sensitivity analyses were performed in subgroups of individuals with a combination of gallbladder, biliary tract, and pancreas diseases (for whom it was assumed that controls would also have undergone computed tomography) and 3- and 12-month survival free of malignant tumors after the NFAT diagnosis. The data were analyzed from September to November 2023. Diagnosis of NFATs. Main study outcomes were prevalence and incidence of fractures after adjustment for sex, age, and comorbidities. Secondary outcomes were fragility fractures, fractures with fall on the same level, and fracture locations (distal arm and vertebral and hip fractures). Fracture incidence after adrenalectomy was also studied. Among 20 390 patients, 12 120 (59.4%) were women, and the median (IQR) age was 66 (57-73) years; among 125 392 controls, 69 994 (55.8%) were women, and the median (IQR) age was 66 (57-73) years. Previous fractures were more common in patients diagnosed with NFATs compared with controls (4310 of 20 390 [21.1%] vs 20 323 of 125 392 [16.2%]; odds ratio [OR], 1.39; 95% CI, 1.34-1.45; adjusted OR [AOR], 1.27; 95% CI, 1.23-1.33). During the follow-up period (median [IQR], 4.9 [2.2-8.2] years), incident fractures were more common in patients with NFATs (3127 of 20 390 [15.3%] vs 16 086 of 125 392 [12.8%]; hazard ratio [HR], 1.40; 95% CI, 1.34-1.45; adjusted HR [AHR], 1.27; 95% CI, 1.22-1.33). An association between NFATs and vertebral fractures was found (AOR, 1.51; 95% CI, 1.33-1.72; AHR, 1.83; 95% CI, 1.60-2.09). In men younger than 50 years, NFATs were associated with fractures (AOR, 1.45; 95% CI, 1.21-1.74; AHR, 1.48; 95% CI, 1.20-1.82). There was no association among individuals who had undergone adrenalectomy (AHR, 1.12; 95% CI, 0.90-1.38). The association between NFATs and fractures remained significant and of similar magnitude in all sensitivity analyses. In this cohort study, NFATs were associated with fractures, particularly among younger men; thus, patients with NFATs should have bone health evaluation with appropriate treatment and monitoring, especially in younger men.

Effects of Short-Term Hand Tractor Operation on Upper Limb Responses of Users

ABSTRACT Objectives Continuous exposure to hand-arm vibration integrated with poor posture and forceful movements are known causes of musculoskeletal disorders (MSD). In most related studies, force and vibration levels in experimental research is controlled. This study aims to determine how actual hand tractor field operation can affect the upper limb of users. It intends to characterize upper limb muscle activation applied during actual hand tractor usage. Lastly, it determines the immediate impacts on hand strength and perceived upper limb discomfort after the operation. Methods We recruited 15 farm operators with a mean working experience of 20.1 ± 12.2 years. They were asked to operate a hand tractor on paddy fields for at most 8 minutes. Handle vibration was measured using a tri-axial accelerometer. The total unweighted vibration acceleration was computed and used to represent the handle vibration magnitude. Muscle activation was measured using surface electromyography (sEMG). Six sEMG sensors were attached to the dominant and non-dominant side of the extensor carpi radialis (ECR), bicep, and deltoid. Pre- and post-task hand strength and subjective discomfort rating were also taken. Results The total unweighted handle vibration acceleration is 17.45 ± 7.53 m/s2. This exceeds the allowable safe value. Meanwhile, the percentage of maximum voluntary contraction (% MVC) of the muscles ranged from 6% to 14% with the ECR having a significantly higher activation (p < .05) than the bicep and deltoid. The post-task grip strength of the dominant hand was lower than its pre-task value (p < .01) while that of the non-dominant side did not vary significantly. There is a modest trend of higher hand discomfort of the non-dominant side on post-task than pre-task rating (p < .10). Although, overall, the perceived discomfort ranged from none to mild discomfort. Conclusion In conclusion, the study showed an indication that the effects of vibration on humans are evident even at mild muscle exertion, with the exertion predominantly concentrated on the distal arm area clearly affecting grip strength and hand discomfort. In such cases, future recommendations can revolve around the improvement of the hand tractor handle grip to impose grip comfort and ease.

450 Inflammatory Brachial Plexitis Mimics Postoperative Iatrogenic Neurological Deficits

INTRODUCTION: A common cause of neurosurgical malpractice cases is the misrepresentation of idiopathic brachial neuritis (incidence: 1/1000) as an iatrogenic neurological insult caused by a surgeon. METHODS: Confirmed postprocedural brachial neuritis patients from a single quaternary care institution were identified and analyzed. RESULTS: We identified 6 (3 female) postprocedural brachial neuritis patients with mean age 63.7 (range 50-75) years. Procedures included 5 cervical spine surgeries (3 multilevel ACDFs, 2 multilevel posterior fusions with laminectomies, 1 multilevel disc arthroplasty) and 1 intrajugular central venous catheter placement. Average time to symptom onset was 1 week post-procedure (range 1 day-2.5 weeks). Initial symptom was moderate-to-severe shoulder (5), arm (4), and/or neck (1) pain. Subsequently, all developed axillary/shoulder weakness; 3 distal arm/hand weakness, 2 winged scapula, and 2 dyspnea/orthopnea. For diagnosis, two patients had confirmatory EMG, 1 had MR neurography confirming plexus inflammation, and 3 had both (positive EMG findings and inflammation on MR Neurography). Average time to accurate diagnosis was 3.1 (range 1.5-5) months. Average number of clinicians seen prior to accurate diagnosis: 5. Treatments included opioids (5), steroids (1), and/or physical therapy (6). All experienced partial pain relief by 1-8 weeks; 2 had persistent pain requiring gabapentin past 6 months. All patients continued to experience motor deficits past 6 months: (4 patients had atrophy and 2-4/5 motor strength in proximal the proximal arm, 1 had distal arm 3/5 motor strength, and 1 had scapular winging). CONCLUSIONS: Postoperative idiopathic brachial plexitis mimics iatrogenic nerve damage following neurosurgical procedures. Recognition of this entity is difficult, and 6 patients at our institution saw on average 5 providers over 3 months prior to accurate diagnosis. Brachial plexitis has a prolonged course with typically only partial recovery at 6 months.

Focal finger palsy and wrist pain due to cortical infarction: a case report

Abstract Background Hand knob infarction induced focal weakness of contralateral hand or distal arm, only accounts for less than 1% of all ischemic strokes. To date, there is no case with pain during sleep as the onset symptoms being reported. The atypical symptoms of hand knob infarction might increase the risk of delaying treatment especially in the hyperacute phase of stroke. Case presentation A 70-year-old man awoke from sleep due to sudden pain of his right medial wrist and presented to the emergency department with difficulty extending his right index and middle fingers within the time window of intravenous thrombolysis. But the intravenous thrombolysis was not given based on the NIHSS score (0) and atypical symptoms. MRI showed multiple DWI hyperintense lesions, including partial left hand knob area and left posterior central gyrus. CTA showed a severe focal stenosis of proximal left internal carotid artery. Conclusions The hand knob infarction might onset with unusual pain and should be carefully inspected in patients combined with acute onset of focal hand paresis.

Joint Stress Analysis of the Navicular Bone of the Horse and Its Implications for Navicular Disease.

The horse's navicular bone is located inside the hoof between the deep flexor tendon (DDFT) and the middle and end phalanges. The aim of this study was to calculate the stress distribution across the articular surface of the navicular bone and to investigate how morphological variations of the navicular bone affect the joint forces and stress distribution. Joint forces normalised to the DDFT force were calculated from force and moment equilibria from morphological parameters determined on mediolateral radiographs. The stress distribution on the articular surface was determined from the moment equilibrium of the stress vectors around the centre of pressure. The ratio of the proximal to the distal moment arms of the DDFT, as well as the proximo-distal position and extent of the navicular bone, individually or in combination, have a decisive influence on the position and magnitude of the joint force and the stress distribution. If the moment arms are equal and the bone is more proximal, the joint force vector originates from the centre of the joint surface and the joint load is evenly distributed. However, in a more distal position with a longer distal moment arm, the joint force is close to the distal edge, where the joint stress reaches its peak. Degenerative navicular disease, which causes lameness and pathological changes in the distal portion of the bone in sport horses, is likely to be more severe in horses with wedge-shaped navicular bones than in horses with square bones.

Ligand redox controlled amine dehydrogenation and imine hemilability in singlet diradical azo-aromatic Ni(II) complexes: characterization of the electron transfer series of azo-imine complexes of Ni(II).

Herein, using azo-amine (H2L) and azo-imine (L1-3) ligands, singlet diradical Ni(II) complexes [1] and [2] were synthesized from Ni(0)(COD)2 in THF. In separate reactions, homoleptic NiII complexes, [3a]2+-[3c]2+, were synthesized from [NiII(H2O)6](ClO4)2 and L1-3, respectively. All these complexes were characterized thoroughly. The X-ray structures of [1] and [2] showed that the amine side arm in [1] and the imine side arm in [2] are de-coordinated. The dN-N lengths in these two complexes were found to be ∼1.32 Å, which corresponds to the one-electron reduced azo-bond length. These complexes, [1] and [2], showed 1H NMR signals characteristic of diamagnetic compounds. These studies, along with DFT calculations, indicated that the unpaired spins on ligands coupled antiferromagnetically with the two unpaired spins on NiII to result in s = 0 ground states. Complex [1] showed ligand-based redox-induced dehydrogenation of the distal amine side arm to result in L1. Complexes [3a]2+-[3c]2+ have dN-N lengths of ∼1.27 Å and dC-N lengths of ∼1.28 Å. In cyclic voltammetry, complex [3a]2+ showed four well-resolved reversible reductive waves at 0.5 V to -1.6 V in dichloromethane. The first two waves became irreversible when they were measured in acetonitrile solution. The electron transfer series of [3a]2+ was further characterized by spectro-electrochemistry, EPR, and DFT calculations. These showed that all the reductions were associated with the ligand. It was further probed by redox events in complexes [3b]2+ and [3c]2+. While the electron donor -OMe group on the phenyl ring of the azo moiety in [3b]2+ showed a prominent cathodic shift of the potentials, the -F substitution on the phenyl group on the imine side arm of [3c]2+ has almost no effect. It has to be noted here that the oxidation of [2] by two electrons returns it back to complex [3a]2+. Reduction of [3a]2+ by two electrons also resulted in complex [2], indicating reversible ligand redox-induced hemilability of the imine moiety between [3a]2+ and [2]. Moreover, characterization of the electron transfer series of [3a]2+ and [2] has shown superior redox non-innocent behaviour and coordination ability of the azo-pyridine moiety in nickel(II) complexes over the imino-pyridine moiety of the ligand.

Loss of function in NSD2 causes DNA methylation signature similar to that in Wolf-Hirschhorn syndrome

PurposeWolf-Hirschhorn syndrome (WHS), a contiguous gene syndrome caused by heterozygous deletions of the distal short arm of chromosome 4 that includes NSD2, reportedly causes specific DNA methylation signatures in peripheral blood cells. However, the genomic loci responsible for these signatures have not been elucidated. The present study aims to define the loci underlying WHS-related DNA methylation signatures and explore the role of NSD2 in these signatures. MethodsWe conducted genome-wide methylation analysis of individuals with WHS or NSD2 variants using an array method. We studied genome-edited knockin mice and induced pluripotent stem cells to explore the function of NSD2 variants. ResultsThree undiagnosed cases with NSD2 variants showed WHS-related DNA methylation signatures. In patient-derived induced pluripotent stem cells and genome-edited knockin mice, these variants cause NSD2 loss of function, respectively. The p.Pro905Leu variant caused decreased Nsd2 protein levels and altered histone H3-lysine 36 dimethylation levels similarly to what was observed in Nsd2 knockout mice. Nsd2 knockout and p.Pro905Leu knockin mice exhibited common DNA methylation changes. ConclusionThese results revealed that WHS-related DNA methylation signatures are dependent on NSD2 dysfunction and could be useful in identifying NSD2 variants of uncertain significance.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Does Action Observation of the Whole Task Influence Mirror Neuron System and Upper Limb Muscle Activity Better Than Part Task in People With Stroke?

Background: Task-based action observation and imitation (AOI) is a promising intervention to enhance upper limb (UL) motor function poststroke. However, whether whole/part task must be trained in the AOI therapy needs further substantiation. Objective: The objective of this study is to assess and compare the mirror neuron activity and UL muscle activity during AOI of reaching task in terms of whole task (complete movement) and part task (proximal arm movements and distal arm movements). Methods: In this cross-sectional study, 26 participants with first-time unilateral stroke were asked to observe the prerecorded videos of a reaching task in terms of a whole task and proximal and distal components, followed by imitation of the task, respectively. Electroencephalographic (EEG) mu rhythm suppression and electromyographic amplitude of six UL muscles were measured during the task. Results: The analysis of EEG revealed a statistically significant mu suppression score, indicating mirror neuron system activity, during AOI of the whole task in C3 (p = <0.001) and C4 (p = <0.001) electrodes compared to the part task. Percentage maximum voluntary contraction amplitudes of the deltoid (p = 0.002), supraspinatus (p = <0.001), triceps brachii (p = 0.002), brachioradialis (p = 0.006), and extensor carpi radialis (p = <0.001) muscles showed a significant increase in muscle activity during AOI of the whole task. Also, there seems to be a task observation-specific activation of muscles following AOI of proximal or distal tasks. Conclusion: The practice of the whole task should be given emphasis while framing the AOI treatment module to enhance reaching in people with stroke. Trial registration: Clinical Trials Registry-India (CTRI) identifier: CTRI/2018/04/013466.

System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor.

Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites. To describe a grading system for surgical field extension of soft tissue sarcomas. Grading system: CD-grading is a description system consisting of C and D values in the surgical field extension, which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. C1/D1 are positive values and C0/D0 are negative. With a known location, 1/0 values can be "p" (proximal), "d" (distal), and "b" (in the tumor bed), and the description method is as follows: flap type, CxDx [x = 0, 1, p, d or b]. Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented. The cases involved a distal upper arm (elbow) synovial sarcoma reconstructed using a pedicled latissimus dorsi (pedicled flap: CpDp); a distal upper arm (elbow) pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm (transpositional flap: CdD0); an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap (transpositional flap: C0D0); and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh (pedicled flap: CdDd). The reconstruction method is chosen by the surgeon based on size, location, and other tumor characteristics; however, the final surgical field cannot be determined based on preoperative images alone. CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. The CD-grading system gives a new perspective to the flap reconstruction classification. The CD-grading system also provides important information for follow-up imaging of a possible recurrence.

Small Arteriovenous Anastomosis in Fistula Creation: Establishing a Functional Vascular Access while Minimizing Steal Syndrome

ObjectivesThe size selection of the arteriovenous (AV) anastomosis in dialysis access creation requires a careful balance: the diameter must be large enough to accommodate sufficient flow for hemodialysis, but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of dialysis access with sometimes devastating consequences. Conventional teaching recommends an 7-10 mm anastomosis. We sought to assess the efficacy of using a smaller (5-6 mm) anastomosis in new arteriovenous fistula (AVF) creation. MethodsWe conducted a comparative retrospective analysis of patients who underwent fistula creation with a small versus regular size anastomosis at any upper extremity anatomic site between March 2019 and October 2020 at our institution. Anatomic sites included radiocephalic, brachiocephalic and brachiobasilic. All arteriovenous anastomoses were measured intra-operatively to be 5-6 mm in diameter for the small size groups and 8-10mm for the regular size group. Endpoints included steal syndrome, functional patency, primary patency and secondary patency. ResultsOut of 110 patients who underwent an AVF creation, 59.1% received a 5-6 mm anastomosis with a median follow-up time of 10±6 months. Patients’ demographics and comorbidities were relatively similar between the two groups except for a higher rate of hyperlipidemia (55.4% vs. 28.9%, P=0.008) in the small size group. Patients in the small size group were more likely to undergo a radiocephalic fistula (40% vs. 4.5%, P<0.001) and to have a smaller mean vein diameter on preoperative duplex ultrasound (3.2±1mm vs. 3.9±1mm, P=0.0016) when compared to their regular size counterparts. During follow-up, none of the patients in the small group developed steal syndrome (0% vs. 9%, P=0.015). At 1 year, patients in the regular size group achieved higher rates of primary patency (67.9% vs. 46.9%, P=0.02); however, no difference was seen in 1-year primary-assisted patency (84.9% vs. 73.6%, P=0.3), secondary patency (89.6% vs. 79.5%, P=0.3) nor in functional patency (87.7% vs. 82.2%, P=0.64) between the small and regular size groups, respectively. ConclusionsThe use of a 5-6 mm anastomosis in the creation of new arteriovenous fistulas of the upper extremities appears to be a technically safe option for dialysis access. Our experience suggests that smaller anastomosis still creates enough flow to maintain a functional AV access while minimizing the incidence of steal syndrome. Additionally, even with smaller vein sizes pre-operative, adequate dialysis access can be created via a small sized anastomosis, including distal arm access. Larger studies with longer follow-up are needed to evaluate long-term outcomes of small anastomosis fistulas.

The Advantages of Employing Single Injection Technique in Axillary Block for Upper Limb Surgery Within Anesthetic Practice

Abstract Introduction: The axillary plexus block is one of the most used regional anesthesia techniques in upper limb surgery. In this study, we retrospectively evaluated the advantages of using the technique with a single injection in the axillary block, a technique that was used in the Orthopedic Clinic of SCJU between 1.01.2016 and 31.05.2016. Methods: The patients admitted to the study were those with ASA I-III in the number of 50 of which 35 were men and 15 women who underwent axillary brachial plexus block using the single injection technique with the help of the neurostimulator. All patients had surgical interventions in the region of the distal arm, elbow, forearm and hand. The axillary block was performed with the nerve stimulator, using a 22g and 50mm needle, the puncture site used was above the artery where, after obtaining the motor response to the 0.5 mA impulse, Ropivacaine 0.5% 20 ml was injected. Later we analyzed the installation time of the motor and sensory block, what success rate it had and the possible complications. Results: The average motor block installation time was 21+/-1.3 min in the 35 patients. The motor block installation time was 19.2+/-1.5 min and the sensory block a was 16.19+/-1.1 min. block success rate was 91.5 percent. There were no recent or late complications. Conclusions: Axillary plexus block using the single injection technique can be used with great benefits, few complications and low failure rate of the technique.

Characteristics of upper limb mass, muscle CSA and stiffness in adolescent baseball players with and without elbow injury

Since elbow injuries are common in adolescent baseball players, this study aimed to determine the relationship between musculoskeletal status and elbow injuries in 47 baseball players aged 12–14 years. Participants answered a questionnaire and had their general body measurements taken. Magnetic resonance imaging was used to evaluate muscle cross sectional areas (CSA) of the upper arm flexor and extensor muscles, and x-ray absorptiometry was used to determine the mass of the upper arm and the total mass of the forearm and hand. Shear wave elastography was used to determine muscle stiffness of the biceps brachii, brachialis, pronator teres, and brachioradialis. An orthopedic surgeon performed a clinical assessment and elbow ultrasonography for each participant to diagnose elbow injuries. The measured values were compared between the elbow injury and control groups using two-sample t-tests. The elbow injury group had significantly higher muscle stiffness in the brachialis (p < 0.001) and brachioradialis (p = 0.004) muscles and greater elbow flexor CSA of the distal upper arm (p = 0.004) than the control group. The total mass of the forearm and hand and the mass ratio of the forearm and hand to the upper arm were significantly greater in the elbow injury group than in the control group (p = 0.002 and p < 0.001). Thus, it may be necessary to increase flexibility of the brachialis and brachioradialis flexible by stretching and massaging in addition to evaluating the mass distal to the elbow and the elbow flexor muscle size of the distal upper arm to manage elbow injury in youth baseball players.Characteristics of Upper Limb Mass, Muscle Cross-Sectional Area and Stiffness in Adolescent Baseball Players with and without Elbow Injury.

Conservative treatment of distal radial fractures

Distal fracture of the radius is common in all age groups. Under careful consideration of individual indications and contraindications, conservative treatment with reduction and immobilization can have significant advantages over the frequently applied surgical approach, particularly in older patients. Immobilization after closed reduction enables satisfactory wrist function to be achieved according to individual patient expectations. A.Patients with a. significant comorbidities, b. high surgical risk from an anesthesiology perspective (ASA > 3), c. low functional requirements, d. low cosmetic expectations regarding residual visible deformity. B.Young patients with an extension fracture and additional a.< 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b.< 5 mm radial shortening after closed reduction, c.< 2 mm intraarticular displacement after closed reduction. A.Patient age < 65years with an extension fracture and additional a.> 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b.> 5 mm radial shortening after closed reduction, c.> 2 mm intraarticular displacement after closed reduction. B.Flexion fracture for which ligamentotaxis for closed reduction is not possible. C.Open distal radial fracture. D.Fracture dislocations. E.Impairments of peripheral circulation, motor or sensory function of the hand after reduction. After puncturing the fracture hematoma and infiltrating the fracture gap with local anesthetic, the forearm is suspended using Chinese finger traps on the thumb and middle finger. Constant traction in the longitudinal axis of the forearm is ensured by a weight applied via a wide cushioned cuff to the distal upper arm. Reduction then is enabled with the additional reductive effect of ligamentotaxis. After minimal cushioning of the forearm with cotton wool and crepe bandage, a dorsal gypsum longuette is applied. After the plaster bandage has hardened, peripheral circulation, motor function, and sensitivity are checked. The reduction is controlled by X‑ray and documented. A.General procedures to reduce swelling; sufficient analgesics should be prescribed. B.The circular plaster cast is applied once swelling has subsided sufficiently, generally after 2-3days. C.The duration of cast wearing should be planned at 5weeks. A total of 73patients (55women and 18men) aged 65-88years were followed up for 12months to investigate functional outcomes after surgical and conservative therapy. While surgical patients had better functional scores up to 12weeks after treatment begin, there was no longer a significant difference in the 6‑ and 12-month follow-up results. The measured grip strength was consistently better in the surgically treated group. Clinically visible deformities were present in 78% of the conservatively treated patients; however, the patients were satisfied with the functional or cosmetic results. No deformities were seen in the surgically treated patients. All fractures were completely healed after 6months. The rate of complications was significantly higher in the surgery group, with 13complications compared to 5 in the conservative treatment group.