Medical Research Council Grade Research Articles

Retrospective analysis of peripheral neuropathy in blood cancer survivors evaluated for cellular therapy.

12087 Background: Blood cancer survivors (BCS) sustain peripheral neuromotor decline from toxic therapies but also aging, diabetes and cancer. Peripheral neuropathy (PN) threatens balance and quality of life, and pre-existing nerve deficits raise future PN risk. The evaluation for cellular therapies is an opportunity to identify functional deficits and optimize their management before additional toxic exposures or disease progression. PN is often diagnosed by paresthesias, but toe strength and sensory deficits also impact balance. We aim to quantify the prevalence of these 3 PN manifestations and walking difficulty in BCS evaluated at our center for possible cellular therapies and compare BCS with and without paresthesias. Methods: We retrospectively analyzed clinical data from 5 years of physical therapy (PT) evaluations during the medical assessment for cellular therapy. As count (%) or mean ± SD we described foot paresthesias [Functional Assessment of Cancer Therapy (FACT) Item NTX2], hallux extension weakness (Medical Research Council Grade ≤4 either side), hallux vibration deficit (biothesiometer ≥24.7 V), and reported trouble walking (FACT An6). We then dichotomized the cohort by NTX2 and compared groups with Chi-square, Fisher’s exact or Wilcoxon rank sum tests. Results: 598 (87.6%) of 683 BCS evaluated by PT had FACT data (79.1% White, 5.5% Latinos); 1 in 2 BCS reported paresthesias, 71.2% as moderate-severe. See table for group comparisons. Race (p=.654) & ethnicity (p=.608) were n.s. 506 BCS with FACT (84.6%) had both strength and sensory data; we found ≥ 1 hallux deficit in 396 (78.3%), more commonly with paresthesias (86.3% vs. 69.5%, p<.001). Conclusions: At cellular therapy evaluation, 1 in 2 BCS reported foot paresthesias, and 3 in 4 had strength or sensory hallux deficit. Regardless of the cause, these deficits could contribute to the trouble walking reported by 44%. BCS with paresthesias were older and had more myeloma, diabetes, chemotherapy, hallux deficits, and trouble walking. But trouble walking and hallux deficits were also common without paresthesias. Research is needed to quantify hallux-gait relationships in BCS, and to establish the highest-value rehabilitative approaches to improve strength and walking before further toxic exposures. [Table: see text]

Robotic thoracic surgery for neurogenic tumors.

Thoracic neurogenic tumors usually present as benign nerve sheath tumors that can be resected via transthoracic or posterior approaches, depending on the anatomical location. Robot-assisted thoracic surgery (RATS) is increasingly being used for the transthoracic approach, but evidence is very limited. The authors initiated the current study to evaluate the efficacy and safety of RATS for thoracic neurogenic tumors. This retrospective study is based on a prospectively created database that includes all RATS surgeries between 2018 and 2023. All patients with histologically confirmed neurogenic tumors were included in the study. The patients' medical and surgical records as well as radiological and pathological findings were analyzed. During a 5-year period, 27 patients underwent robotic resection of neurogenic tumors at a high-volume thoracic surgery center. Two patients had previously undergone posterior laminectomy for resection of the intraspinal components. The pathologies included schwannomas (18, 64%), ganglioneuromas (8, 29%), 1 paraganglioma, and 1 neurofibroma occurring close to a schwannoma unilaterally in the same patient. The median tumor size was 4.7 cm (range 0.9-11.4 cm). The median operating time was 69 minutes (range 27-169 minutes), and the median postoperative stay was 3 days (range 1-19 days). There was one conversion due to adhesions after a previous surgery. No major bleeding occurred. There was no perioperative mortality. Morbidity included a lymphatic fistula (n = 1), pneumonia (n = 1), prolonged air leak (n = 1), and 4 cases of postoperative pain persisting for more than 4 weeks. Neurological complications were mostly observed in patients with tumors located at the thoracic apex: 2 cases of Horner's syndrome, 2 cases with compensatory hyperhidrosis, 1 patient with paresis of the recurrent laryngeal nerve, and a T1 lesion resulting in a minor motor deficit of the small hand muscles (Medical Research Council grade 4) and hypoesthesia of the respective dermatome. RATS for thoracic neurogenic tumors is feasible and safe. Tumors at the thoracic apex are at high risk of neurological deficit and should be approached with care. Close interdisciplinary collaboration between neurosurgeons and thoracic surgeons is necessary for optimal patient selection and a good postoperative outcome.

