Distal Limb Research Articles

Treatment of acute aortic dissection type A with paraplegia and distal limb ischemia within a hybrid operating room

ObjectiveAcute aortic dissection type A is among the most lethal surgical emergencies. Patients may suffer from occlusion of the aorta or its branches causing end-organ malperfusion complicating the diagnosis and worsening the prognosis. Paraplegia is a rare manifestation that affects less than 5% of patients. If type A aortic dissection and occlusion of the downstream thoraco-abdominal aorta occur simultaneously and require acute treatment, a medical dilemma occurs; what should be treated first?Case reportWe describe a case with an extensive acute type A aortic dissection with signs of consciousness and severe malperfusion syndrome.ResultsThe treatment was successfully performed within a hybrid surgery suite with simultaneous open surgery and endovascular repair techniques supported by cardiopulmonary bypass circulation.ConclusionA hybrid operating room might offer the opportunity to simultaneously repair complicated aortic dissection with malperfusion syndrome, by open aortic surgery and endovascular techniques.

Use of a novel helical fan beam imaging system for computed tomography of the distal limb in sedated standing horses: 167 cases (2019-2020).

To evaluate the diagnostic capabilities of a novel helical fan beam CT system used for imaging of horses with a range of clinical distal limb problems. 167 horses. Medical records were reviewed of horses presented for CT of the distal limb at 2 university-based veterinary hospitals. The following data were recorded: age, sex, breed, presenting complaint, sedation used for imaging, scanning time, procedure time, other diagnostic imaging methods performed, imaging diagnosis, clinical diagnosis, and complications during imaging. Most horses were Thoroughbreds and Quarter Horses. Procedure times ranged from 15 to 40 minutes, with scanning completed in 15 to 45 seconds for each region of interest. The foot or pastern region was commonly scanned (88/167 [53%] horses), with navicular bone disease diagnosed in 42 of 88 (48%) horses. The fetlock region was also commonly scanned (42/167 [40%] horses), with palmar or plantar osteochondral disease diagnosed in 17 of 42 (40%) horses. Horses were compliant during scanning, and no complications with sedation or damage to the scanner occurred. A specific imaging diagnosis for the lameness was achieved more frequently with CT imaging (166/167 [99%]) than with planar digital radiography (26/58 [45%]). The helical fan beam CT system could be used safely to scan sedated standing horses from the carpal or tarsal region distally. Subjectively, the machine was easy to operate, allowing CT to be incorporated into lameness investigations. CT imaging was very likely to result in a clinical diagnosis in horses with distal limb lameness.

Linfedema progressivo crônico em um cavalo Friesian: aspectos clínicos e abordagem diagnóstica - relato de caso

ABSTRACT Chronic Progressive Lymphoedema (CPL) is a disabling disease of draft horses that affects lymphatic system function typically in the distal limbs. Deformities of distal limbs, especially of the pastern, with fibrosis and skin nodular lesions are consequences of disease progression. A 15-year-old Friesian stallion presented for evaluation with history of forelimb enlargement and nodule formations distal to the carpus for four years. Simple radiographs showed soft tissue nodular lesions and venous contrasted radiography showed intense enlargement of II common digital palmar vein of both forelimbs. Tissue culture tests revealed Streptococcus equi and Proteus mirabilis isolation and skin scraping test identified Chorioptes bovis mites. Histological examination revealed perivasculitis and lymph vessels distention. History, clinical and histological findings, and complementary exams suggested CPL diagnosis. We were unable to find previously published cases describing this disease in Brazil, where the increasing number of draft horses requires attention to this problem. The correct and early diagnosis substantially delays disease progression. Therefore, we highlight the need for nationwide propagation of these data to ensure better diagnosis and early treatment of future CPL cases.

Solving equine distal limb lumps and bumps

No conflicts of interest have been declared.

Mid-term results of the endovascular exclusion of associated aorto-iliac aneurysms with large diameter (27 or 28 mm) flared limbs

In the endovascular treatment of associated aortoiliac aneurysms, the choice of the technique of distal anchoring faces a lack of standardization and the results of flared distal limbs also called “bell-bottom” remain discussed. The objective was to report the short and mid-term results of the distal endovascular management of aortoiliac aneurisms with the implantation of large diameter flared limbs. The primary outcomes were the rate of reoperation for type 1b endoleak and the appearance of a limb event (composite criterion).

