Median Medical Research Council Research Articles

Acetabular revision for iliopsoas impingement: a study of 55 cases at 3 years of follow-up. Does the procedure achieve the Minimal Clinically Important Difference (MCID) in the Oxford-12 score in more than 80% of cases?

IntroductionSeveral surgical options can be offered to manage iliopsoas impingement. Research published on cup replacements often concerns a small population size or multicentre studies, suggesting a variety of indications. We conducted a retrospective single centre study screening according to a specific protocol of a population of patients who had a cup replacement for iliopsoas impingement. The objectives were: 1) to specify the functional outcomes and the achievement of the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) according to the Oxford-12 score, and 2) to assess the complication rate. HypothesisOur hypothesis was that acetabular replacements achieve a Minimal Clinically Important Difference (MCID) in more than 80% of cases. Patients and methodsFifty-five hips underwent acetabular revision between 2011 and 2020. Forty-three were performed as first-line surgery, eight after failed tenotomy and four after failed anterior hip capsule thickening plasty. A CT scan of all the hips revealed a median overhang of 9 mm (7; 12) and a 7 ° cup anteversion (2; 19). Follow-up included assessment of the Oxford-12 score using MCID and PASS, the Merle d'Aubigné score, an assessment of hip flexion muscle strength using the Medical Research Council scale, and an assessment of satisfaction and complications. ResultsAt a mean follow-up of 3 years (2–10), the difference in the Oxford score before and at follow-up was 18 points (15; 27) (p < 0.001), the median Medical Research Council score was 4.5 (4; 5) and patients were satisfied or very satisfied in 73% of cases (40/55). The MCID was achieved for 87% of the hips (48/55), and the PASS was achieved in 67% of cases (33/55). The rate of complications involving surgical revision was 10.9% (6/55) with respectively: two anterior dislocations, one early infection on day 10 resolved after wound irrigation and appropriate antibiotic therapy, one intraoperative fracture of the trochanter requiring osteosynthesis and one arthroscopic revision to remove a free cement fragment. ConclusionDue to a good functional outcome but a high complication rate, a cup replacement can be offered for iliopsoas impingement associated with acetabular malposition or significant overhang. Level of evidenceIV.

Nerve transfer for upper extremity reanimation in people with spinal cord injury: A 2-year follow-up case series

Objective To describe the 2-year functional outcomes of nerve transfer (NT) for upper extremity reanimation. Study Design A prospective case series. Setting A highly specialized rehabilitation hospital for spinal cord injury (SCI) in Italy. Intervention Upper limb nerve transfer (32 NTs, 15 upper limbs). Participants Twelve male individuals with traumatic SCI (AIS A or B, neurological level from C4 to C7) were enrolled; 24-month follow-up data were available for 11. Outcome measures We evaluated the strength recovery of recipient muscles through the Medical Research Council (MRC) Scale for Muscle Strength. Upper limb function and independence were assessed with the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) test version 1 and the Spinal Cord Independent Measure III (SCIM III). Patient satisfaction was also evaluated. Results After 24 months, median MRC scores (range) were: triceps 2 (1–2); extensor digitorum communis 3 (1–4); extensor pollicis longus 2.5 (1–4); flexor digitorum profundus 2 (0–4); flexor pollicis longus 2 (0–4). No complication occurred. GRASSP prehension ability and prehension performance total scores significantly improved at 24 months from 1 (0–4) to 2 (0–7) and from 1 (0–8) to 5 (0–-22), respectively. The SCIM III self-care sub-scale score improved at 24-month follow-up (p = 0.009). This study has important limitations, including a limited generalizability of the results and a small sample size that does not allow definitive conclusions to be drawn. A large multicenter prospective study is needed to confirm our findings. Conclusions NT represents a functional surgery option with few complications for the resuscitation of upper limbs in persons with tetraplegia.

Pulmonary rehabilitation in patients with prior COVID-19 infections

Abstract&#x0D; Background: Patients with prior COVID-19 infections can develop persistent dyspnea and physical limitation. This may reflect chronic lung disease, chronic heart disease, or neuromuscular disease. Treatment approaches include pulmonary rehabilitation. This study analyzed the benefits of conventional pulmonary rehabilitation in patients with chronic symptoms following COVID-19 infections.&#x0D; Methods: Twenty-eight patients completed pulmonary rehabilitation at University Medical Center in Lubbock, Texas. The primary outcome was the time spent on four different types of exercise equipment during aerobic exercise sessions.&#x0D; Results: This study included 15 women and 13 men, with a mean age of 54.4 years. The racial distribution included 12 White patients, 10 Hispanic patients, and 6 Black patients. Ten patients had a smoking history, 19 patients used supplemental oxygen, 14 patients had hypertension, and 11 patients had diabetes. The median COPD Assessment Test (CAT) score was 21.5 (Q1, Q3: 17.5,29), the median Patient Health Questionnaire-9 (PHQ-9) score was 8 (Q1, Q3: 4.5,15.5), and the median Medical Research Council (MRC) score was 2. Twenty-six patients had the abnormal chest x-rays within 3 months of starting the rehabilitation program; these included 5 patients with focal interstitial infiltrates, 9 patients with diffuse interstitial infiltrates, 6 patients with focal opacities, and 6 patients with bilateral opacities. These patients completed 22.9 (Q1, Q3: 6.8,36) exercise sessions. There were statistically significant increases in all machine times on all 4 machines.&#x0D; Conclusion: This study indicates pulmonary rehabilitation can significantly increase aerobic activity levels in patients with prior COVID-19 infections. This improvement occurred in patients with important comorbidity, abnormal chest x-rays, and chronic oxygen supplementation requirements. Patients with prior COVID-19 infections and persistent respiratory symptoms should be referred to pulmonary rehabilitation.&#x0D; &#x0D; Key words: COVID-19, long COVID, rehabilitation

Effect of nusinersen treatment on quality of life and motor function in adult patients with spinal muscular atrophy

The aim of this study was to assess the effect of 4 loading doses of nusinersen on motor function and quality of life (QoL) in adult patients with spinal muscular atrophy (SMA). Twenty-one adult patients with genetically confirmed SMA who were treated with 4 loading doses of nusinersen were included in this study. All patients were evaluated with the Medical Research Council (MRC) scale, the Hammersmith Functional Motor Scale Expanded (HFMSE), and the Short Form Survey-36 (SF-36) at baseline (V1) and before the first nusinersen maintenance treatment, which was at the 15th month of treatment (V2). The SF-36 score was compared between the patients and 35 age-matched healthy controls. Of the twenty-one patients with a median age of 36 years, 10 were nonambulatory, and 11 were ambulatory. The physical component score and the mental component score of the SF-36 were significantly lower in the SMA patient group at baseline than in the healthy group. The median HFMSE scores significantly improved at V2 in both ambulatory and nonambulatory SMA patients (p < 0.05). The median MRC score significantly increased at V2 in the ambulatory SMA patient group (p = 0.04) but not in the nonambulatory SMA patient group (p = 0.19). There was a significant improvement in physical QoL in all the SMA patients at V2 (p = 0.02), but there was no significant improvement in mental QoL (p = 0.15). The loading nusinersen treatment significantly improved motor function scores, muscle strength, and physical QoL.

What happens in the medium-term to capsule-thickening plasties for iliopsoas impingement after total hip arthroplasty? Evaluation of 14 procedures at 4 years’ follow-up

IntroductionIn 2015, we described a capsule-thickening technique via an anterior approach for iliopsoas cup impingement. To our knowledge, medium-term results have not been reported. We therefore retrospectively analyzed all cases in the initial series and those since 2015, to assess this original technique over a longer follow-up: (1) to analyze complications, and (2) to assess functional outcome. HypothesisThe study hypothesis was that this surgical solution has a success rate sufficient for it to be included in the therapeutic armamentarium for iliopsoas impingement. Material and methodFourteen patients were included. Nine plasties were in first line, 3 after tenotomy, and 2 after cup exchange. The anterior Hueter approach was used, visualizing anterior cup overhang, sometimes associated with penetration of the anterior capsule, and enabling capsule-thickening by a folded Vicryl™ mesh. Functional results were analyzed. ResultsAt a median 4years’ follow-up (IQR: 2–5; range: 1–9), change over baseline in Oxford score was 7 points (p=0.004), median Medical Research Council thigh flexion strength score was 5 (IQR: 5–5), and 50% of patients (7/14) were satisfied or very satisfied. The major complications rate was 7% (1/14), for 1 irrigation of infected hematoma, cured without recurrence; there was also 1 minor case of injury to the lateral cutaneous nerve of the thigh. Forty-three percent of patients (6/14) exhibited a minimal clinically important difference (MCID) and 64% (9/14) a patient-acceptable symptom state (PASS). Median anatomic overhang on anatomic CT transverse slice was 7mm (IQR: 3–8; range: 0–13). Four patients underwent secondary acetabular component exchange; their median overhang was 7.5mm (IQR: 7–8) compared to 5mm (IQR: 2–8) for the other patients (p-value non-calculable). ConclusionThis surgical option seems interesting when acetabular overhang is not too great, especially as it does not affect flexion strength. Level of evidenceIV.

Efficacy of Teleconsultation-Based Rehabilitation in Children with Landry-Guillain-Barré Syndrome: An Open Label Randomized Controlled Trial (Tele Rehab-LGBS Trial).

To evaluate the feasibility and efficacy of teleconsultation-based rehabilitation in children with Landry-Guillain-Barré syndrome(LGBS), measured with Medical Research Council (MRC) sum score and Hughes score. A pragmatic, prospective, parallel open label randomized controlled trial was conducted among a total of 50 childrenwith LGBS. The children were randomized using computer generated block randomization into 2 groups (25 in each group): Standard ofcare (Group A) and teleconsultation-based rehabilitation (Group B). Primary and secondary outcomes were measured with MRC sum scoreand Hughes score at 12- and 24-wkfollow-up. The mean age was 6.4 ± 3.3 y; 29 (58%) were boys. Baseline MRC sum score (median, IQR), and Hughes score (median, IQR) in group A was 24 (7-31) and 5 (4-5) respectively; and in group B was 18 (9-24) and 4 (4-5) respectively. At discharge, median (IQR) MRC sum score in group A and B was 34 (28-41), and 30 (25-43) (p value = 0.31) respectively. Tele-rehabilitation was provided to group B for 24 wk with 96% compliance. At 12 wk, median MRC sum score in group A and group B were similar [48 (IQR 44-54) vs. 52 (IQR 46-60), p value = 0.08]. At 12 wk and 24 wk, median Hughes score in group A and B were similar. At 24 wk, 15 out of 23 subjects of group A and 18 out of 25 subjects of group B were ambulatory (p value = 0.61). Teleconsultation-based rehabilitation was feasible with a high compliance rate. The functional outcomes measured with MRC sum score and Hughes score were similar in both the groups at 12 and 24 wk follow-up. Teleconsultation-based rehabilitation has similar efficacy as physical rehabilitation.

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

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

Clinical Outcomes of Upper Extremity Nerve Transfers in Neuralgic Amyotrophy.

Neuralgic amyotrophy (NA) is a disease affecting peripheral nerves. Treatment has historically been conservative, as the natural course of the disease was thought to be self-limiting. Recent work has demonstrated that as many as two-thirds of people with NA have persistent pain, fatigue, or weakness. At the authors' center, supercharged end-to-side (SETS) nerve transfers are commonly performed in patients with NA to optimize motor recovery while allowing for native axonal regrowth. The authors describe the technique and clinical outcomes of patients with NA affecting the anterior interosseous nerve (AIN) who were treated with SETS nerve transfer from extensor carpi radialis brevis to AIN. Ten patients (90% male; mean age, 51.3 ± 9.7 years) underwent extensor carpi radialis brevis-to-AIN transfer at a mean period of 6.4 ± 1.4 months after onset of symptoms. Mean postoperative follow-up duration was 14.8 ± 3.2 months. Before surgery, all patients demonstrated clinically significant weakness in the flexor pollicis longus (FPL), flexor digitorum profundus muscle to the index finger (FDP2), or both. FPL strength improved from a median Medical Research Council (MRC) grade of 1.5 to 4 ( P = 0.011) and FDP2 strength improved from a median MRC grade of 1 to 5 ( P = 0.016). A postoperative MRC grade of 4 or greater was achieved in nine of 10 (90%) FPL and 10 of 10 (100%) FDP muscles. This is the first report of SETS nerve transfer for the treatment of NA. The outcomes of this work suggest that SETS nerve transfers may be an option to optimize motor outcomes in patients with NA. Therapeutic, IV.

Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia

Cervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia. To evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia. In this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022. Nerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release. The primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively. Twenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P < .001) for finger extensors, with 79% of hands gaining an MRC grade of 3 or higher for finger extension; and 2 (IQR, 1-3; P < .001) for finger flexors, with 52% of hands gaining an MRC grade of 3 or higher for finger flexion. The secondary outcomes of SHFT, MHQ, DASH, and SF36-PCS scores improved beyond the established minimal clinically important difference. Both early (<12 months) and delayed (≥12 months) nerve transfers after SCI achieved comparable motor outcomes. Continual improvement in motor strength was observed in the finger flexors and extensors across the entire duration of follow-up. In this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI.

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury.

Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. III.

Self-management programme of activity coping and education—SPACE for COPD(C)—in primary care: a pragmatic randomised trial

IntroductionWe have previously developed a supported self-management programme (SMP): Self-management Programme of Activity, Coping and Education for chronic obstructive pulmonary disease (COPD), which was successfully delivered on an individual basis....

Quantifying long-term upper-limb activity using wearable motion sensors after nerve reconstruction for neonatal brachial plexus palsy.

Standard, physician-elicited clinical assessment tools for the evaluation of function after nerve reconstruction for neonatal brachial plexus palsy (NBPP) do not accurately reflect real-world arm function. Wearable activity monitors allow for the evaluation of patient-initiated, spontaneous arm movement during activities of daily living. In this pilot study, the authors demonstrate the feasibility of using body-worn sensor technology to quantify spontaneous arm movement in children with NBPP 10 years after nerve reconstruction and report the timing and magnitude of recovered arm movement. Eight children with NBPP who underwent brachial plexus reconstruction approximately 10 years prior were recruited to take part in this single-institution prospective pilot study. Per the treatment protocol of the authors' institution, operated patients had severe, nonrecovering nerve function at the time of surgery. The patients were fitted with an activity monitoring device on each of the affected and unaffected arms, which were worn for 7 consecutive days. The duration (VT) and power (VM) with which each arm moved during the patient's normal daily activities were extracted from the accelerometry data and ratios comparing the affected and unaffected arms were calculated. Demographic data and standard physician-elicited clinical measures of upper-extremity function were also collected. Three children underwent nerve grafting and transfer and 5 children underwent graft repair only. The mean (± SD) active range of motion was 98° ± 53° for shoulder abduction, 130° ± 24° for elbow flexion, and 39° ± 34° for shoulder external rotation. The median Medical Research Council grade was at least 2.5 for all muscle groups. The median Mallet grade was at least 2 for all categories, and 13.5 total. The VT ratio was 0.82 ± 0.08 and the VM ratio was 0.53 ± 0.12. Wearable activity monitors such as accelerometers can be used to quantify spontaneous arm movement in children who underwent nerve reconstruction for NBPP at long-term follow-up. These data more accurately reflect complex, goal-oriented movement needed to perform activities of daily living. Notably, despite severe, nonrecovering nerve function early in life, postsurgical NBPP patients use their affected arms more than 80% of the time that they use their unaffected arms, paralleling results in patients with NBPP who recovered spontaneously. These data represent the first long-term, real-world evidence to support brachial plexus reconstruction for patients with NBPP.