Acute Flaccid Myelitis: Mid-Term Clinical Course of Knee Extension Paralysis and Outcomes of Nerve Transfer.

Acute flaccid myelitis (AFM) is a rare debilitating poliomyelitis-like illness characterized by the sudden onset of flaccid palsy in the extremities. The purpose of this study was to report the mid-term clinical course of knee extension in AFM and the effect of contralateral obturator nerve-to-femoral nerve transfer (CONFNT) for restoration of knee extension in AFM. Twenty-six patients with lower extremity palsy due to AFM were referred to our clinic for possible surgical reconstruction. Their median age was 4.0 years, and the first evaluation of the palsy was done at a mean of 6 months after paralysis onset. The paralysis ranged from lower limb monoplegia to quadriplegia. The clinical course of knee extension was assessed using the British Medical Research Council (MRC) grading scale and surface electromyography (EMG). Five patients with unilateral paralysis of knee extension underwent CONFNT. The mean follow-up period for 19 limbs with complete paralysis of knee extension (MRC grade M0) in 13 patients who were evaluated for spontaneous recovery was 43 months. No patient who had complete paralysis of knee extension at >6 months and paralysis of the hip adductor muscle had improvement of knee extension to better than M2. Five of the original 26 patients were treated with CONFNT and followed for a mean of 61 months. Two of 5 patients had the CONFNT ≤8 months after paralysis onset and obtained M4 knee extension. Only 1 of the 3 patients with CONFNT performed approximately 12 months after paralysis onset obtained M3 knee extension; the other 2 obtained only M1 or M2 knee extension. The paralysis of the lower extremity in our patients with AFM was similar to that in poliomyelitis. However, in AFM, spontaneous recovery of knee extension was possible if there were signs of recovery from hip adductor paralysis up to 6 months after paralysis onset. CONFNT may enhance the recovery of knee extension and seems to be a reliable reconstruction for restoring knee extension if performed no more than 8 months after paralysis onset. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A study to assess the relationship between vitamin D3 levels and the risk of acute exacerbation in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is one of the top three causes of mortality worldwide. Vitamin D deficiency in COPD has been associated with poor lung function and decreased muscle power, which further increases the risk of exacerbations. The role of vitamin D in preventing acute exacerbations of COPD has conflicting results in the literature. Hence, we planned this study to assess the relationship between vitamin D3 levels and the risk of acute exacerbations among COPD patients in a tertiary care center in north India. This was a prospective randomized control trial that was performed on 100 consecutive stable COPD patients attending the Department of Respiratory Medicine at Maharishi Markandeshwar Medical College and Hospital, Solan, India. The patients with subnormal vitamin D3 levels (i.e., less than 30 ng/mL) were divided into the intervention and control groups. Baseline demographic profiles, lung function, COPD assessment test (CAT) score, modified Medical Research Council grade and chest radiology were performed and repeated after 12 months in all these patients. All these parameters were recorded and compared with the baseline values obtained at the beginning of the study. Out of 100 subjects, 96 had vitamin D deficiency, of which 48 were assigned to the intervention group and 48 to the control group. Among the 100 subjects, 74 (74%) were males and 26 (26%) were females, with a mean age of 66.9±9.4 years. The mean vitamin D level was 14.71±6.69 in these 96 patients. The vitamin D level improved after 3 months of supplementation to the mean level of 45.56±16.18 in the intervention group. Vitamin D supplementation was positively correlated with a decrease in the rate of acute exacerbations in the intervention group in terms of reduction in mean CAT score (4.17 in intervention and 1.43 in non-interventional group, p<0.001), number of acute exacerbations (1.7 in intervention and -1.05 in non-interventional group, p<0.001), and number of emergency visits (p=0.0121) during the 9-month period after attainment of a normal vitamin D level. Vitamin D supplementation plays a key role in COPD patients with D3 hypovitaminosis in decreasing COPD acute exacerbations, improving the CAT score, and reducing the number of emergency visits.

Global trends and outcomes of nerve transfers for treatment of adult brachial plexus injuries.

The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/- C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized.Level of evidence: III.

Functional outcomes of different surgical treatments for common peroneal nerve injuries: a retrospective comparative study

BackgroundThis study aims to assess the recovery patterns and factors influencing outcomes in patients with common peroneal nerve (CPN) injury.MethodsThis retrospective study included 45 patients with CPN injuries treated between 2009 and 2019 in Jing’an District Central Hospital. The surgical interventions were categorized into three groups: neurolysis (group A; n = 34 patients), nerve repair (group B; n = 5 patients) and tendon transfer (group C; n = 6 patients). Preoperative and postoperative sensorimotor functions were evaluated using the British Medical Research Council grading system. The outcome of measures included the numeric rating scale, walking ability, numbness and satisfaction. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal time interval between injury and surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function.ResultsSurgical interventions led to improvements in foot dorsiflexion strength in all patient groups, enabling most to regain independent walking ability. Group A (underwent neurolysis) had significant sensory function restoration (P < 0.001), and three patients in Group B (underwent nerve repair) had sensory improvements. ROC analysis revealed that the optimal time interval for achieving M3 foot dorsiflexion recovery was 9.5 months, with an area under the curve (AUC) of 0.871 (95% CI = 0.661–1.000, P = 0.040). For M4 foot dorsiflexion recovery, the optimal cut-off was 5.5 months, with an AUC of 0.785 (95% CI = 0.575–0.995, P = 0.020). When using M3 toe dorsiflexion recovery or S4 sensory function recovery as the gold standard, the optimal cut-off remained at 5.5 months, with AUCs of 0.768 (95% CI = 0.582–0.953, P = 0.025) and 0.853 (95% CI = 0.693–1.000, P = 0.001), respectively.ConclusionsOur study highlights the importance of early surgical intervention in CPN injury recovery, with optimal outcomes achieved when surgery is performed within 5.5 to 9.5 months post-injury. These findings provide guidance for clinicians in tailoring treatment plans to the specific characteristics and requirements of CPN injury patients.

Outcomes of surgically managed adult traumatic brachial plexus injuries in an upper-middle-income country

BackgroundTraumatic brachial plexus injuries (TBPIs) are debilitating and complex to treat. The last five decades have seen advances in surgical management, and consequently improved functional outcomes in patients with these injuries. There is limited data available describing the outcomes of surgically managed TBPIs within the South African context. This study aimed to identify the common causes of injury, injury characteristics, and functional outcomes of surgically managed patients with TBPIs. MethodsWe conducted a retrospective chart review of all adult patients that underwent surgery for TBPIs over a period of ten years at a specialised hand unit in South Africa. The minimum follow-up period was one year. Patient demographic details, injury characteristics and functional outcomes were collected. Statistical analysis was performed to determine factors associated with functional outcomes. A good functional outcome for recovery was defined as a Medical Research Council (MRC) grade of three or more for the affected elements of the plexus at the most recent follow-up. ResultsForty-seven patients of median age 32 years were included in the final analysis. Most patients were male (87.2 %). The majority of patients were injured in motor vehicle accidents (MVAs) or from penetrating stab wounds (48.9 % and 38.3 % respectively). The median pre-operative MRC grade of the affected elements of the brachial plexus was 0.0, and post-operatively was 2.0. Fourteen patients (14 of 47, 29.8 %) had a good outcome and 33 had a poor outcome (33 of 47, 70.2 %). There was no difference in outcome comparing penetrating injury mechanisms to closed traction or blunt injuries, (p = 0.386, OR 1.75, 95 % CI 0.49–6.20). All patients with pan-plexal injuries had a poor outcome (15 of 33, 46 %). All patients who received intercostal (6 of 33, 18 %) or phrenic nerve transfers (3 of 33, 9 %) had a poor outcome. ConclusionAdult traumatic BPIs in this South African sample typically presented more than two months after injury and were comprised of a high proportion of penetrating injuries. Just under a third of surgically managed patients had a good outcome. Pan plexal injuries have uniformly poor outcomes. We recommend early referral for all TBPIs to a unit that manages BPI to improve outcomes.

Prevalence, Risk Factors of Deep Venous Thrombosis in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Cross-sectional Study

Introduction: It is important to increase awareness and identify the predictors of Deep Vein Thrombosis (DVT) in Chronic Obstructive Pulmonary Disease (COPD) patients presenting with worsening dyspnoea, as they are at a high-risk for Venous Thromboembolism (VTE) due to immobility, inflammation, and comorbidities. Aim: To determine the prevalence of DVT in hospitalised patients with acute exacerbation of COPD, as well as to identify associated risk factors for DVT in this group. Materials and Methods: A cross-sectional study was conducted from March 2021 to June 2022 in the Department of Respiratory Medicine at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. The sample population consisted of hospitalised patients with acute exacerbation of COPD who were aged over 40 years. All patients underwent routine blood investigations, Electrocardiograph (ECG), echocardiogram, arterial blood gas analysis, D-dimer test, chest radiograph, and lower-limb venous Doppler. Risk assessment was performed using the Modified Well’s criteria for DVT, and pretest probability was determined for all patients. The Chi-square test was used as a test of significance, with a p-value &lt;0.05 considered statistically significant in all analyses. Results: The mean age of the study population was found to be 60.80±10.21 years. Among the 74 patients included in the study, it was found that 3 (4.05%) patients had DVT. There was no statistically significant difference between the DVT and non DVT groups regarding age, sex, obesity, modified Medical Research Council (mMRC) grade of breathlessness, smoking status, severity of airflow obstruction in spirometry, COPD class, type of respiratory failure, and presence of comorbidities. However, there was a statistically significant difference between the DVT and non DVT groups in terms of elevated D-dimer (&gt;500 ng/mL), history of immobilisation for more than three days, and Modified Wells’ score (&gt;2). Conclusion: Patients with acute exacerbation of COPD, associated with a significant history of immobilisation and high D-dimer values, along with a high-risk pretest probability using clinical predictors such as the Modified Wells’ score for DVT, should be considered for evaluation of VTE and early initiation of prophylactic anticoagulation therapy to prevent Pulmonary Thromboembolism.

Prevalence and predisposing factors of post-stroke complex regional pain syndrome: Retrospective case-control study

Poststroke complex regional pain syndrome (CRPS) is an important complication in stroke survivors. The identification of factors associated with post-stroke CRPS is important for preventive measures and early diagnosis. A total of 141 first-ever stroke survivors in the subacute stage were retrospectively analyzed. Demographic data, diagnosis time, duration of hospitalization, location of brain lesion, etiology, comorbidities, and blood test findings were investigated. Clinical data included Medical Research Council (MRC) grade, Fugl-Meyer assessment (FMA), National Institute for Health Stroke Scale (NIHSS), Berg Balance Scale (BBS). Among 141 patients with subacute stroke, 22 were diagnosed with CRPS, with a prevalence of 15.6%. The mean time to diagnosis was 38.6 (±16.5) days. The prevalence according to the degree of paralysis was 33.3% in MRC grades 0 and 1, 8.6% in grade 2, and 0% in grade 3 or higher. The incidence rates within 1 month after stroke were 1.42% and 22.47% between 1 and 3 months after stroke, respectively. The independent risk factors for CRPS were hospitalization duration and FMA, NIHSS, and BBS scores. The sensitivity and specificity of the NIHSS score for predicting post-stroke CRPS were 86.4% and 59.7%, respectively, with an optimal cutoff value of 7.5. CRPS of the affected upper limb in stroke patients is associated with stroke severity, including paralysis, and the incidence increases over time during the subacute phase. Additionally, having sufficient strength to move through a full range of motion against gravity had a protective effect against CRPS.

Characterizing peroneal nerve injury clinicoradiological patterns with MRI in patients with sciatic neuropathy and foot drop after total hip replacement.