Healing time of experimentally induced distal limb wounds in horses is not reduced by local injection of equine-origin liquid amnion allograft.

To assess the efficacy of an equine-origin liquid amnion allograft (ELAA) derived from both amniotic fluid and amniotic membrane on the healing time of experimentally induced distal limb wounds in horses. 8 adult horses. On day 0, horses were anesthetized and a 2.5 X 2.5-cm, full-thickness skin wound was created on the dorsal aspect of each metacarpus and bandaged. On day 9, wound margins were injected with ELAA (treatment) or 0.9% NaCl (control). Bandages were changed at specific intervals through day 91 and, on each occasion, wounds were photographed to allow calculation of wound area. Exuberant granulation tissue was resected, if present. Wounds were deemed healed when completely epithelialized. Mean wound area was compared between groups throughout the study period. Only 1 wound (control) remained unhealed at day 91. No difference was found between the treatment and control groups in either wound area over time (P = 1.0) or time for wounds to reduce in size by 95% (P = .2) Exuberant granulation tissue required resection twice (1 control wound and 1 treatment wound). In this model, a single treatment with ELAA administered locally by SC injection did not accelerate distal limb wound healing in horses. However, it is possible that naturally occurring, chronic, or nonhealing wounds would respond differently.

Impact factors of POCUS-guided cannulation for peripheral venoarterial extracorporeal membrane oxygenation: One single-center retrospective clinical analysis.

We aimed to evaluate associated factors for point-of-care ultrasound (POCUS)-guided percutaneous catheterization for venoarterial extracorporeal membrane oxygenation (VA-ECMO). VA-ECMO cases from March 2018 to October 2020 in Department of Intensive Care Unit, Binhaiwan Central Hospital of Dongguan, were enrolled. Clinical data, outcomes, and complications were recorded and summarized. Fifty-nine cases were enrolled, among which 88.1% succeeded in POCUS-guided catheterization via Seldinger technique, whereas 59.3% succeeded at the first puncture. Results showed that artery diameter and times of arterial punctures were independent associated factors for Seldinger puncture (P = .018, odds ratio [OR] = 23.374, 95% confidence interval [CI] = 1.706-320.270; P = .031, OR = 145.098, 95% CI = 1.592-13220.980), and artery diameter and cardiac ejection fraction value (≥30%/<30%) were independent associated factors for first puncture (P = .044, OR = 1.622, 95% CI = 1.014-2.596; P = .013, OR = 5.565, 95% CI = 1.441-21.488). For extracorporeal cardiopulmonary resuscitation patients, artery diameter was independent associated factor for Seldinger puncture (P = .022, OR = 2.070, 95% CI = 1.110-3.858), and cardiac ejection fraction value (≥30%/<30%) was independent associated factor for first puncture (P = .007, OR = 9.533, 95% CI = 1.847-49.204). Thirteen patients (22.0%) had local hemorrhage post puncture, 8 patients (13.6%) presented distal limb arterial ischemia, and 8 patients (13.6%) suffered puncture-related thrombosis. Vasoactive Inotropic Score was found to be independent associated factor for local hemorrhage (P = .039, OR = 0.994, 95% CI = 0.988-1.000), and the Acute Physiology and Chronic Health Evaluation II score was independent associated factor for thrombosis (P = .025, OR = 0.935, 95% CI = 0.882-0.992). Diabetes and cardiopulmonary resuscitation time before catheterization were independent factors for distal limb ischemia (P = .026, OR = 220.774, 95% CI = 1.905-25591.327; P = .017, OR = 1.054, 95% CI = 1.009-1.101). POCUS-guided percutaneous catheterization via Seldinger technique can be the first choice for VA-ECMO cannulation, especially for a team without angiotomy qualifications. Before cannulation, evaluating the target artery and heart function by ultrasound can help predict outcome of catheterization. Assessing risk factors (diabetes, cardiopulmonary resuscitation time before catheterization, Vasoactive Inotropic Score, the Acute Physiology and Chronic Health Evaluation II score) is helpful for prevention and treatment of complications.

Glycogen accumulation in GNE myopathy

Patient 1, a 23-year-old male, and patient 2, a 28-year-old female, developed progressive painless footdrop at age 18 and 20 years, respectively. The weakness progressed to involve distal upper limb and proximal muscles. Neurologic examination showed generalized limb weakness, most severely affecting tibialis anterior. Creatine kinase levels were mildly elevated. Needle electromyography detected myopathic motor unit potentials and frequent fibrillation potentials. Muscle biopsy revealed several fibers harboring rimmed vacuoles and a few fibers containing non-rimmed vacuoles filled with periodic acid-Schiff-positive, diastase-labile material, consistent with glycogen (Fig. 1).

Cytotoxic lesions of the corpus callosum after COVID-19 vaccination

A 23-year-old previously healthy man (Patient 1) and a 33-year-old woman with a past history of depression (Patient 2) developed neurological symptoms approximately 1 week after receipt of the first COVID-19 mRNA vaccination and deteriorated over the next week. Patient 1 reported nausea, headache, a high fever, and retrograde amnesia. Patient 2 reported visual disturbance, headache, dysarthria, a left forearm tremor, dysesthesia of the mouth and distal limbs, and visual agnosia. PCR test results for SARS-CoV-2 were negative. Complete blood cell count, biochemistry, and antibody test and cerebrospinal fluid test findings were unremarkable. Diffusion-weighted and fluid-attenuated inversion recovery MRI of the brain showed a high signal intensity lesion at the midline of the splenium of the corpus callosum compatible with cytotoxic lesions of the corpus callosum (CLOCCs). High-dose intravenous methylprednisolone improved their symptoms and imaging findings. CLOCCs should be considered in patients with neurological manifestation after COVID-19 vaccination.

Low effective mechanical advantage of giraffes’ limbs during walking reveals trade-off between limb length and locomotor performance

Giraffes (Giraffa camelopardalis) possess specialized locomotor morphology, namely elongate and gracile distal limbs. While this contributes to their overall height and enhances feeding behavior, we propose that the combination of long limb segments and modest muscle lever arms results in low effective mechanical advantage (EMA, the ratio of in-lever to out-lever moment arms), when compared with other cursorial mammals. To test this, we used a combination of experimentally measured kinematics and ground reaction forces (GRFs), musculoskeletal modeling, and inverse dynamics to calculate giraffe forelimb EMA during walking. Giraffes walk with an EMA of 0.34 (±0.05 SD), with no evident association with speed within their walking gait. Giraffe EMA was about four times lower than expectations extrapolated from other mammals, ranging from 0.03 to 297 kg, and this provides further evidence that EMA plateaus or even diminishes in mammals exceeding horse size. We further tested the idea that limb segment length is a factor which determines EMA, by modeling the GRF and muscle moment arms in the extinct giraffid Sivatherium giganteum and the other extant giraffid, Okapia johnstoni. Giraffa and Okapia shared similar EMA, despite a four to sixfold difference in body mass (Okapia EMA = 0.38). In contrast, Sivatherium, sharing a similar body mass with Giraffa, had greater EMA (0.59), which we propose reflects behavioral differences, such as a somewhat increased capability for athletic performance. Our modeling approach suggests that limb length is a determinant of GRF moment arm magnitude and that unless muscle moment arms scale isometrically with limb length, tall mammals are prone to low EMA.

Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study

Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0–100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1–3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25–75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6–12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72–82]) and the AxB group (73 [67–80]). Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110–175) min vs 170 (110–250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.

Robot-Assisted Bimanual Training Improves Hand Function in Patients With Subacute Stroke: A Randomized Controlled Pilot Study.