Specialized Weaning Unit in the Trajectory of SARS-CoV-2 ARDS: Influence of Limb Muscle Strength on Decannulation and Rehabilitation.

Patients with ARDS due to COVID-19 may require tracheostomy and transfer to a weaning center. To date, data on the outcome of these patients are scarce. The objectives of this study were to determine the factors associated with time to decannulation and limb-muscle strength recovery. This was an observational retrospective study of subjects with COVID-19-related ARDS requiring tracheostomy after prolonged ventilation, who were subsequently transferred to a weaning center from April 4, 2020-May 30, 2020. Forty-three subjects were included. Median age (interquartile range) was 61 (48-66) y; 81% were men, and median body mass index (BMI) was 30 (26-35) kg/m2. Tracheostomy was performed after a median of 19 (12-27) d of mechanical ventilation, and the median ICU length of stay prior to transfer to the weaning center was 30 (21-46) d. On admission to the weaning center, the median Medical Research Council (MRC) score was 36 (27-44). Time to decannulation was 9 (7-18) d after admission to the weaning center. The only factor independently associated with early decannulation was the MRC score on admission to the weaning center (odds ratio 1.16 [95% CI 1.06-1.31], P = .005). Two factors were independently associated with MRC gain ≥ 10: BMI (odds ratio 0.88 [95% CI 0.76-0.99], P = .045) and MRC on admission (odds ratio 0.91 [95% CI 0.82-0.98], P = .03. Three months after admission to the weaning center, 40 subjects (93%) were weaned from mechanical ventilation and 36 (84%) had returned home. MRC score at weaning center admission predicted both early decannulation and limb-muscle strength recovery.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy.

Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies. A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher. Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury. Therapeutic, IV.

Electrocardiogram parameters for predicting future arrhythmia in patients with stable chronic obstructive pulmonary disease

Arrhythmia is one of the common comorbidities in chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate arrhythmia predictors by using ECG in non-hypoxemic patients with stable COPD in outpatient clinics.Fifty patients with COPD and 21 age-sex matched healthy controls were enrolled. Exclusion criteria were having history of exacerbation in the last two months, any cardiac symptoms, comorbidities, hypoxemia for COPD patients, and additionally, history of smoking for healthy controls. Twelve-lead ECGs were obtained from all patients.Mean was 55 ± 4 year in all participants. Median Medical Research Council (MRC) score of COPD patients was 2 and median value of FEV1 was 49%. Median heart rate of COPD patients was 77/min with normal sinus rhythm, significantly faster than healthy controls. P-min, QTcmin, Tp-edisp, Tp-e/QT were significantly different from the control group. In patients with COPD, whilst significant correlations between pulmonary functions and Qtcmin, Qtc-max, p-min were found, there were no significant differences between groups of spirometric stages. Smoking and mMRC dyspnea scale were not correlated with ECG findings.This study showed that non-hypoxemic COPD patients with decreased pulmonary functions, without cardiac symptoms and comorbidities, could have risks for atrial, ventricular arrhythmias regardless of dyspnea, smoking.

Rehabilitation Characteristics of Acute-stage COVID-19 Survivors Managed with Extracorporeal Membrane Oxygenation in the Intensive Care Unit.

ABSTRACTObjectives:This study aimed to describe the rehabilitation characteristics of patients with acute stage coronavirus disease managed with extracorporeal membrane oxygenation (ECMO) in the intensive care unit.Methods:This retrospective study enrolled coronavirus disease patients who underwent rehabilitation following ECMO between April 21, 2020, and August 20, 2021. The following patient data were evaluated: age, sex, weaning, peak C-reactive protein, lowest albumin level, white blood cell count, use of steroids and muscle relaxants, duration of respiratory management, ECMO management and rehabilitation, Medical Research Council (MRC) score, and Barthel index after sedation and at discharge.Results:ECMO was performed in 20 patients, and 16 were weaned successfully. The median durations of ECMO and respiratory management in survivors were 14.5 and 38 days, respectively. The median MRC scores after sedation and after rehabilitation therapy were 18 and 45, respectively. The median rehabilitation duration after sedation was 14 days. The MRC score after sedation showed significant correlations with the durations of ECMO and intubation. The median Barthel index values after sedation and at discharge were 0 and 30, respectively.Conclusions:Rehabilitation was important for patients with severe coronavirus disease because muscle weakness advanced in proportion with the durations of ECMO and ventilation management in the intensive care unit.

Inpatient Delirium in Guillain-Barré Syndrome: Frequency and Clinical Characteristics in a Mexican Hospital

BackgroundDelirium has a prevalence of 14%-56% in hospitalized patients. Risk factors include advanced age, invasive mechanical ventilation (IMV), and prolonged intensive care unit stay. Neuropsychiatric symptoms have been reported to be related to autoimmune responses secondary to Guillain-Barré syndrome (GBS) with direct involvement of the central nervous system (CNS) or to delirium. There are few reports of the frequency of delirium in patients with Guillain-Barré syndrome (GBS).ObjectiveTo describe the frequency of and the characteristics associated with delirium in patients with GBS.Material and methodsA single-center, cross-sectional study was conducted in patients with GBS diagnosis between 2015 and 2019. The diagnosis of delirium was made using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria. We compared patients with and without delirium. We performed both univariate and multivariate analyses to identify factors associated with delirium.ResultsA total of 154 patients with GBS were included, of which 20 (12.9%) fulfilled the DSM-5 criteria for delirium. The mean age was 48 ± 18.2 years, the median Medical Research Council (MRC) sum score was 29.3 ± 21.9 points, 65% had bulbar cranial nerve involvement, 80% presented autonomic dysfunction, 85% had ICU stay, and 90% had mechanical ventilation requirement. In the multivariate analysis, the following were the independent factors for the development of delirium: age ≥ 60 (odds ratio (OR): 5.7; 95% confidence interval (CI): 1.3-23.5), time from symptom onset to admission ≤ 3 days (OR: 4.3; 95% CI: 1.1-16.8), autonomic dysfunction (OR: 13.1; 95% CI: 3-56), and intensive care unit stay (OR: 9.5; 95% CI: 2.1-42.6).ConclusionDelirium is not frequent in patients with Guillain-Barré syndrome. Patients with advanced age, rapid motor progression, bulbar cranial nerve involvement, prolonged intensive care unit stay, and mechanical ventilation need are more likely to present delirium.

Defining the Reliability of Deltoid Reanimation by Nerve Transfer When Using Abnormal but Variably Recovered Triceps Donor Nerves.

Upper brachial plexus injuries to the C5/6 roots or axillary nerve can result in severe deficits in upper limb function. Current techniques to reinnervate the deltoid muscle utilise the well-described transfer of radial nerve branches to triceps to the axillary nerve. However, in around 25% of patients, there is a failure of sufficient deltoid reinnervation. It is unclear in the literature if deltoid reanimation should be attempted with a nerve transfer from a weak but functioning triceps nerve. The authors present the largest series of triceps to axillary nerve transfers for deltoid reanimation in order to answer this clinical question. Seventy-seven consecutive patients of a single surgeon were stratified and analysed in four groups: (1) normal triceps at presentation, (2) abnormal triceps at presentation recovering to clinically normal function preoperatively, (3) abnormal triceps at presentation remaining abnormal preoperatively, and lastly (4) where pre-operative triceps function was deemed insufficient for use, requiring alternative reconstruction for deltoid reanimation. The authors considered deltoid re-animation of ≥ M4 as successful for the purpose of this study. Median Medical Research Council (MRC) values demonstrate group 1 achieves this successfully (M5), while median values for groups 2–4 result in M4 power (albeit with decreasing interquartile ranges). Median post-operative shoulder abduction active range of motion (AROM) values were represented by 170° (85–180) in group 1, 117.5° (97.5–140) in group 2, 90° (35–150) in group 3, and 60° (40–155) in group 4. For both post-operative assessments, subgroup analyses demonstrated statistically significant differences when comparing group 1 with groups 3 and 4 (p < 0.05), while all the other group to group pairwise comparisons did not reach significance. The authors postulated that triceps deficiency can act as a surrogate marker of a more extensive plexus injury and may predict poorer outcomes if the weakness persists representing the trending differences between groups 2 and 3. However, given no statistical differences were demonstrated between groups 3 and 4, the authors conclude that utilising an abnormal triceps nerve that demonstrates sufficient strength and redundancy intraoperatively is preferable to alternative transfers for deltoid reanimation. Lastly, in group 4 patients where triceps nerves are damaged and unusable for nerve transfer, alternative operations can also achieve sufficient outcomes and should be considered for restoration of shoulder abduction.

Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline.

Spinal cord infarction (SCI) is a potentially devastating disorder presenting with an acute anterior spinal artery syndrome, accounting for an estimated 1% of stroke presentations. Aetiologies include aortic surgical complications, systemic hypotension, fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted magnetic resonance imaging (MRI). There are no treatment guidelines for non-perioperative cases although there is limited literature regarding potential therapies, including hyperbaric oxygen treatment (HBOT) and cerebrospinal fluid (CSF) drainage. We describe 13 cases of acute SCI, five receiving HBOT, and three also receiving pentoxifylline and drainage of lumbar CSF. Data for all patients with MRI-proven SCI at Fiona Stanley Hospital from 2014-2019 were reviewed. Thirteen patients, median age 57 years (31-74), 54% female, were identified. Aetiologies: two fibrocartilaginous emboli; seven likely atherosclerotic; two thromboembolic; two cryptogenic. All presented with flaccid paraplegia except one with Brown-Sequard syndrome. Levels ranged from C4 to T11. Five patients received HBOT within a median time of 40 hours from symptom onset, with an average 15 treatments (10-20). Three of these received triple therapy (HBOT, pentoxifylline, CSF drainage) and had median Medical Research Council manual muscle testing power of 5, median modified Rankin Score (mRS) of 1 and American Spinal Injury Association (ASIA) score of D on discharge, compared with 2 power, mRS 3.5 and ASIA B in those who did not. SCI can be severely disabling. Triple therapy with pentoxifylline, CSF drainage and HBOT may reduce disability and further prospective trials are required.

Predictors of Clinically Important Changes in Actual and Perceived Functional Arm Use of the Affected Upper Limb After Rehabilitative Therapy in Chronic Stroke

ObjectiveTo identify the predictors of minimal clinically important changes in actual and perceived functional arm use of the affected upper limb after rehabilitative therapy. DesignRetrospective, observational cohort study. SettingOutpatient rehabilitation settings. ParticipantsA cohort of 94 patients with chronic stroke. InterventionsPatients received robot-assisted therapy, mirror therapy, or combined therapy for 4 weeks. Main Outcome MeasuresThe primary outcome measures, assessed pre- and post intervention, included actual functional arm use measured by an accelerometer and perceived functional arm use measured by the Motor Activity Log (MAL). Candidate predictors included age, sex, time after stroke, side of stroke, and scores on the Fugl-Meyer Assessment, Modified Ashworth Scale, Medical Research Council scale, Wolf Motor Function Test, MAL (quality of movement), and Nottingham Extended Activities of Daily Living. ResultsBeing male (odds ratio [OR], 3.17; 95% CI, 1.13-8.87) and having a higher than median Medical Research Council score (OR, 2.68; 95% CI, 1.12-6.41) significantly predicted minimal clinically important changes assessed by an accelerometer. Fugl-Meyer Assessment scores (odds ratio, 1.06; 95% CI, 1.02-1.11) were a significant predictor of achieving clinically important changes in MAL amount of use. Wolf Motor Function Test (quality) scores (OR, 3.05; 95% CI, 1.38-6.77) could predict clinically important improvements in MAL quality of movement. ConclusionsPredictors of clinically important changes in the use of the affected upper limb after robot-assisted therapy, mirror therapy, or combined therapy in patients with chronic stroke for 4 weeks differ for actual vs perceived use. Further studies are recommended to validate these findings in a larger sample.