Sciatic nerve injury following total hip arthroplasty (THA) predominantly affects the peroneal division of the sciatic nerve, often causing a foot drop. This can result from a focal etiology (hardware malposition, prominent screw, or postoperative hematoma) or nonfocal/traction injury. The objective of this study was to compare the clinicoradiological features and define the extent of nerve injury resulting from these two distinct mechanisms. Patients who developed a postoperative foot drop within 1 year after primary or revision THA with a confirmed proximal sciatic neuropathy based on MRI or electrodiagnostic studies were retrospectively reviewed. Patients were divided into two cohorts: group 1 (focal injury), including patients with an identifiable focal structural etiology, and group 2 (nonfocal injury), including patients with a presumed traction injury. Patient demographics, clinical examinations, subsequent surgeries, electrodiagnostic study results, and MRI abnormalities were noted. The Student t-test was used to compare time to onset of foot drop and time to secondary surgery. Twenty-one patients, treated by one surgeon, met inclusion criteria (8 men and 13 women; 14 primary THAs and 7 revision THAs). Group 1 had a significantly longer time from THA to the onset of foot drop, with a mean of 2 months, compared with an immediate postoperative onset in group 2 (p = 0.02). Group 1 had a consistent pattern of localized focal nerve abnormality on imaging. In contrast, the majority of patients in group 2 (n = 11) had a long, continuous segment of abnormal size and signal intensity of the nerve, while the other 3 patients had a segment of less abnormal nerve in the midthigh on imaging. All patients with a long continuous lesion had Medical Research Council grade 0 dorsiflexion prior to secondary nerve surgeries compared with 1 of 3 patients with a more normal midsegment. There are distinct clinicoradiological findings in patients with sciatic injuries resulting from a focal structural etiology versus a traction injury. While there are discrete localized changes in patients with a focal etiology, those with traction injuries demonstrate a diffuse zone of abnormality within the sciatic nerve. A proposed mechanism involves anatomical tether points of the nerve acting as points of origin and propagation for traction injuries, resulting in an immediate postoperative foot drop. In contrast, patients with a focal etiology have localized imaging findings but a highly variable time to the onset of foot drop.

Effect of shorter nerve graft and selective motor branch of recipient nerve on nerve transfer surgery for elbow flexion in patients with brachial plexus injury.

The spinal accessory nerve (SAN) is commonly used as a donor nerve for reinnervation of elbow flexors in brachial plexus injury (BPI) reconstruction. However, no study has compared the postoperative outcomes between SAN-to-musculocutaneous nerve (MCN) transfer and SAN-to-nerve to biceps (NTB) transfer. Thus, this study aimed to compare the postoperative time to recovery of elbow flexors between the two groups. A total of 748 patients who underwent surgical treatment for BPI between 1999 and 2017 were retrospectively reviewed. Among them, 233 patients were treated with nerve transfer for elbow flexion. Two techniques were used to harvest the recipient nerve: the standard dissection technique and the proximal dissection technique. The postoperative motor power of elbow flexion was assessed every month for 24 months using the Medical Research Council (MRC) grading system. Survival and Cox regression analyses were used to compare the time to recovery (MRC grade ≥ 3) between the two groups. Of the 233 patients who underwent nerve transfer surgery, there were 162 patients in the MCN group and 71 patients in the NTB group. At 24 months after surgery, the MCN group had a success rate of 74.1%, and the NTB group had a success rate of 81.7% (p = 0.208). When compared with the MCN group, the NTB group had a significantly shorter median time to recovery (19 months vs 21 months, p = 0.013). Only 11.1% of patients in the MCN group regained MRC grade 4 or 5 motor power 24 months after nerve transfer surgery compared with 39.4% patients in the NTB group (p < 0.001). Cox regression analysis showed that the SAN-to-NTB transfer in combination with the proximal dissection technique was the only significant factor affecting time to recovery (HR 2.33, 95% CI 1.46-3.72; p < 0.001). SAN-to-NTB transfer in combination with the proximal dissection technique is the preferred nerve transfer option for restoration of elbow flexion in traumatic pan-plexus palsy.

Nerve Transfer Surgery in Acute Flaccid Myelitis: Prognostic Factors, Long-Term Outcomes, Comparison With Natural History

BackgroundNerve transfer surgery is sometimes offered to patients with acute flaccid myelitis (AFM). The objectives of this study were to evaluate surgical efficacy, assess which clinical and neurophysiological data are valuable for preoperative planning, and report long-term outcomes. MethodsThis is a single-center, retrospective case series of patients with AFM who received nerve transfer surgery. All patients had preoperative electromyography and nerve conduction studies (EMG/NCS). Matched control muscles that did not receive nerve transfer surgery were defined in the same cohort. ResultsTen patients meeting inclusion criteria received a total of 23 nerve transfers (19 upper extremity, four lower extremity). The mean age at symptom onset was 3.8 years, surgery was 0.5 to 1.25 years after diagnosis, and mean follow-up was 2.3 years (range 1.3 to 4.5 years). Among muscles with preoperative strength Medical Research Council (MRC) grade 0, muscles receiving nerve transfers performed significantly better than those that did not (MRC grade 2.17 ± 0.42 vs 0 ± 0, respectively, P = 0.0001). Preoperative EMG/NCS predicted worse outcomes in recipient muscles with more abundant acute denervation potentials (P = 0.0098). Donor nerves found to be partially denervated performed equally well as unaffected nerves. Limited data suggested functional improvement accompanying strength recovery. ConclusionsNerve transfer surgery is an effective strategy to restore strength for patients with AFM with persistent, severe motor deficits. Postoperative outcomes in patients with complete paralysis are better than the natural history of disease. This study demonstrates the utility of preoperative clinical and electrophysiological data in guiding patient selection for nerve transfer surgery.