Study DesignA randomized controlled pilot study.BackgroundBimanual therapy (BMT) is an effective neurorehabilitation therapy for the upper limb, but its application to the distal upper limb is limited due to methodological difficulties. Therefore, we applied an exoskeleton hand to perform robot-assisted task-oriented bimanual training (RBMT) in patients with stroke.ObjectiveTo characterize the effectiveness of RBMT in patients with hemiplegic stroke with upper limb motor impairment.InterventionsA total of 19 patients with subacute stroke (1–6 months from onset) were randomized and allocated to RBMT and conventional therapy (CT) groups. The RBMT and CT groups received 90 min of training/day (RBMT: 60 min RBMT + 30 min CT; CT: 60 min CT for hand functional training + 30 min regular CT), 5 days/week, for 4 weeks (20 sessions during the experimental period).AssessmentsClinical assessments, including the Fugl–Meyer assessment of the upper extremity (FMA-UE), action research arm test (ARAT), and wolf motor arm function test (WMFT), were conducted before and after the intervention.ResultsWithin-group analysis showed a significant improvement in the FMA-UE and WMFT in both the CT and RBMT groups. A significant improvement in the Fugl–Meyer assessment (FMA) of the wrist and hand for the distal part in the RBMT group occurred earlier than that in the CT group. A significant improvement in WMFT time was found in both groups, but the WMFT functional ability assessment was only found in the RBMT group. No significant improvements in ARAT assessment were observed in either the CT or RBMT groups. Compared with CT, significant improvements were found in terms of the proportion of minimally clinically important differences after RBMT in FMA-UE (χ2 = 4.34, p = 0.037). No adverse events were reported by any of the participants across all sessions.ConclusionsThis study is the first to apply RBMT to the distal part of the upper limb. Both RBMT and CT are effective in improving the upper limb function in patients with subacute stroke. RBMT shows superior potential efficacy in facilitating recovery of the distal part of upper extremity (UE) motor function in the early stage. Future randomized control studies with a large sample size and follow-up assessments are needed to validate the present conclusions.

NOTCH2NLC-related oculopharyngodistal myopathy type 3 complicated with focal segmental glomerular sclerosis: a case report

BackgroundOculopharyngodistal myopathy (OPDM) is an adult-onset neuromuscular disease characterized by progressive ocular, facial, pharyngeal, and distal limb muscle involvement. Recent research showed that GGC repeat expansions in the NOTCH2NLC gene were observed in a proportion of OPDM patients, and these patients were designated as having OPDM type 3 (OPDM3). Heterogeneous neuromuscular manifestations have been described previously in studies of OPDM3; however, kidney involvement in this disease has rarely been reported.Case presentationHere, we report the case of a 22-year-old Chinese patient with typical manifestations of OPDM complicated with focal segmental glomerular sclerosis (FSGS). This patient with sporadic FSGS exhibited distal motor neuropathy and rimmed vacuolar myopathy in clinical and pathological examinations. An expansion of 122 CGG repeats located in the 5’ untranslated region (UTR) of the NOTCH2NLC gene was identified as the causative mutation in this patient. The clinical and histopathological findings fully met the criteria for the diagnosis of OPDM3. In addition, intranuclear inclusions were detected in the renal tubule epithelial cells of this patient, indicating that the kidney may also be impaired in NOTCH2NLC-related GGC repeat expansion disorders (NREDs).ConclusionsOur case report demonstrated the clinicopathological cooccurrence of sporadic FSGS and OPDM3 in a patient, which highlighted that the kidney may show inclusion depositions in OPDM3, thus expanding the clinical spectrum of NREDs.

Geometrical Changes of the Aorta as Predictors for Thromboembolic Events After EVAR With the Anaconda Stent-Graft

Purpose: Thromboembolic events (TE), including limb graft occlusion (LGO) and distal limb embolization (DLE), are common complications after endovascular aneurysm repair (EVAR). The aim of this study was to find predictors for TE in patients treated with the Anaconda stent-graft for infrarenal aneurysms. Materials and Methods: Geometrical and anatomical variables were retrospectively analyzed in a consecutive Anaconda cohort. Pre- and postoperative CT scans were used to derive geometrical parameters length, curvature, torsion, and tortuosity index (TI) from the center lumen lines (CLLs). Limb characteristics, pre-to-post EVAR and mid-term-follow-up changes in the parameters were evaluated for their predictive value for TE. Results: Eighty-four patients (mean age 74±8.3 years, 74 men) were enrolled. The risk of TE was lowered with pre-to-post implant decreasing TI (steps of 0.05: OR: 1.30, 95% CI: 1.01-1.66, p=0.04), pre-to-post implant decreasing mean curvature (OR: 1.08, 95% CI: 1.01-1.16, p=0.03), and a larger degree of circumferential common iliac artery (CIA) calcification (OR: 0.98, 95% CI: 0.97-1.00, p=0.03). The only LGO predictor was the caudal relocation of maximal curvature after EVAR (OR: 1.01, 95% CI: 1.00-1.01, p=0.04). Preventors of DLE were CIA diameter (OR: 0.87, 95% CI: 0.76-0.99, p=0.04), circumferential CIA calcification (OR: 0.97, 95% CI: 0.95-1.00, p=0.03), mean and maximal curvature of the preoperative aortoiliac trajectory (OR: 0.86, 95% CI: 0.79-0.94, p<0.01 and OR: 0.97, 95% CI: 0.95-1.00, p=0.03, respectively) and pre-to-postoperative decrease in mean curvature (OR: 1.11, 95% CI: 1.02-1.21, p=0.02). Midterm TE predictors were length (OR: 0.95, 95% CI: 0.89-1.01, p=0.08) and torsion maximum location (OR: 1.01, 95% CI: 0.99-1.01, p=0.10). Conclusion: The present study confirms that treatment of infrarenal AAA with an Anaconda stent-graft is related to a relatively high TE rate which decreases with a pre-to-postoperative reduction in curvature and TI, and a larger degree of circumferential CIA calcification. In other words, more aortoiliac straightening and more circumferential CIA calcification may prevent TE development after EVAR with this stent-graft.

