Lower Limb Symptoms Research Articles

Diagnosis, Notification, and Managements of ALS: A Personal Perspective from 40 years of Experience as a Clinical Neurologist

This narrative summary presents the author's 40-year experience as a clinical neurologist who treated patients with amyotrophic lateral sclerosis (ALS). Five representative cases from the author's first 20 years at Chiba University Hospital and its affiliated hospitals were selected, including a patient of respiratory-onset who was ignorantly extubated by a female relative for patient's distress to the intratracheal tube. Based on the latter 20 years of experience at the author's current hospital, the author first describes a famous patient with ALS who was being treated at this medical center before the author was assigned to this hospital and fought against ALS for 31 years before eventually succumbing to total locked-in syndrome. Thereafter, the author has summarized the ages, sex, phenotypes, comorbidities, responses to the available treatment options, and total number of years that have elapsed for the 24 patients that the author initially examined in the outpatient clinic. In terms of diagnostic delay, the author describes "foot drop" in patients who developed lower limb symptoms, and hoarseness in those who developed bulbar palsy. Furthermore, the author discusses issues regarding family caregiving capacity, patient's and families' understanding of notification, and medical management (i.e., medications, rehabilitation for ADL, nutrition and respiration, complications of frontotemporal dementia, and medical cooperation with other clinics and hospitals).

Identifying high-risk groups for deep vein thrombosis after primary total knee arthroplasty using preoperative Caprini scores and D-dimer levels.

Caprini score and D-dimer are well-recognized markers in deep vein thrombosis (DVT) assessment. However, their utility in guiding post-arthroplasty DVT risk is hampered by susceptibility to various post-operative factors, limiting their effectiveness as reminders. Conversely, these markers exhibit greater stability in the pre-operative setting. Despite this, research on the pre-operative predictive value of Caprini score and D-dimer for DVT following primary total knee arthroplasty (TKA) remains scarce. In a retrospective study, we analyzed data from patients who underwent primary TKA, between August 2015 and December 2022. Upon admission, Caprini scores were assessed, and comprehensive blood panels were obtained from fasting blood samples. For all patients, lower limb vascular Doppler ultrasonography was performed pre-operatively to exclude those with pre-existing DVT, and all patients underwent DVT examination again post-operatively. Our study included 2,873 patients, averaging 67.98 ± 7.54years, including 676 men and 2,197 women. In this study, 303 (10.55%) patients developed postoperative DVT, and 57 (1.98%) cases presented with lower limb symptoms. DVT incidence in patients with pre-operative Caprini scores of 1-2 (6.50%), 3 (10.28%), and ≥ 4 (18.05%) showed significant differences (P < 0.05). DVT rates were 14.80% in patients with pre-operative D-dimer levels of ≥ 1mg/L, higher than the 8.98% in those with levels of < 0.5mg/L, and 10.61% in those with levels 0.5-1mg/L (P < 0.05). In patients with Caprini scores of 1-2 and D-dimer levels ≤ 0.5mg/L, the occurrence rate of postoperative DVT was only 5.84%. For patients with Caprini scores ≥ 4 and D-dimer levels ≥ 1.0mg/L, the postoperative DVT occurrence rate soared to 24.81%, with the OR(odds ratio) was 4.744 compared to the former group. Patients with preoperative higher Caprini scores and D-dimer are more likely to develop DVT after TKA. Additionally, those with a preoperative Caprini score ≥ 4 and D-dimer level ≥ 1.0mg/L have a significantly increased risk (24.81%) of developing DVT, identifying them as a high-risk group for DVT following TKA. These findings hold significant value for DVT risk stratification in primary TKA patients and the formulation of preoperative interventions to mitigate the risk of DVT.