Clinical effect of aerobic exercise training in chronic obstructive pulmonary disease: A retrospective study.

Aerobic exercise training is a kind of pulmonary rehabilitation for lung diseases. This was a retrospective study to assess the efficacy of aerobic exercise training in chronic obstructive pulmonary disease (COPD) at a stable stage. A total of one hundred and fifty-six stable COPD patients who had accepted self-education only or self-education combined with an aerobic exercise training between January 2017 to January 2019 were reviewed retrospectively. A total of 79 patients who had received self-education combined with an aerobic exercise training schedule comprised the aerobic exercise training group (AET group) and 77 patients who had received self-education only were regarded as the education group (EDU group). The acute incidence rate in AET group was 7.6% better than that in EDU group 20.7% (P < .05). The AET group patients expressed higher levels of 6 minutes walking distance (6MWD) (P < .05) and better evaluations of both lung function (P < .05) and T lymphocyte immune response (P < .05), as well as significantly decreased chronic obstructive pulmonary disease assessment test (CAT) scores and modified British medical research council (mMRC) grades (P < .05). Patients in EDU group did not report any changes in any of these characteristics. The aerobic exercise training intervention contributed to an increasing in 6MWD and decrease in CAT scores and mMRC grades, as well as improving the T lymphocyte immune response in stable COPD patients.

A pilot study of an integrated, personalized, respiratory andmotor telerehabilitation program for pediatric patients with hereditary neuromuscular disorders.

Telerehabilitation provides physical training to patients through telecommunication networks. We examined the feasibility, safety, and efficacy of an integrated, personalized, respiratory and motor telerehabilitation program for pediatric patients with hereditary neuromuscular disorders (NMDs). Stable pediatric patients were recruited for a 16-week home training program with personalized pulmonary, upper and lower limb exercises. Patients reviewed instructional videos at home and attended bi-weekly follow-ups through video or audio calls, text messages, or emails. The primary outcomes were respiratory function, Medical Research Council (MRC) grading, hand/pinch strength, 6-minute walk test, and Pediatric Quality-of-Life Inventory 3.0 Neuromuscular Module survey. The secondary outcomes were study compliance and user feedback. Patients with spinal muscular atrophy (n = 4), congenital myasthenic syndrome (n = 2), and Duchenne muscular dystrophy (n = 2) completed the program. The median weekly exercise time was 101.3 min (range: 30.0-266.9). No extra face-to-face physiotherapy sessions were requested by the patients. No adverse events were reported. After the study, patients showed improvements in maximal expiratory pressure (35.0 vs. 47.5 cm H2O, p = .028) and maintained their MRC grade, hand/pinch strength, and walking distance. Patients also reported improvements in the Pediatric Quality-of-Life Inventory 3.0 Neuromuscular Module survey score (74.5 vs. 87.0, p = .036). Patients rated the overall program highly (mean: 4.00/5.00) and recommended it as a standard of care (mean: 4.38/5.00). Our telerehabilitation program was feasible, safe, and possibly effective for this pilot cohort of stable pediatric patients with hereditary NMDs. Larger-scale studies for longer periods are warranted to confirm the results.