Kinematics of the equine distal sesamoid (navicular) bone of the thoracic limb.

To quantify the translation and angular rotation of the distal sesamoid bone (DSB) using computed tomography (CT) and medical modeling software. 30 thoracic limbs from equine cadavers. Partial (n = 12), full (8), and matched full and subsequently transected (10) thoracic limbs were collected. Bone volume CT images were acquired in three positions: extension (200° metacarpophalangeal angle), neutral (180°), and maximal flexion (110°). Mean translation and angular rotation of each DSB were recorded. Differences were determined with two-way ANOVA and post hoc Tukey's tests for pairwise comparisons; P value was set at < 0.05. Dorsal translation was significant during extension (1.4 ± 0.4 mm full limbs and 1.3 ± 0.2 mm partial limbs, P < 0.001). Distal translation was significant during extension (1.9 ± 0.4 mm full and 1.1 ± 0.4 mm partial) and flexion (5.4 ± 0.7 mm full and 6.22 ± 0.6 mm partial, P < 0.001). Rotation was significant (P < 0.001) about the mediolateral axis during extension (17.1° ± 1.4°) and flexion (2.6° ± 1.3°). Translation and rotation of the DSB were significantly different (P < 0.001) between full and partial limbs. This study provides the first quantification of translation and angular rotation of the DSB within the equine hoof. Partial limbs had significantly reduced movement compared to full limbs, suggesting that transection of flexor tendons alters distal thoracic limb kinematics. Further studies are required to determine if pathologic changes in the podotrochlear apparatus have an impact in clinical lameness outcomes.

Positron emission tomography: a horse in the musculoskeletal imaging race.

Positron emission tomography (PET) has established itself as a pertinent tool in equine musculoskeletal imaging in the last few years. With the ability to provide functional information regarding both bone and soft tissues, PET has found several clinical applications in horses. PET is currently used in horses as an enhanced bone scan, providing high-resolution 3-dimensional information, in particular for imaging of the racehorse fetlock. Combined with CT and MRI, PET is particularly pertinent in horses for the assessment of subchondral bone and enthesis. The development of a dedicated PET scanner to image the distal limb of horses with standing sedation led to new applications, where PET is used as a first-line advanced imaging tool, in particular for foot, fetlock, and tarsal imaging. A complimentary clinical review of when to seek advanced imaging in equine athletes can be found in the companion Currents in One Health by Garrett in the July 2022 issue of the Journal of American Veterinary Medical Association. The clinical use of PET in human medicine remains mainly focused on oncological imaging; however, numerous small-scale clinical studies have demonstrated valuable applications for musculoskeletal imaging. These include assessment of foot and ankle pain, osteoarthritis of the knee and hip, osteoporosis, response to bisphosphonates, and chronic osteomyelitis. The use of musculoskeletal PET in dogs remains quite limited, but a few studies have recently been published and clinical interest is growing. The available research data and clinical applications between horses, humans, and dogs are currently quite disparate, but all suggest great promises for earlier and more accurate clinical diagnosis, as well as better understanding of pathophysiology and response to treatment. Translating knowledge from a species to another will undoubtedly help further growth of musculoskeletal PET.