Role of unilateral partial facet joint preservation in postero-lateral approach lumbar interbody fusion for patients with degenerative lumbar spinal stenosis presenting bilateral lower limb symptoms: a retrospective study

BackgroundPosterolateral decompression and fusion with internal fixation is a commonly used surgical approach for treating degenerative lumbar spinal stenosis (DLSS). This study aims to evaluate the impact of preserving a portion of the unilateral facet joint during decompression on surgical outcomes and long-term recovery in patients.MethodsThis study analyzed 73 patients with DLSS accompanied by bilateral lower limb neurological symptoms who underwent single-level L4/5 posterolateral decompression and fusion surgery from January 2022 to March 2023. Patients were categorized into two groups based on the type of surgery received: Group A comprised 31 patients who underwent neural decompression without facet joint preservation, while Group B consisted of 42 patients who underwent neural decompression with preservation of partial facet joints on one side. Regular follow-up evaluations were conducted, including clinical and radiological assessments immediately postoperatively, and at 3 and 12 months thereafter. Key patient information was documented through retrospective chart reviews.ResultsMost patients in both groups experienced favorable surgical outcomes. However, four cases encountered complications. Notably, during follow-up, Group B demonstrated superior 1-year postoperative interbody fusion outcomes (P < 0.05), along with a trend towards less interbody cage subsidence and slower postoperative intervertebral disc height loss. Additionally, Group B showed significantly reduced postoperative hospital stay (P < 0.05).ConclusionUnder strict adherence to surgical indications, the posterior lateral lumbar fusion surgery, which preserves partial facet joint unilaterally during neural decompression, can offer greater benefits to patients.

Generation of a human induced pluripotent stem cell (iPSC, DVSi001-A) with a heterozygous mutation in KRAS (A209T)

Human varicose veins are commonly claimed to be responsible for lower limb symptoms. Mutation in KRAS gene has been implicated in various diseases, including cancers and vascular diseases. While little known about the novel mutation in KRAS gene and its contribution to the development of varicose veins. Here, we have generated human induced pluripotent stem cell (iPSC) line, which harboured a novel mutation in KRAS (c.209A>T) gene. This cell line provided a novel tool for understanding the mechanism of KRAS mutation in the pathogenesis of varicose veins.

Aviation Podiatry - What place does podiatry have in aerospace medicine?

Introduction: With there being 12 commercial airlines within the U.K and over 4 billion passengers travelling by aircraft every year, it is of no surprise that thousands of men and women are employed as cabin crew. Physical demands imposed upon cabin crew have long been recognized and known to place this particular population at an increased risk of experiencing a work-related injury. Whilst previous research would also suggest that there is a relationship between footwear and the occurrence of musculoskeletal (MSK) lower limb symptoms, there is a need to consider such a relationship specifically among an aviation cabin crew population. Methods: Quantitative data was obtained from a sample of 250 junior crew at a leading airline in the Middle East over 12 months. The sample involved both female and male crew of a healthy BMI who were aged between 22-30 years. All participants were asked closed questions with regard to their lower limb health and footwear. Dynamic gait scans utilizing a Podotech scanner were also used to assess the participant's gait and validate other data. Results: The screening found that 34% of the crew were found to have an MSK podiatric issue with 30% requiring orthoses. Of the 34%, 30% of this group had footwear issues. Common biomechanical issues were identified in the sample group. A holistic approach to care that included the provision of aviation podiatry allowed longer-term treatment outcomes to be achieved. The use of orthotics that were made from EVA and in accordance with recent podiatric research proved beneficial in helping to address underlying biomechanical issues. Conclusion: The findings presented a more detailed analysis of lower limb biomechanical issues among cabin crew and how such issues could have wider implications for the occupational role of the sample group. Consideration to podiatric issues among aviation staff, as a whole, should not be overlooked. Given the incidence of lower limb issues among the sample group, future rehabilitation and prevention strategies would clearly benefit from the specialist insights of an aviation podiatrist contributing as part of a multi-disciplinary aeromedical team.

Features, measurements, determinants, treatments, and outcomes of musculoskeletal symptoms in postmenopausal women: A scoping review

BackgroundThe literature lacks a consistent review of musculoskeletal symptoms in postmenopausal women. AimTo identify features, measurements, determinants, treatments, and outcomes of musculoskeletal symptoms in postmenopausal women. MethodA scoping review was completed using six databases: Embase, Medline, Cochrane, CINAHL, Web of Science, and Scopus up to December 2022. Sixty-three articles were identified. ResultsMusculoskeletal symptoms in postmenopausal women include somatic symptoms of non-specific origin, upper and lower limb symptoms, spinal pain, and decline in physical performance. Measurements were categorized into four groups: musculoskeletal symptoms for menopause, general musculoskeletal symptoms, menopause-specific quality of life, and general quality of life questionnaires. The determinants were grouped into four themes: demographics, physical determinants, psychosocial determinants, and lifestyle. Pharmacological interventions, supplementation options, and exercise regimens exist for postmenopausal women with musculoskeletal symptoms. ConclusionA comprehensive policy is needed to address musculoskeletal symptoms in postmenopausal women, promoting diverse treatments for improved quality of life.

Morphological Evaluation of Lumbar Facet Joints in Professional Baseball Players.

Many professional baseball players experience low back pain, a major cause of which is lumbar facet joint arthropathy. To evaluate the relationship between the dominant hand side and facet joint morphology in baseball movement. Cross-sectional study; Level of evidence, 3. Participants were 25 Japanese professional baseball players (11 pitchers and 14 fielders) with low back pain and lower limb symptoms. Player age, hand dominance, and length of professional playing experience were recorded, and the lateral diameter of all lumbar facet joints was determined from the axial computed tomography scans. We defined the facet joints ipsilateral and contralateral to the dominant hand as dominant and nondominant, respectively. The nondominant-to-dominant (N/D) ratio of the lateral diameter was calculated, and differences between the pitchers and fielders were analyzed using the unpaired t test. The average player age and length of professional playing experience were 26.9 years (range, 19-37 years) and 7.2 years (range, 1-15 years), respectively. The right hand was dominant in 9 pitchers and 5 fielders, while the left hand was dominant in 2 pitchers and 9 fielders. In pitchers, the average lateral facet joint diameter on the nondominant side was significantly larger than on the dominant side at all vertebral levels except L1 to L2 (P < .05 for all). The N/D ratio for each facet joint was 1.06 (L1-L2), 1.11 (L2-L3), 1.10 (L3-L4), 1.12 (L4-L5), and 1.12 (L5-S1). In fielders, the average lateral facet joint diameter on the dominant side was significantly larger than on the nondominant side at L3 to L4 (P < .05), with N/D ratios of 0.98 (L1-L2), 0.96 (L2-L3), 0.94 (L3-L4), 0.97 (L4-L5), and 0.98 (L5-S1). The N/D ratio was significantly larger in pitchers than in fielders at all levels (P < .05 for all). The facet joints of professional baseball players were enlarged asymmetrically, with different tendencies observed between pitchers and fielders. Although pitching and batting are movements that transmit the rotation from the lower limbs to the upper limbs, the effects of rotation and lateral flexion were associated significantly with facet joint hypertrophy.

Microlumbar Discectomy vs Minimally Invasive Tubular Microdiscectomy: A Prospective Comparative Analysis

Background and Aim: Lumbar disc prolapse is a common cause of backache and radicular symptoms in lower limbs. Different surgical options have been described to compare the functional outcome, complications, and recurrence following surgery for lumbar disc prolapse by classical microlumbar discectomy (MLD) and minimally invasive tubular microdiscectomy. The advantages of one procedure over the other were also analyzed. Methods and Materials/Patients: A prospective, observational study conducted over a period of 1 year in the Department of Neurosurgery, Government Medical College Thiruvananthapuram, among patients who underwent surgical treatment for lumbar disc herniation by either microlumbar discectomy or minimally invasive surgery using a tubular retractor system. Ninety-nine patients who satisfied the inclusion and exclusion criteria were analyzed and tabulated for the outcome. Results: The two groups did not show a statistical difference in terms of functional outcome, complications, or recurrence rate. However, the need for post-operative analgesics, blood loss, and hence hospitalization was less in the tubular discectomy group. Conclusion: Both procedures are equally effective in terms of surgical results. However, the advantages and the subtle tendency of the patients to adopt “keyhole” make the tube an attractive option.

Long-term outcomes of endovascular treatment of acute lower limb deep-vein thrombosis combined with May–Thurner syndrome: A single-center retrospective cohort study

Abstract: OBJECTIVE: May–Thurner syndrome (MTS) is a common cause of lower-extremity deep venous thrombosis (DVT). Stenting is effective in the treatment of MTS; however, there are still complications that may affect the patency of the stent. In addition, the long-term efficacy of stenting remains uncertain. This retrospective study investigated the efficacy and prognosis of endovascular treatment of acute proximal DVT with MTS. MATERIALS AND METHODS: Between June 2014 and December 2017, 122 patients with acute symptomatic proximal DVT at our hospital underwent endovascular surgery. The clinical data of the patients were retrospectively collected including follow-up information. The analysis used the generalized additive mixed model and Kaplan–Meier curves (log-rank test). RESULTS: Of the 122 patients, 75 underwent only catheter-directed thrombolysis (CDT), and 47 underwent CDT with stent placement. Characteristics such as age (P = 0.630 ) and gender (P = 0.842) did not show significant differences between the two groups. The freedom from target lesion revascularization did not show significant differences between the two groups (P = 0.82). There were no significant differences between the two groups in the Venous Clinical Severity Score and Villalta Score. CONCLUSIONS: Endovascular treatment of acute lower limb DVT with MTS has good overall efficacy. In young patients with DVT caused by multiple factors besides MTS, prolonged anticoagulation and close follow-up may be more appropriate than primary stenting after thrombus clearance and significant relief of lower limb symptoms.

A rare case of priapism secondary to intervertebral disc prolapse: Case report and literature review

Abstract Lumbar canal stenosis (LCS) is characterized by narrowing of the central spinal canal or lateral recesses and foramina, leading to compression of nerve tissues. It causes neurogenic claudication, which manifests as back pain and variety of lower limb symptoms such as pain, tingling/numbness, or paresthesia on ambulation. A rare symptom of LCS is priapism, which is thought to occur due to parasympathetic dysfunction. We describe a case of a 45-year-old man, who presented with neurogenic claudication and intermittent priapism due to lumbar intervertebral disc prolapse, which resolved completely after surgical decompression, and literature review for the same.

Is unilateral-approach full-endoscopic lumbar fusion effective for single-level lumbar spondylolisthesis with bilateral symptoms? A preliminary report of 43 CT analysis.

To investigate the clinical results and radiological parameters changes after unilateral-approach endoscopic lumbar interbody fusion (Endo-LIF) for lumbar spondylolisthesis with bilateral symptoms. 43 single-level lumbar spondylolisthesis patients with bilateral lower limb symptoms were included from June 2020 to May 2022. All patients underwent unilateral-approach Endo-LIF and postoperative computed tomography. Radiological parameters including disk height (DH), degree of upper vertebral slip (DUVS), and foramen intervertebral parameters including bilateral foraminal height (FH), contralateral foraminal areas (FA) were evaluated. The clinical outcomes including low back pain and bilateral leg pain were evaluated using Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) before and after surgery. All cases were successfully completed surgery and followed for average 15.16 ± 5.2months. DH (44% ± 11%) and DUVS were significantly improvement postoperatively compared with preoperatively (p < 0.05). Statistically significant increases in bilateral FH (25% ± 11% on the surgical side, 17% ± 8% on the contralateral side) and contralateral FA (26% ± 6%) were observed (p < 0.05). The VAS and the ODI scores were significantly decreased in comparison with the preoperative scores (p < 0.05). Unilateral-approach with contralateral indirect decompression in Endo-LIF can acquire satisfactory clinical outcomes. Therefore, unilateral-approach Endo-LIF may be a promising option for lumbar spondylolisthesis with bilateral symptoms.

Development and validation of a patient reported outcome measure for health-related quality of life for locally recurrent rectal cancer: a multicentre, three-phase, mixed-methods, cohort study

Locally recurrent rectal cancer (LRRC) occurs in 5-10% of patients following previous treatment of rectal cancer. It has a significant impact on patients' overall health-related quality of life (HrQoL). Major advances in surgical treatments have led to improved survival outcomes. However, due to the lack of disease-specific, validated patient-reported outcome measure (PROM), HrQoL, is variably assessed. The aim of this study is to develop a disease-specific, psychometrically robust, and validated PROM for use in LRRC. A multicentre, three phase, mixed-methods, observational study was performed across five centres in the UK and Australia. Adult patients (>18 years old) with an existing or previously treated LRRC within the last 2 years were eligible to participate. Patients completed the proposed LRRC-QoL, EORTC QLQ-CR29, and FACT-C questionnaires. Scale structure was analysed using multi-trait scaling analysis and exploratory factor analysis, reliability was assessed using Cronbach's and the intra-class coefficient, convergent validity was assessed using Pearson's correlation, and known-groups comparison was assessed using the student t-test or ANOVA. Between 01/03/2015 and 31/12/2019, 117 patients with a diagnosis of LRRC were recruited. The final scale structure of the LRRC-QoL consisted of nine multi-item scales (healthcare services, psychological impact, pain, urostomy-related symptoms, lower limb symptoms, stoma, sexual function, sexual interest, and urinary symptoms) and three single items. Cronbach's Alpha and Intraclass correlation values of >0.7 across the majority of scales supported overall reliability. Convergent validity was demonstrated between LRRC-QoL Pain Scale and FACT-C Physical Well Being scale (r=0.528, p<0.001), LRRC-QoL Psychological Impact scale with EORTC QLQ CR29 Body Image (r=0.680, p<0.001) and the FACT-C Emotional Well Being scale (r=0.326, p<0.001), and LRRC-QoL Urinary Symptoms scale with EORTC QLQ-CR29 Urinary Frequency scale (r=0.310, p<0.001). Known-groups validity was demonstrated for gender, disease location, treatment intent, and re-recurrent disease. The LRRC-QoL has demonstrated robust psychometric properties and can be used in clinical and academic practice. None.

Factors associated with spinal instability in low back lumbar diseases with leg pain: Analysis of sagittal translation and segmental angulation.

Determining the association between radiographic spinal instability assessment and lower back lumbar diseases with lower limb symptoms can contribute to evidence-based assessment and treatment in clinical practice and rehabilitation. Therefore, radiological evidence of lumbar spine instability assessment, such as sagittal translation (ST) and segmental angulation (SA), is clinically important. To identify factors associated with the assessment of spinal instability in lumbar disc herniation with leg pain and discogenic low back pain using ST and SA. We examined 112 patients with lumbar disc herniation with leg pain and 116 with discogenic low back pain at our clinic from 2016 to 2021. Data on age, gender, sports activities, and occupation were collected from medical records. Additionally, ST and SA of L4 and L5 during maximum trunk flexion and extension were measured using radiography. Simple and multiple logistic regression analyses were used for statistical analysis. Simple logistic regression analysis showed that ST and SA (odds ratio [OR]: 1.11; 95% confidence interval [CI]: 1.03-1.19) were associated with lumbar disc herniation. Multiple logistic regression analysis showed that only ST was associated with lumbar disc herniation (OR: 2.29; 95% CI: 1.78-3.00). Multiple logistic regression analysis showed that ST was associated with lumbar disc herniation with leg pain and had a stronger association than SA.

The Correlation of Frequency of Work-Related Disorders with Type of Work among Polish Employees.

Musculoskeletal disorders have a significant negative impact on the quality of life of the population. These conditions, as well as other work-related disorders, generate costs associated with treatment and work absence, which makes it a growing problem in industrialized countries. Available data from studies on individual populations of workers indicate a higher incidence of certain symptoms in these groups. Due to the lack of studies on the general population, we aimed to perform the preliminary study evaluating the occurrence of pain and work-related conditions depending on the type of occupational work among Polish employees to identify further possible areas for research. Data was collected using an electronic self-administered questionnaire, which was distributed in groups bringing together various professionals. The data obtained from 379 participants have been analyzed and divided according to performed work into sedentary, forced posture, standing, physical and requiring physical activity. Our study reveals a correlation between the frequency of work-related disorders and type of work performed in the Polish population. A significant correlation between the type of occupational work and prevalence of ankle, knee and shoulder pain, as well as heavy legs or upper limb paresthesia was found. According to our findings, female employees may be more vulnerable to lower limb symptoms. A place of residence also seems to affect the prevalence of upper back pain and heavy legs. The analysis also showed a correlation between the occurrence of hip, knee and ankle pain and the level of education of the participants. Surprisingly, lower extremity paresthesia was significantly more common among participants undertaking additional physical activity, compared to non-physically active respondents.

扶阳罐循经温推法对阳虚寒凝型糖尿病周围神经病变下肢症状的效果观察

扶阳罐循经温推法对阳虚寒凝型糖尿病周围神经病变下肢症状的效果观察

ФУНКЦИОНАЛЬНЫЕ И АНАТОМИЧЕСКИЕ ИЗМЕНЕНИЯ НИЖНИХ КОНЕЧНОСТЕЙ ВО ВРЕМЯ БЕРЕМЕННОСТИ

Objective. To evaluate the prevalence of functional and anatomical changes in the lower extremities of pregnant women and discuss their possible causes and current therapeutic recommendations. Patients and methods. To assess changes in the lower extremities, 100 pregnant women at 38.5±1.3 weeks of gestation age were consecutively enrolled in an individual direct questionnaire. Patients’ ages ranged from 19 to 43 years (mean 31.4±5.3). The number of previous pregnancies and labours were 2.4±1.5 and 1.8±1.2 respectively. The demographic part of the questionnaire included information on age, height, body weight and shoe size before pregnancy and antepartum, medical and obstetric history and physical activity. The clinical section of the original questionnaire contained sections related to the assessment of skin, vascular, neurological and musculoskeletal disorders. Results. During pregnancy, there was an increase in women’s body weight from 66.6±14.8 kg to 78.8±14.6 kg and an increase in casual shoe size by 0.3 cm from 37.9±1.3 to 38.2±1.2 (in 27% of observations). More than half (57%) of study participants described their level of daily physical activity as moderate. The study showed that 85% of pregnant women reported functional or anatomical changes in the lower extremities, which included dermatological changes in 53%, vascular changes in 49%, peripheral nerves changes in 22%, and musculoskeletal changes in 69%. Conclusion. The gestational period is characterised by significant endocrine, immunological and metabolic changes of the pregnant woman, which provokes a range of both physiological and pathological conditions. Establishing the prevalence of lower limb symptoms and syndromes will provide the basis for developing an effective system of medical prevention and treatment of undesirable lower extremities effects.

Imaging the lower limb network in Parkinson’s disease

BackgroundDespite the significant impact of lower limb symptoms on everyday life activities in Parkinson’s disease (PD), knowledge of the neural correlates of lower limb deficits is limited. ObjectiveWe ran an fMRI study to investigate the neural correlates of lower limb movements in individuals with and without PD. MethodsParticipants included 24 PD and 21 older adults who were scanned while performing a precisely controlled isometric force generation task by dorsiflexing their ankle. A novel MRI-compatible ankle dorsiflexion device that limits head motion during motor tasks was used. The PD were tested on their more affected side, whereas the side in controls was randomized. Importantly, PD were tested in the off-state, following overnight withdrawal from antiparkinsonian medication. ResultsThe foot task revealed extensive functional brain changes in PD compared to controls, with reduced fMRI signal during ankle dorsiflexion within the contralateral putamen and M1 foot area, and ipsilateral cerebellum. The activity of M1 foot area was negatively correlated with the severity of foot symptoms based on the Movement Disorder Society‐Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS-III). ConclusionOverall, current findings provide new evidence of brain changes underlying motor symptoms in PD. Our results suggest that pathophysiology of lower limb symptoms in PD appears to involve both the cortico-basal ganglia and cortico-cerebellar motor circuits.

Radiographic predictors for recurrence of lumbar symptoms after prioritized cervical surgery in patients with tandem spinal stenosis.

The purpose of the current study was to explore radiographic predictors for recurrence of lumbar symptoms after prioritized cervical surgery in patients with tandem spinal stenosis (TSS). The current retrospective cohort study included 74 patients with TSS, who underwent prioritized cervical surgery. Based on presence or absence of improvement in lower limb symptoms, patients were grouped into improved and non-improved groups. Medical records and radiological parameters including age, sex, body mass index, cervical and lumbar parameters were analyzed. In improved group, patients were divided into relapsed and non-relapsed groups based on recurrence in lower limb symptoms. Lumbar symptoms improved in 70.1% (n = 52) of patients. Comparison between the improved and non-improved group showed that there were no statistically significant differences in cervical parameters while comparisons between the relapsed and non-relapsed groups showed significant differences in redundant nerve roots (RNRs) (p = 0.029), narrow segment (p = 0.042) and lumbar stenosis index (LSI) (p = 0.003). In multivariate logistic regression analysis, LSI > 10 (p = 0.016) was independently associated with recurrence of lumbar symptoms. Finding of the current study indicated that LSI > 10 was associated with recurrence of lumbar symptoms in TSS patients following cervical surgery.

Myeloneuropathy induced by recreational nitrous oxide use with variable exposure levels.

Although several case series have described nitrous-oxide-associated neurological disorders, a comprehensive assessment of exposure characteristics (e.g., time to onset, level of exposure) in substance abusers has not been performed. The aim of this study was to describe the onset patterns of recreational use of nitrous-oxide-induced neurological disorders. All cases of neurological disorders related to nitrous oxide recreational use reported to the Hauts-de-France addictovigilance center between January 2019 and August 2020 were selected. Only cases requiring hospitalization with informative data to perform the nitrous oxide causality assessment were included. A total of 20 cases from five hospitals were included. The male-to-female ratio was 6:1 and the median age was 19years (range 16-34). The neurological presentation (myeloneuropathy 64%, 7/11; sensorimotor neuropathy 36%, 4/11) included for all patients gait disorders due to proprioceptive ataxia and limb hypoesthesia. The median dose used per occasion was 100 cartridges (range 5-960; n=19). The median time from the start of nitrous oxide use to the onset of neurological symptoms was 6months (range 0.7-54; n=16). The cumulative dose was significantly higher in patients with damage to all four limbs than in patients with lower limb symptoms only (p=0.042). A low intermittent exposure may be sufficient to cause neurological damage in some subjects, suggesting that, at the population level, there is no safe exposure to nitrous oxide in recreational settings. The severity of neurological impairment could increase once used at high doses and for prolonged durations of nitrous oxide.

Effect of customised preformed foot orthoses on gait parameters in children with juvenile idiopathic arthritis: A multicentre randomised clinical trial

BackgroundChildren with juvenile idiopathic arthritis (JIA) can experience significant physical impairment of the lower extremity. Prolonged joint disease and symptoms may cause gait alterations such as reduced walking speed and increased plantar pressures in diseased areas of their feet. There is limited robust clinical trials investigating the effect of non-invasive mechanical therapies such as foot orthoses (FOs) on improving gait parameters in children with JIA. Research questionAre customised preformed FOs effective in improving gait parameters in children with JIA? MethodsA multicentre, parallel design, single-blinded randomised clinical trial was used to assess the gait impacts of customised preformed FOs on children with JIA. Children with a diagnosis of JIA, exhibiting lower limb symptoms and aged 5–18 were eligible. The trial group received a low-density full length, Slimflex Simple device which was customised chair side and the control group received a sham device. Peak pressure and pressure time integrals were used as the main gait outcomes and were measured using portable Tekscan gait analysis technology at baseline, 3 and 6 months. Differences at each follow-up were assessed using the Wilcoxon rank sum test. Results66 participants were recruited. Customised preformed FOs were effective in altering plantar pressures in children with JIA versus a control device. Reductions of peak pressures and pressure time integrals in the heel, forefoot and 5th metatarsophalangeal joint were statistically significant in favour of the trial group. This was associated with statistically significant increased midfoot contact with the trial device at baseline, 3 and 6-month data collections. The trial intervention was safe and well accepted by participants, which is reflected in the high retention rate (92%). SignificanceClinicians may prescribe customised preformed FOs in children with JIA to deflect pressure from painful joints and redistribute from high pressure areas such as the rearfoot and forefoot.