Sociodemographic correlates with prevalence of comorbidities in patients with chronic obstructive pulmonary disease: a study from a Chinese National Survey

An increase in the prevalence of comorbidities has been reported in patients with chronic obstructive pulmonary disease (COPD). However, contemporary estimates of the overall prevalence of the sociodemographic correlates of COPD comorbidities are scarce and inconsistent in China. This study aimed to investigate the prevalence of sociodemographic correlates of comorbidities in patients with COPD across China. This was a cross-sectional study. We used data from the Enjoying Breathing Program between May 2020 and April 2022. Participants with COPD from 17 provinces (or equivalent) were included. Comorbidity clusters were stratified based on the number of comorbidities per person. Univariable and multivariable analyses were used to determine the sociodemographic associations of patients with COPD with specific clusters of comorbidities after adjusting for age, sex, and other prespecified covariates. Tetrachoric correlation analyses were performed to determine the associations between specific comorbidities. A total of 3913 participants with COPD were included, of whom 1744 (44.7%) had at least one comorbidity; 25.4% had one comorbid disease, 12.9% had two, and 6.4% had three or more concurrent diseases. The most common comorbidities were hypertension (17.8%), asthma (9.9%), bronchiectasis (8.2%), diabetes (8.2%), and coronary artery disease (7.7%). In the logistic regression models adjusted for a broad set of factors, patients with COPD residing in the east region of China and having health insurance experienced a decreased likelihood of comorbidities (from OR=0.70 [95% confidence interval [CI], 0.53-0.93] to OR=0.50 [95% CI, 0.25-0.99]). However, patients over 80 years had increased risk (OR 1.43 [95% CI 1.01-2.03]), as did those in all Modified Medical Research Council (mMRC) grade categories (grade 1: OR=1.30 [95% CI, 1.02-1.65]; grade 2: OR=1.39 [95% CI, 1.07-1.8]; grade 3: OR=1.67 [95% CI, 1.23-2.26]; and grade 4: OR=1.81 [95% CI, 1.00-3.28]) and in Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2 classification (OR=1.30 [95% CI, 1.03-1.65]) relative to their respective references. The associations observed in these subgroups were consistent regardless of the number of comorbidities per person. Tetrachoric correlations demonstrated negative associations in pairwise comparisons of the top five comorbidities, ranging from-0.03 to-0.31 (p<0.001 in all groups). In China, comorbidities are highly prevalent among patients with COPD, with older age, higher mMRC grade, and lung function decline being the major risk factors. Studies with larger sample sizes are required to elucidate the complex mechanisms underlying COPD comorbidities. This study was funded by CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-049 and 2022-I2M-C&T-B-107).

Prospective study comparing outcomes of primary intraplexal repair versus distal nerve transfers in Narakas grade I birth brachial plexus palsy.

To compare the results of intraplexal repair and distal nerve transfer in babies with birth brachial plexus palsy (BBPP), children with Narakas group I obstetric palsy were assigned to two groups of 16 each. Children in group A were treated with classical intraplexal repair and those in group B were treated by distal nerve transfers. At 6 months, all the children in group B had achieved Modified Medical Research Council (MMRC) grade 3 elbow flexion along with 8 of the 16 children in group A, which was a statistically significant difference. At 6 months, all the children in group B achieved MMRC grade 3 or higher shoulder abduction and 8 of the 16 children in group A had done so, which was also statistically significant. At the final follow-up, the distal transfer surgical treatment group had a significantly higher Mallet score. Distal nerve transfers have a significant advantage in early recovery in elbow flexion and shoulder abduction, but the outcomes became similar after 9 months.Level of evidence: III.

The Clinical Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Through a Posterior Approach.

Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance. This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets. A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°. Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.

Relationship between Chronic Obstructive Pulmonary Disease Severity and Surface Electromyography Parameters during Fatigue Caused by Knee Extensor Contractions

Objective: Skeletal muscle dysfunction, which is characterized by decreased muscle strength and endurance, contributes to dyspnea during exercise in patients with chronic obstructive pulmonary disease (COPD), regardless of pulmonary function. This study analyzed skeletal muscle function in patients with COPD through surface electromyography (sEMG) evaluations and signal processing and attempted to determine whether sEMG parameters for muscle fatigue reflect the course of the disease. Methods: In 24 patients with COPD, maximal voluntary isometric contraction and ramp contraction were performed during isometric knee extension, and the sEMG activity of the rectus femoris muscle was measured. The patients were divided into three groups according to their modified Medical Research Council (mMRC) grade and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. Patients with mMRC grades 0 and 1 were classified into group A, grade 2 into group B, and grades 3 and 4 into group C. Patients with GOLD stage 1 were classified into group I, stage 2 into group II, and stages 3 and 4 into group III. sEMG parameters were compared between groups using one-way analysis of variance. Results: There were significant differences in the minimum median frequency and fatigue index between the mMRC groups. However, the sEMG parameters did not differ significantly among the GOLD groups. Conclusion: Muscle fatigue differs according to the severity of subjective dyspnea in COPD. sEMG evaluations and signal processing can play supplementary roles in evaluating muscle endurance and predicting functional capacity in COPD.

Baseline dependent minimally important differences for clinical outcomes of pulmonary rehabilitation in people with COPD

IntroductionMinimally important differences (MIDs) for common outcomes of pulmonary rehabilitation are well documented for people with chronic obstructive pulmonary disease (COPD). It is not known whether MIDs differ based on COPD disease characteristics. This study aimed to estimate MIDs for clinical outcomes of pulmonary rehabilitation dependent upon baseline characteristics. MethodsA database containing 2791 people with COPD was split into derivation (n=2245; age 66±9 years; 50% males; FEV1 47±20% predicted) and comparator (n=546; age 66±9 years; 47% males; FEV1 46±21% predicted) cohorts. MIDs were estimated using 0.5 x SD (symmetrically distributed) or 0.5 x IQR (non-symmetrically distributed) for: 6-minute walk test (6MWT), constant work rate test (CWRT), COPD assessment test (CAT), St. George's respiratory questionnaire (SGRQ), hospital anxiety and depression scale (HADS), and fat-free mass index (FFMI). MIDs were estimated based on baseline outcome scores, lung function, modified medical research council (mMRC) grade and FFMI. ResultsMID estimates were comparable to previously reported values. MIDs for SGRQ domains (Symptom=8.7 points, Activity=7.1 points, Impact=8.1 points) and FFMI were produced (0.36kg/m2). There was greater variation of change in 6MWT, SGRQ-activity, SGRQ-impact, HADS and FFMI on which the MIDs were determined when categorising for baseline values (all, p<0.05). Greater variation of change in 6MWT on which the MIDs were determined was evident with COPD disease severity grouping (p<0.05). The magnitude of change in 6MWT, CAT, CWRT, SGRQ-activity, and FFMI with baseline mMRC score categorisation resulted in greater variation on which the MIDs were determined (all, p<0.05). Baseline stratification for FFMI resulted in greater variation of change in CWRT (p<0.001) and HADS-depression (p = 0.043) on which MIDs were determined. DiscussionFindings suggest that baseline presentation should be considered for people with COPD when assessing the efficacy of pulmonary rehabilitation. However, clinical significance of the variation underpinning MIDs is yet to be determined.

Effectiveness of Adjunctive High-Dose Infliximab Therapy to Improve Disability-Free Survival Among Patients With Severe Central Nervous System Tuberculosis: A Matched Retrospective Cohort Study.

Few treatment options exist for patients with severe central nervous system (CNS) tuberculosis (TB) worsening due to inflammatory lesions, despite optimal antitubercular therapy (ATT) and steroids. Data regarding the efficacy and safety of infliximab in these patients are sparse. We performed a matched retrospective cohort study based on Medical Research Council (MRC) grading system and modified Rankin Scale (mRS) scores comparing 2 groups of adults with CNS TB. Cohort A received at least 1 dose of infliximab after optimal ATT and steroids between March 2019 and July 2022. Cohort B received only ATT and steroids. Disability-free survival (mRS score ≤2) at 6 months was the primary outcome. Baseline MRC grades and mRS scores were similar between the cohorts. Median duration before initiation of infliximab therapy from start of ATT and steroids was 6 (IQR: 3.7-13) months and for neurological deficits was 4 (IQR: 2-6.2) months. Indications for infliximab were symptomatic tuberculomas (20/30; 66.7%), spinal cord involvement with paraparesis (8/30; 26.7%), and optochiasmatic arachnoiditis (3/30; 10%), worsening despite adequate ATT and steroids. Severe disability (5/30 [16.7%] and 21/60 [35%]) and all-cause mortality (2/30 [6.7%] and 13/60 [21.7%]) at 6 months were lower in cohort A versus cohort B, respectively. In the combined study population, only exposure to infliximab was positively associated (aRR: 6.2; 95% CI: 2.18-17.83; P = .001) with disability-free survival at 6 months. There were no clear infliximab-related side effects noted. Infliximab may be an effective and safe adjunctive strategy among severely disabled patients with CNS TB not improving despite optimal ATT and steroids. Adequately powered phase 3 clinical trials are required to confirm these early findings.