Muscle Paralysis Research Articles

An evaluation of 30 years’ experience in the use of botulinum toxin injections in the management of sixth nerve palsies

ABSTRACT Intrroduction Sixth nerve palsy is the most common type of extraocular muscle palsy. The therapy options in sixth nerve palsies include monitoring with or without conservative treatment, botulinum toxin injections or strabismus surgery. The aim of this retrospective study was to compare botulinum toxin (BT) injections into the medial rectus to conservative treatment in sixth nerve palsies. The rate of patients improved after intervention and treatment outcomes for the two treatment options were be evaluated at a German tertiary referral center. Methods A service evaluation was conducted on adult patients with sixth nerve palsy. Patient files were reviewed and data including abduction deficit and size of deviation were collected retrospectively. Patients which presented between January 1987 and April 2022 were considered. Patients were allocated into two treatment groups: BT injected into medial rectus or conservative treatment, which included observation, providing occlusion and Fresnel prisms. Inclusion criteria were attendance of two visits with orthoptic assessment. Exclusion criteria included presence of further oculomotor palsies, strabismus, strabismus surgery and suppression. Non-parametric statistical analysis was conducted using IBM® SPSS Statistics. Results A total of 606 adult patients with unilateral or bilateral sixth nerve palsy attended during the named period. A total of 137 adult patients met the inclusion criteria. Of which, 36 had a bilateral palsy, 101 had a unilateral palsy. 45.26% (n = 62) were treated with BT injections and 54.75% (n = 75) were treated conservatively. The median initial abduction deficit was greater in the BT group, (−4 to −5 after Scott and Kraft) than in the conservative treatment group (−1). The initial angle of deviation at distance was significantly larger in the BT group than in the conservative treatment group (p = <0.001). The rate of improvement in the BT group was 24.19% (n = 15) and 20% (n = 15) in the conservative treatment group. When excluding longstanding palsies rates of improvement in both groups increased to 28.85%. The improvement of the angle of deviation at distance in all patients was greater in the BT group (p = <.001). The improvement of abduction in bilateral palsies were greater in the BT group (p = .016), but in unilateral palsies, there was no significant difference in abduction improvement in the two treatment groups (OD p = .3, OS p = .406). Conclusion This service evaluation found that BT injection into medial rectus in unilateral and bilateral sixth nerve palsies did not increase the rate of improvement compared to conservative treatment. But BT injections reduced the angle of deviation to a greater extent than conservative treatment. Additionally, BT was able to improve abduction in bilateral palsies to a greater extent than conservative treatment. It is recommended a BT injection is considered in symptomatic bilateral sixth nerve palsies to enable fixation and improved ocular motility. More research is needed to verify reliable clinical guidelines for the use of BT in sixth nerve palsies.

New perspectives of the role of skeletal muscle derived extracellular vesicles in the pathogenesis of amyotrophic lateral sclerosis: the 'dying back' hypothesis.

Amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord, and is characterized by muscle weakness, paralysis and ultimately, respiratory failure. The exact causes of ALS are not understood, though it is believed to combine genetic and environmental factors. