Duration Of Paralysis Research Articles

Rapid sequence induction via an intraosseous needle.

The use of the intraosseous (IO) route for drug administration has been widely reported in the prehospital and military trauma setting, for use in paediatric patients and for use in the cardiac arrest scenario for rapid access. We wish to highlight its use for rapid sequence induction (RSI) in the adult population in a case of difficult intravenous access. A patient presented to our hospital as a stand-by call to the Emergency Department resuscitation area. He was peri-arrest with cardiogenic shock. He was cyanosed with unrecordable oxygen saturations and blood pressure but was very combative. Intubation to facilitate oxygenation was required urgently due to his rapidly deteriorating condition. Multiple attempts at securing intravenous access had been unsuccessful. An EZ-IO (Prometheus Medical Ltd, Hereford, UK) Intraosseous Vascular Access System was inserted in his right proximal tibia. Rapid sequence induction was performed using fentanyl 200mg, ketamine 100mg and suxamethonium 100mg. No fasciculations were observed. We waited 30 s and attempted direct laryngoscopy, which obtained a Grade I Cormack-Lehane View. Intubation was secured at first attempt. The induction process felt very similar in nature and speed to a standard intravenous induction. Post intubation, rapid intravenous access was secured in the right external jugular and then a femoral central line sited. The intraosseous route for drug administration has been used for many years. Studies comparing the pharmacokinetic data of intraosseous versus central venous drug delivery have primarily been undertaken in animals. One study has compared intraosseous versus intravenous rocuronium in anaesthetised swine. They compared electromyographic data obtained following tibial intraosseous administration to that of peripheral intravenous administration and demonstrated no statistically significant difference in the onset time between the two groups. They also demonstrated that the duration of paralysis with the intraosseous route was longer than with the intravenous. They concluded that rocuronium could be administered via the intraosseous route in the same doses as when using the intravenous route. With regard to human studies, a prospective, randomised crossover study has compared the delivery of intraosseous to intravenous morphine in adults and demonstrated that there was no statistically significant difference in the majority of the pharmacokinetic data including the maximum plasma concentration, time to maximum concentration and area under plasma concentration time curve. The majority of reports of using intraosseous for RSI have come from military and trauma experience. A recent observational study has been published in the Emergency Medicine Journal looking at whether RSI via IO was comparable to the intravenous route in terms of grade of view and number of attempts at intubation. The study demonstrated that in the 34 patients who received RSI via IO for trauma they had a 97% first pass intubation rate and that 91% of patients had a Grade 1 Cormack-Lehane view. They were unable to compare this directly to RSI via the intravenous route, as intraosseous access is often the preferred route of access in a military trauma setting. A further military study retrospectively reviewed 830 adult trauma cases and found that 1014 IO devices were inserted over a 60-month period. They demonstrated that the devices were used to infuse anaesthetic induction drugs, analgesia, tranexamic acid, blood and blood products, and intravenous fluids. Of the 1205 times that the IO route was used to infuse drugs, anaesthetic induction agents were the most common drug given, being used for this purpose in 61.8% of cases. With regard to complications, there were no serious complications reported and 14 minor complications that included failure to correctly place IO device, failure to infuse drug, or fracture of needle. This is similar to a Danish study that looked at complications associated with intraosseous access. They showed that serious complications such as compartment syndrome or osetomyelitis are very rare and that problems such as difficulty penetrating periosteum, difficulty aspirating bone marrow and difficulties injecting or infusing fluids or drugs are more common. One of the concerns with the use of the intraosseous route in awake patients is the side effects of pain on insertion and pain on injection. Reports have

Delayed Facial Palsy After Microvascular Decompression for Hemifacial Spasm.

The purpose of this article is to study the etiology, treatment, and prognosis of delayed facial palsy (DFP) after microvascular decompression (MVD) for the hemifacial spasm. Between January 2012 and January 2014, 562 patients who underwent MVD for hemifacial spasm at our institution were retrospectively studied. Among 562 patients, 34 patients developed DFP after MVD with an incidence of 6%. The duration of palsy was 15 to 136 days (average 51.2 days). There was statistical relevance between preoperative duration of the course, the facial nerve for indentation, and the incidence of delayed facial paralysis. All the symptoms of facial paralysis were obviously improved. DFP is not an unusual complication after MVD, and prognosis is fairly good.

Evaluation and Treatment Options of Post Traumatic Facial Nerve Palsy

Facial nerve paralysis by trauma is common cause after idiopathic. Facial palsy as a result of intra cranial, intra temporal and extra temporal blunt injury or fracture and both. Sudden and immediate facial nerve palsy needs early surgical intervention for better outcome. Facial nerve decompression and terminoterminal anastmosis surgical intervention had done in present study. It is a prospective study was done between 2004 to 2006 in Department of Otolaryngology and Head & Neck Surgery in Gandhi Medical College and Associate Hamidia Hospital, Bhopal, (M.P.). The complete clinic examination, otoscopic, audio logical, topodiagnostic, and radiological evaluation were done in all the patients. The outcome of these patients was done on the HouseBrackmann nerve grading system. All patients have infra nuclear type of facial nerve palsy. The maximum incidence of facial nerve paralysis found in the age group between 21 to 30 years. The most common mode of injury was motor vehicle accident in ten patients (60%) and thirteen (76%) patients show complete facial nerve palsy, three (18%) patients were temporal bone fracture and two patients were suffered head injury. Out of 17 patients, 13 patients were normal hearing. Suprachordal (47%) involvement is the most common site of lesion in traumatic facial nerve paralysis. Sudden and immediate onset facial nerve paralysis needs early surgical intervention for better outcome. Facial nerve decompression was better outcome comparing to termino terminal anastmosis. The facial nerve paralysis prognosis depends upon degree of paralysis, duration of paralysis, site of injury and patients’ factors.

Preoperative motor strength and time to surgery are the most important predictors of improvement in foot drop due to degenerative lumbar disease

ObjectivePalsy of dorsiflexion, or foot drop, may be due to degenerative lumbar disease and amenable to posterior spinal decompression. The objective of this study is to measure prognostic factors of and time to foot drop improvement after posterior lumbar decompression. MethodsWe retrospectively reviewed 71 patients undergoing first-time, posterior lumbar decompression for foot drop due to degenerative spinal disease. Patient sex, age, comorbidities (Charlson Comorbidity Index), preoperative anterior tibialis strength (manual muscle testing, MMT), and duration of foot drop were ascertained from clinical notes. Prognostic factors affecting foot drop improvement were calculated with a discrete time proportional hazards model, in which follow-up times and outcome measures were binned into six time intervals: 1week, 6weeks, 3months, 6months, 1year, and ≥1year. ResultsOf the 71 patients, the mean age was 54.6±16.0years, and 66.2% (n=47) were males. The mean Charlson Comorbidity Index was 2.42. During a mean follow-up of 30.4months, dorsiflexion function improved postoperatively in 73.2% (n=52) of patients. The median time to surgery from onset of foot drop was within 6weeks, and the median preoperative MMT strength of patients with foot drop improvement was 3. Following a discrete-time proportional hazards model, duration of anterior tibialis palsy (HR=0.67, P=0.004) and preoperative muscle strength (HR=1.10, P=0.010) were significant predictors of foot drop improvement. Following an adjusted Kaplan–Meier analysis, the median time to foot drop improvement was within 6weeks of surgical intervention. ConclusionsPreoperative muscle strength and palsy duration were statistically significant predictors of foot drop improvement. Furthermore, the median time to improvement was 6weeks.

PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics.

The application of surgical treatments is greatly enhanced by the availability of anesthetic agents, such as neuromuscular blockers. Succinylcholine chloride (2,2′-[(1,4-dioxo-1, 4-butanediyl) bis (oxy)] bis [N, N, N-trimethylethanaminium] dichloride), also known as suxamethonium chloride, is a depolarizing neuromuscular blocking agent (NMBA) on the World Health Organization's List of Essential Medicines. Because of its rapid onset of action and short half-life, it is commonly used in medical procedures that require short-term skeletal muscle paralysis, including rapid intubation in emergency medical situations. The clinical application of succinylcholine (SCH) is tempered by the occurrence of rare, but dramatic adverse reactions and some were the earliest known examples of pharmacogenetics. In many cases, patients with functionally characterized single nucleotide polymorphisms (SNPs) in specific genes in either the pharmacokinetic (PK) or pharmacodynamic (PD) pathways of SCH are at increased risk of these adverse reactions. The ubiquity of SCH in medical procedures makes understanding the pharmacogenomics of SCH critical for identifying susceptible patients such that suitable interventions and alternatives may be utilized. Figure 1 illustrates the PD and PK pathways of SCH and a fully interactive version of these pathways can be accessed at PharmGKB (https://www.pharmgkb.org/pathway/PA166122732). Figure 1 Stylized cells depicting the metabolism and mechanism of action of succinylcholine. Note: the star symbol on the DHPR indicates that it has been activated by depolarization of the t-tubules. A fully interactive version is available at PharmGKB http://www.pharmgkb.org/pathway/PA166122732 ... Pharmacodynamics Structurally, SCH consists of two acetylcholine (ACh) molecules linked end to end by their acetyl groups [1, 2]. ACh is the endogenous agonist of the nicotinic acetylcholine receptor (nAChR), a ligand-gated, non-specific cation channel that is formed by five sub-units organized around a central pore. There are two α1 subunits, and one β1, δ, and e sub-units. Each sub-unit of the nACHR is encoded by one of four genes (α1 is encoded by CHRNA1, β1 is encoded by CHRNB1, δ is encoded by CHRND, and e is encoded by CHRNE) (Figure 1). The nAChR is located on the motor end plate of neuromuscular junction (NMJ) of the skeletal muscle membrane, also known as the sarcolemma. Binding of an agonist, such as ACh or SCH, promotes the open state of the channel. When the nAChR opens, sodium ions rush into the cell and potassium ions rush out resulting in membrane depolarization and generation of an action potential. In myocytes, depolarization stimulates muscle contraction [3-5]. L-type voltage gated calcium channels, also known as dihydropyridine receptors (DHPR), are located on invaginations of the sarcolemma called the transverse tubules (T-tubules). The DHPR is a complex of four sub-units (α1, α2δ, β, γ) and a distinct gene encodes each sub-unit. CACNA1S encodes the α1 sub-unit (also called Cav1.1), the primary sub-unit of the channel that contains the voltage sensor, gating apparatus and channel pore of DHPR [6]. The DHPR is mechanically coupled to the ryanodine receptor (RYR1), a homotetrameric voltage gated calcium channel that is located on the sarcoplasmic reticulum (SR) and encoded by the RYR1 gene [7] (Figure 1). When skeletal muscles are at rest, the troponin complex allosterically inhibits the formation of a cross-bridge between myosin and actin. When calcium is released into the myoplasm, it binds the troponin complex and allows myosin to bind to actin to initiate muscle contraction and continues for as long as ATP is freely available [8]. Upon depolarization of the sarcolemma, the DHPR undergoes a conformational change and transmits a signal to RYR1, which opens to release SR calcium stores into the myoplasm to initiate muscle contraction. Muscle relaxation occurs when calcium ATPases on the sarcoplasmic reticulum (SERCA) remove calcium from the myoplasm and pump it back into the SR [9]. Because it is a depolarizing NMBA, SCH first induces muscle fasiculations followed by flaccid muscle paralysis. SCH takes effect within 60 seconds of intravenous administration and paralysis lasts between 4-6 minutes during which time patients are monitored with an electric nerve stimulator [1]. Because of its short half-life SCH is indicated for medical procedures requiring short-term muscle paralysis, such as endotracheal intubation, neuromuscular surgery, and electroconvulsive therapy. Because SCH paralyzes the respiratory muscles, patients require mechanical ventilation and close monitoring for the duration of paralysis. It has no direct effect on smooth or cardiac muscle contraction. SCH is often administered in combination with other anesthetics, analgesics and narcotics because although it blocks muscle contraction it has no effect on pain perception [1, 2, 10].

Health-related quality of life in 794 patients with a peripheral facial palsy using the FaCE Scale: a retrospective cohort study.

To describe the health-related quality of life of patients visiting a tertiary referral centre for facial palsy, and to analyse factors associated with health-related quality of life, using the FaCE Scale instrument. Retrospective cohort study. The Facial Nerve Center at the Massachusetts Eye and Ear Infirmary, a tertiary referral centre. Patients with a peripheral facial palsy visiting the centre for an initial consultation between August 2007 and June 2012. The total FaCE score and the FaCE social function subdomain. Multiple regression models were developed to identify factors associated with the total FaCE score and FaCE social function score. A total of 794 patients with a mean age of 47.0 ± 16.0 years were analysed in this study, of which 59.9% were female. The mean House-Brackmann, Sunnybrook, total FaCE and FaCE social function scores were 3.6 ± 1.5, 48.2 ± 21.2, 47.3 ± 19.3 and 55.5 ± 19.2, respectively. Increasing age (r = -0.229, P < 0.001) was associated with a lower total FaCE score. Female gender (r = -4.422, P = 0.033) and increased duration of palsy (r = -0.018, P = 0.041) were associated with lower FaCE social function scores. While counselling patients on what to expect during the recovery process after facial paralysis is an important part of any clinical visit, FaCE score correlations suggest that female patients with chronic facial palsy and increased age constitute a patient category that may require additional time and attention to prevent or mitigate psychosocial dysfunction.

A Comparative Meta-Analysis of Tick Paralysis in the United States and Australia

Context. Tick paralysis is a neurotoxic envenoming that mimics polio and primarily afflicts children, especially in hyperendemic regions of the Western United States of America (US) and Eastern Australia. Objective. To compare the epidemiology, clinical and electrodiagnostic manifestations, and outcomes of tick paralysis in the US versus Australia. Methods. A comparative meta-analysis of the scientific literature was conducted using Internet search engines to identify confirmed cases of tick paralysis in the US and Australia. Continuous variables including age, time to tick removal, and duration of paralysis were analyzed for statistically significant differences by unpaired t-tests; and categorical variables including gender, regional distribution, tick vector, tick attachment site, and misdiagnosis were compared for statistically significant differences by chi-square or Fisher exact tests. Results. Tick paralysis following ixodid tick bites occurred seasonally and sporadically in individuals and in more clusters of children than in adults of both sexes in urban and rural locations in North America and Australia. The case fatality rate for tick paralysis was low, and the proportion of misdiagnoses of tick paralysis as Guillain–Barré syndrome (GBS) was greater in the US than in Australia. Although electrodiagnostic manifestations were similar, the neurotoxidromes differed significantly with prolonged weakness and even residual neuromuscular paralysis following tick removal in Australian cases compared with US cases. Discussion. Tick paralysis was a potentially lethal envenoming that occurred in children and adults in a seasonally and regionally predictable fashion. Tick paralysis was increasingly misdiagnosed as GBS during more recent reporting periods in the US. Such misdiagnoses often directed unnecessary therapies including central venous plasmapheresis with intravenous immunoglobulin G that delayed correct diagnosis and tick removal. Conclusion. Tick paralysis should be added to and quickly excluded from the differential diagnoses of acute ataxia with ascending flaccid paralysis, especially in children living in tick paralysis-endemic regions worldwide.

How to rehabilitate long-term facial paralysis.

To project the surgical resuscitation methods that we apply to the lower part of the face and the eyes with the aim of preventing functional and psychological problems that can occur in patients with facial paralysis. Twenty-two patients with facial nerve paralysis due to acoustic neuroma, trauma, cholesteatoma, and parotid carcinoma were included in this study. In the lower facial region, the temporal muscle was suspended to the lower lip. In the upper facial region, eyelid gold implantation was performed. The reanimation results of the upper and lower facial regions were graded as excellent, good, fair, and poor in consideration of the symmetry after rest and smile according to May classification in the third month after the surgery. The study group comprised 15 men (68.2%) and 5 women (31.8 %) (mean age, 63.82 ± 14.18 years; range, 8-78 years). Of the patients, 18.2% (n = 4) had acoustic neuroma, 40.9% (n = 9) had facial trauma, 27.3% (n = 6) had cholesteatoma, and 13.6% (n = 3) had parotid carcinoma.Reanimation techniques were applied to 40.9% (n = 9) of the patients during the first 2-4 years, whereas 59.1% (n = 13) of patients underwent surgery after 4 years.In a total of 17 patients (77.3%) who had lower lip intervention, 4 patients (23.5%) had excellent results, 7 patients (41.2%) had good results, and 6 patients (35.3%) had moderate results.In the 22 patients who underwent the eyelid procedure, 5 patients (22.7 %) had excellent results, 13 patients (59.1 %) had good results, and 3 patients (18.2 %) had moderate results. Poor results were not observed in any patient. Facial paralysis is a disease that causes serious functional and psychological problems in patients. Therefore, the choice of treatment method is dependent on the etiology, duration of paralysis, expectations of the patient, and experience of the surgeon. Being less invasive methods, obtaining immediate results, requiring single surgical stage, and having long-lasting results and dynamic muscle transfer and static suspension methods are preferred.

Incomplete Blinking May Attribute to the Development of Meibomian Gland Dysfunction

Purpose: To investigate the relationship between meibomian gland dysfunction (MGD) and incomplete blinking caused by cranial nerve seven (CN VII) palsy.Methods: A prospective case series of 60 consecutive patients with unilateral CN VII palsy was evaluated for MGD. According to the House–Brackmann scale, patients were divided into complete or incomplete blinking group, with the incomplete group further subdivided to early, middle or late stage according to the paralysis duration. Schirmer’s I test, tear break-up time (BUT), superficial punctate keratopathy, eyelid abnormality, ability and quality of meibum expression were evaluated. Unaffected contralateral eyes were used as control for comparison.Results: A paired sample t-test between affected and unaffected eyes demonstrated a significant difference for BUT, superficial punctate keratopathy, eyelid abnormality, ability and quality of meibum expression in the incomplete blinking group. However, only BUT showed significant difference between affected and unaffected eyes in complete blinking group. Furthermore, we showed that paralysis duration was related to the incidence of MGD. Significant difference was demonstrated between the affected and unaffected eyes for superficial punctate keratopathy, eyelid abnormality, ability and quality of meibum expression in the middle and late stage, but not early stage.Conclusions: These findings suggest that the inability to blink completely induced by CN VII palsy for more than one week might contribute to the development of MGD. Clinical optimization of blinking may ameliorate MGD symptom and benefit CN VII palsy patients.

Impact on bone and muscle area after spinal cord injury

Spinal cord injury (SCI) causes inactivation and consequent unloading of affected skeletal muscle and bone. This cross-sectional study investigated correlations of muscle and bone in spinal cord-injured subjects compared with able-bodied subjects. Thirty-one complete SCI paraplegics were divided according to the neurological level of injury (NLoI) into group A (n=16, above thoracic 7 NLoI, age: 33±16 years, duration of paralysis (DoP): 6±6 years) and group B (n=15, thoracic 8-12, age: 39±14 years, DoP: 5.6±6 years), compared with 33 controls (group C). All were examined with peripheral quantitative computed tomography at 66% of tibia length (bone and muscle area, bone/muscle area ratio). In able-bodied subjects, muscle area was correlated with bone area (P<0.001, r=0.88). Groups A and B differed significantly from the control group in terms of bone and muscle area (P<0.001). In paraplegics, less muscle per unit of bone area (bone/muscle area ratio) was found compared with controls (P<0.001). Bone area was negatively correlated with the DoP in the total paraplegic group (r=-0.66, P<0.001) and groups A and B (r=-0.77, P=0.001 vs r=-0.52, P=0.12, respectively). Muscle area and bone/muscle ratio area correlations in paraplegic groups with DoP were weak. Paraplegic subjects who performed standing and therapeutic walking had significantly higher bone area (P=0.02 and P=0.013, respectively). The relationship between bone and muscle was consistent in able-bodied subjects and it was predictably altered in those with SCI, a clinical disease affecting bone and muscle.

A new paradigm in facial reanimation for long-standing palsies?

Background:A chance observation of return of excellent facial movement, after 18 months following the first stage of cross-face nerve grafting, without free functional muscle transfer, in a case of long-standing facial palsy, lead the senior author (RBA) to further investigate clinically.Patients and Methods:This procedure, now christened as cross-face nerve extension and neurotization, was carried out in 12 patients of very long-standing facial palsy (mean 21 years) in years 1996-2011. The mean patient age and duration of palsy were 30.58 years and 21.08 years, respectively. In patients, 1-5 a single buccal or zygomatic branch served as a donor nerve, but subsequently, we used two donor nerves. The mean follow-up period was 20.75 months.Results:Successive patients had excellent to good return of facial expression with two fair results. Besides improved smile, patients could largely retain air in the mouth without any escape and had improved mastication. No complications were encountered except synkinesis in 1 patient. No additional surgical procedures were performed.Conclusion:There is experimental evidence to suggest that neurotization of a completely denervated muscle can occur by the formation of new ectopic motor end plates. Long-standing denervated muscle fibres eventually atrophy severely but are capable of re-innervation and regeneration, as validated by electron microscopic studies. In spite of several suggestions in the literature to clinically validate functional recovery by direct neurotization, the concept remains anecdotal. Our results substantiate this procedure, and it has the potential to simplify reanimation in longstanding facial palsy. Our work now needs validation by other investigators in the field of restoring facial animation.

Surgical outcomes for painless drop foot due to degenerative lumbar disorders.

Twenty patients presenting with painless drop foot who had undergone lumbar spine surgery for degenerative lumbar diseases were included in this retrospective study. This study aims to investigate which causative factors and patient symptoms significantly affected surgical outcome. Drop foot is a neuromuscular condition that results in dorsiflexion palsy of the ankle. Patients with drop foot often complain of leg pain. Rarely, patients experience painless drop foot due to lumbar degenerative disease. For these patients, the only purpose of surgery is to improve the palsy; this makes it difficult to determine whether surgical intervention is indicated. No studies have focused on the results of surgical treatment for painless drop foot caused by degenerative lumbar diseases. Preoperative strength of the tibialis anterior and duration of palsy were recorded and considered with surgical outcome. Sixty-five percent of patients recovered from drop foot after surgery. Drop foot was caused mainly by impairment of the L5 nerve root. Patients with a longer duration of palsy had poorer results. Duration of palsy had the greatest effect on recovery. As the only goal of this surgery is improvement in the strength of the tibialis anterior, caution must be exercised when considering surgery for patients with longstanding palsy.

3D-Ultrasonography for evaluation of facial muscles in patients with chronic facial palsy or defective healing: a pilot study.

BackgroundWhile standardized methods are established to examine the pathway from motorcortex to the peripheral nerve in patients with facial palsy, a reliable method to evaluate the facial muscles in patients with long-term palsy for therapy planning is lacking.MethodsA 3D ultrasonographic (US) acquisition system driven by a motorized linear mover combined with conventional US probe was used to acquire 3D data sets of several facial muscles on both sides of the face in a healthy subject and seven patients with different types of unilateral degenerative facial nerve lesions.ResultsThe US results were correlated to the duration of palsy and the electromyography results. Consistent 3D US based volumetry through bilateral comparison was feasible for parts of the frontalis muscle, orbicularis oculi muscle, depressor anguli oris muscle, depressor labii inferioris muscle, and mentalis muscle. With the exception of the frontal muscle, the facial muscles volumes were much smaller on the palsy side (minimum: 3% for the depressor labii inferior muscle) than on the healthy side in patients with severe facial nerve lesion. In contrast, the frontal muscles did not show a side difference. In the two patients with defective healing after spontaneous regeneration a decrease in muscle volume was not seen. Synkinesis and hyperkinesis was even more correlated to muscle hypertrophy on the palsy compared with the healthy side.Conclusion3D ultrasonography seems to be a promising tool for regional and quantitative evaluation of facial muscles in patients with facial palsy receiving a facial reconstructive surgery or conservative treatment.

High incidence of catheter-associated venous thromboembolic events in patients with long gap esophageal atresia treated with the Foker process

PurposeTo determine the incidence of catheter-associated venous thromboembolic events (VTE) in long gap esophageal atresia (LGEA) patients treated at Boston Children's Hospital (BCH) and to identify possible risk factors associated with their development. MethodsWe performed a retrospective analysis of LGEA patients from 2005 to 2012. Symptomatic VTEs with radiographic confirmation were defined as events. Potential risk factors were assessed by univariate analysis and multivariate logistic regression. Covariates included age, weight, initial gap length, cumulative days of pharmacologic paralysis and paralytic episodes, number and type of central venous catheters (CVCs), and number of operations. ResultsForty-four LGEA patients were identified. The incidence of CVC associated VTE was 34%. Univariate analysis identified age at Foker 1 (P=.03), paralysis duration (P=.01), episodes of paralysis (P=.001), cumulative number of CVC (P=.007) and length of stay (P=.03) as significant. Multivariate logistic regression identified the number of paralytic episodes as the only significant independent risk factor for VTE (P<.0001). ConclusionsThe incidence of symptomatic VTE was 34%, significantly higher than the VTE incidence of 4.5% reported for our other hospitalized children. These data have led to multidisciplinary discussions regarding thromboprophylaxis and development of a consensus-driven protocol. Since the initiation of this protocol, no VTEs have been identified.

Evidence for the Role of Camkinase II and Synapsin I in the Restoration of Neurotransmission in Botulinum Neurotoxin a Intoxicated Nerve Terminals

At the active zones in the nerve terminals, presynaptic Ca2+ is recognized as an important second messenger that regulates neurotransmission. However, the precise role of Ca2+ in the regulation of exocytosis still remains to be elusive. Synapsin I (SYN1) is a member of the synapsin family (SYN1/2/3) of synaptic vesicle phosphoproteins that is phosphorylated by Ca2+/calmodulin dependent protein kinase II (CaMKII) at the Serine 603. At the motor nerve terminals (MNT), SYN I regulates synaptic transmission and the depolarization signal mediated rise in Ca2+ influx stimulates CaMKII dependent phosphorylation of SYN1. Botulinum neurotoxin A (BoNT/A) selectively proteolyzes SNAP-25 to inhibit acetylcholine (ACh) release and causes life-threatening neuroparalysis. In our efforts to develop therapeutic strategies to counteract BoNT/A at its primary site of action, the MNT, we discovered that mouse MNT express transient receptor potential vanilloid 1 (TRPV1) channel protein and that capsaicin (TRPV1 agonist) antagonized the neuroparalytic effects of BoNT/A. Capsaicin, when injected post BoNT/A exposure, significantly accelerated recovery from neuroparalysis by restoring ACh release and muscle functions. Capsaicin treatment also decreased the total duration of paralysis by 50% and synergistically increased the effects of 3,4 diaminopyridine (blocks K+ channels and prolongs action potential) on ACh release measured by stimulus evoked twitch tension in BoNT/A poisoned nerve muscle preparations. Further, BoNT/A treatment, in vitro, decreased the expression of CaMKII and SYN1 and the phosphorylation of SYN1 in cholinergic Neuro 2a cells. Capsaicin treatment, post BoNT/A, reversed this. We hypothesize that at the MNT, capsaicin stimulated Ca2+ influx via TRPV1 triggers exocytosis by facilitating synaptic transmission via CaMKII mediated phosphorylation of SYN1.

Foot Drop Caused by Lumbar Degenerative Disease: Clinical Features, Prognostic Factors of Surgical Outcome and Clinical Stage

ObjectiveThe purpose of this study was to analyze the clinical features and prognostic factors of surgical outcome of foot drop caused by lumbar degenerative disease and put forward the clinical stage.MethodsWe retrospectively reviewed 135 patients with foot drop due to lumbar degenerative disease. The clinical features and mechanism were analyzed. Age, sex, duration of palsy, preoperative muscle strength of tibialis anterior (TA), sensation defect of affected lower limb, affected foot, diagnosis and compressed nerve roots were recorded and compared with surgical outcome.ResultsFoot drop was observed in 8.1% of all inpatients of lumbar degenerative disease. L5 nerve root compression was observed in 126 of all 135 patients (93.3%). Single, double and triple roots compression was observed respectively in 43, 83, and 9 patients (31.9%, 61.5%, and 6.6%). But there was no significant relationship between preoperative muscle strength of TA and the number of compressed roots. The muscle strength of TA was improved in 113 (83.7%) patients after surgery, but it reached to >=4 in only 21 (15.6%) patients. Improvement of the muscle strength of TA was almost stable at the 6-month follow-up. At the last follow-up, the muscle strength of TA was 1, 2, 3, 4, 5 respectively in 28, 24, 62, 13, 8 patients. Multivariate logistic regression showed duration of palsy (p=0.0360, OR=2.543), preoperative muscle strength of TA (p=0.0064, OR=5.528) and age (p=0.0309, OR=3.208) were factors that influenced recovery following an operation.ConclusionsL5 nerve root was most frequently affected. The muscle strength of TA improved in most patients after surgery, but few patients can get a good recovery from foot drop. Patients of shorter duration of palsy, better preoperative muscle strength of TA and younger age showed a better surgical outcome.

Postdeglutitive residue in idiopathic unilateral vocal fold paralysis

To quantitate postdeglutitive residue and determine its association with paralysis duration (≤6 vs. ≥6 months) in patients with idiopathic unilateral vocal fold paralysis (UVFP). Primary institutional retrospective review. Twenty patients (mean age, 72 years) with idiopathic UVFP and 13 patients (mean age, 66 years) with isolated recurrent laryngeal nerve paralysis (RLNP) who underwent videofluoroscopic swallow studies (VFSSs) were included. Vallecular and pyriform sinus (PS) residues in the anteroposterior view were analyzed quantitatively. In both regions, the symmetry of the affected versus nonaffected sides between patients with idiopathic UVFP and RLNP were compared. Residual differences between short- versus long-term paralysis duration in idiopathic UVFP patients alone were also evaluated. The affected PS of the idiopathic group demonstrated significantly increased residue (P = .007) as compared with the nonaffected PS, but with no significant difference with respect to the vallecula (P = .183). There was no significant difference in the RLNP group. When compared with RLNP patients, the idiopathic group showed significantly increased residue on the affected PS (P = .002), but differences in the vallecular residue were nonsignificant. Pharyngeal residue and the duration of paralysis in idiopathic UVFP patients were not significantly different. Idiopathic UVFP patients were more likely to demonstrate increased residue and asymmetry toward the involved region as compared with RLNP patients, suggesting that nerve involvement in idiopathic UVFP may not be exclusive to the RLN.

Simultaneous or sequential injection of botulinum neurotoxin A does not reduce the duration of paralysis by botulinum neurotoxin A in rat EDL muscle

Simultaneous or sequential injection of botulinum neurotoxin A does not reduce the duration of paralysis by botulinum neurotoxin A in rat EDL muscle

Impact of Acupuncture by Using Life-Energy (Qi) Oriental Needle on the Paralysis of Rats with Experimental Autoimmune Encephalomyelitis

In acupuncture, adaptation to energy flows in body cycles is the key to health and therapy. From the evolution of our thinking about acupuncture, we developed the Life-Energy (Qi) oriental needle (Qi needle). It contains a rotating electromagnetic wave and has a strong affinity for the meridians. We report for the first time on the effect of acupuncture by using a Qi needle (Qi acupuncture) on rat experimental autoimmune encephalomyelitis, a model of human demyelinating multiple sclerosis. Both Qi acupuncture (QA) and general acupuncture (GA) were used on the limbs, at the shaoshang (LU11) and zhongchong (PC9) acupoints, of rats from one day post-immunization (dpi) to 12 dpi. The therapy in the QA groups significantly blocked the onset of EAE paralysis (3/13, 77%, p < 0.05) while all rats in the control EAE groups (12/15) and GA groups (11/13) showed EAE paralysis. In addition, the duration of paralysis was shortened in QA groups (1.5 ± 0.5 days) compared with those of the vehicle (5.5 ± 0.2 days) and GA groups (3.6 ± 1.1 days). The numbers of inflammatory cells and CD4(+) T cells in the QA treated EAE group were significantly reduced compared with those of the EAE control and EAE with GA (p < 0.05). Collectively, the present findings suggest that QA ameliorates the paralysis in rats in an EAE model. The precise mechanism of the amelioration and human studies, however, needs further study.

Comparison of nutritional intake between individuals with acute and chronic spinal cord injury

ObjectiveTo compare the nutritional intake of patients with acute and chronic spinal cord injury (SCI).DesignCross-sectional, observational study.SettingSpinal cord unit.MethodsTwelve in-house patients of a spinal cord unit with acute SCI and paralysis duration of 5.3 ± 2.5 months (acute group) were compared with 12 subjects with chronic SCI (chronic group) with lesion duration of 55.5 ± 21.0 months. All subjects recorded their nutritional intake for 7 days, which was analyzed for intake of energy, proteins, fat, carbohydrates, vitamins, mineral nutrients, fluid, and dietary fiber. Resting energy expenditure (REE) and total body fat were also determined.ResultsThe chronic group showed a significantly higher total body fat content compared to the acute group (19.4 ± 3.8 vs. 15.7 ± 4.3%). All other parameters were not significantly different between groups. Both groups ingested excessive fat and insufficient amounts of carbohydrates compared with common nutritional recommendations. Low intakes of vitamins C, D, E, biotin, folic acid, as well as potassium and iron were found.ConclusionsNo differences were found in the nutritional intakes of two comparable groups of subjects with acute and chronic SCI. Independent of lesion duration, subjects with SCI showed considerable deviations from the general accepted nutritional recommendations concerning macro- and micronutrients intake. Professional nutritional education for persons with SCI should start as soon as possible after injury to prevent nutrition-related secondary complications like cardiovascular diseases. Periodic determinations of body fat content and REE combined with a physical activity program might be helpful as well.