The skeletal taphonomy of anurans from the Eocene Geiseltal Konservat‐Lagerstätte, Germany: insights into the controls on fossil anuran preservation

AbstractThe Geiseltal biota is an Eocene lacustrine Konservat‐Lagerstätte in central Germany. Despite its rich fauna and flora (over 50 000 fossil vertebrates, insects and other invertebrates, plants and trace fossils) the taphonomy of the biota, and of the anurans in particular, is poorly understood. We analysed the skeletal taphonomy of 168 anurans, scoring each specimen for orientation, completeness and articulation. Most are partial skeletons, truncated during preparation. This process introduces measurable artefacts into the taphonomic data, which requires further study. We identified recurring taphonomic states, including disarticulation or loss of abdominal bones, loss of one or more limbs, extensive disarticulation, and extensive loss of elements across the body. Relatively rare states include: loss of distal limb elements only, scattered bones, and isolated, articulated limbs. These data inform a new taphonomic model for the Geiseltal anurans. Comparative analysis of patterns in completeness and articulation in these specimens and anurans from other Cenozoic Lagerstätten reveals repeated patterns in preservation in lacustrine‐hosted settings, such as proximal to distal trends in completeness, preferential loss of small peripheral bones, disarticulation of abdominal bones, and reorientation of major body regions. Taphonomic controls in lacustrine systems are surface water temperature, lake depth, vegetation, exposure to bottom currents, transport mechanisms, scavenging, decay regime, bone size and location in the skeleton; all ultimately controlled by palaeoclimate, lake physiography and hydrology, and anuran anatomy. A universal approach to quantitative analysis of skeletal taphonomy metrics will enable comparative testing of the relationship between preservation and palaeoenvironment for diverse fossil vertebrates.

Three Dimensional-Arterial Spin Labeling Evaluation of Improved Cerebral Perfusion After Limb Remote Ischemic Preconditioning in a Rat Model of Focal Ischemic Stroke.

PurposeTo investigate the application value of 3D arterial spin labeling (3D-ASL) for evaluating distal limb ischemic preconditioning to improve acute ischemic stroke (AIS) perfusion.Materials and MethodsA total of 40 patients with AISs treated in our hospital from January 2020 to December 2020 were recruited, and 15 healthy individuals who were examined in our hospital during the same period were included as the control group; all of these participants were scored on the National Institutes of Health Stroke Scale (NIHSS) and examined by MRI. Sequences included conventional sequences, diffusion-weighted imaging (DWI), magnetic resonance angiography (MRA), and 3D-ASL, and cerebral infarct volume and cerebral blood flow (CBF) in the area of the infarct lesion were measured. After 3 months of treatment, patients with AIS were scored on the modified Rankin Scale (mRS) and divided into good prognosis and poor prognosis groups. In total, 55 adult male Sprague–Dawley rats were divided randomly into three groups: 20 in the middle cerebral artery occlusion (MCAO) group, 20 in the MCAO + limb remote ischemic preconditioning (LRP) group, and 15 in the sham group. In total, 48 h after the procedures, conventional MRI, DWI, and 3D-ASL sequence data were collected, and 2,3,5-trphenyltetrazolium chloride monohydrate (TTC) staining and behavioral scoring were performed. CBF was recorded in the infarct lesion area and the corresponding contralateral area, and the affected/contralateral relative values (rCBF) were calculated to compare the differences in rCBF between different groups. The pathological changes in brain tissues were observed by HE staining, and the expression of vascular endothelial growth factor (VEGF) and platelet endothelial cell adhesion molecule-1 (PECAM-1/CD31) in brain tissues was detected by immunofluorescence and real-time quantitative polymerase chain reaction (RT-qPCR). The protein expression of VEGF was detected by western blotting.ResultsHypertension and internal carotid atherosclerosis are high-risk factors for ischemic stroke, and CBF values in the infarct area are significantly lower than those in the corresponding areas on the contralateral side. NIHSS and mRS scores and CBF values have higher specificity and sensitivity for the prognosis of patients with AIS. LRP significantly reduces the infarct area, improves behavioral deficits in rats with cerebral ischemia, reduces neurological injury and histological damage, protects vascular structures, and promotes neovascularization. In addition, 3D-ASL showed a significant increase in brain tissue perfusion in the ischemic area after LRP, and the expression of VEGF and CD31 showed a significant positive correlation with CBF values.ConclusionThree dimensional (3D) ASL can be used to evaluate LRP to improve stroke perfusion, and its protective effect may be closely related to LRP-induced vascular regeneration.

The return process of physiological umbilical herniation in human fetuses: The possible role of the vascular tree and umbilical ring.

The human intestine elongates during the early fetal period, herniates into the extraembryonic coelom (EC), and subsequently returns to the abdominal cavity (AC). The process by which the intestinal loop returns to the abdomen remains unclear. This study aimed to document positional changes in the intestinal tract with the superior mesenteric artery (SMA) and branches in 3D to elucidate the intestinal loop return process (transition phase). Serial histological cross-sections from human fetuses (crown-rump length [CRL] range: 30-50 mm) in the herniation (n=1), transition (n=7), and return (n=2) phases were selected from the Blechschmidt Collection. The distribution of the SMA trunk and all intestinal and sister branches entering the intestines was visualized so that positional changes in branches were continuous from the herniation to return phases. Positional changes in SMA branches proceeded in an orderly and structured manner; this is essential for continuous blood supply via the SMA to the intestine during transition and for safe intestinal return. Changes in the SMA distribution proceeded prior to the detection of initiation of intestinal tract return, which might start earlier and last much longer than our consensus (i.e., that the return of the herniated intestine begins when the CRL is approximately 40 mm and ends within a short time). In the cross-section of the umbilical ring in the herniation and transition phases, one proximal limb and one distal limb were observed with SMA intestinal branches, which were fully packed in the umbilical ring. The SMA branches were aligned from inferior to superior along the SMA main trunk. In the herniation phase, the distribution of 3rd-13th branches aligned from proximal inferior medial to distal superior left with a slight spiral in the EC, the tips of which suggested an orderly running course of the small intestine. In the transition phase, SMA branches running across the umbilical ring that fed the small intestine were observed, suggesting that the intestine was uncoiled and ran across the umbilical ring almost vertically. The estimated curvature value supported the phenomenon of uncoiling at the umbilical ring; the value at the umbilical ring was lesser than that in the AC and EC. During the transition phase, the proximal and distal limbs transversely ran side by side in the AC, umbilical ring, limbs on the cranial side, and mesentery on the caudal side. The SMA trunk and its branches ran in parallel, cranially to caudally aligned in the mesentery. This layout of the umbilical ring was maintained during the transition phase. In the return phase, the SMA trunk was gently curved from the upper left to the lower right of the AC; around 12 branches spread with a winding staircase appearance. The intestinal tract reached its definitive position immediately after all tissues crossed the umbilical ring and released any restriction. Each SMA branch and the corresponding region of the intestinal tract form a unit and change their position, though the conformation may change within each unit when running across the umbilical ring. We suggest that the slide-stack model requires revision.

Chronic inflammatory demyelinating polyradiculoneuropathy concomitant with nephropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is one of the most common autoimmune peripheral neuropathies in adults. Membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), and other nephropathy have been reported in CIDP patients and are possibly correlated to CIDP pathogenesis. This study reviewed the previously described cases of patients with CIDP and nephropathy in order to provide comprehensive evidence on the diagnosis and treatment regarding CIDP patients in the context of renal diseases. We reviewed our database to identify patients with CIDP and nephropathy. Online database including PubMed, EMBASE, and OVID were searched for relevant cases. We identified a total of 18 cases with CIDP and nephropathy, including 2 cases from our database and 16 ones from online searching. A predominance of male was observed [14 (77.8%)] with the mean age of 53.3 (standard deviation, SD: 16.6) years old. Almost all patients complained paresthesia in distal limbs (94.4%), except one only presented weakness of four extremities. Corticosteroids were prescribed for 14 (77.8%) patients, and 10 showed responsiveness. Three patients experienced relapses during the gradual tapering of steroids. The same immune-mediated pathogenesis may be involved in CIDP and concomitant nephropathy. Male and sensory-predominant CIDP are red flags for complications of renal diseases in CIDP patients. Corticosteroids remain the first-line treatment for CIDP when complicated with renal diseases. Slower tapering or long-term maintenance of steroids may be beneficial for the prognosis of patients with CIDP and nephropathy.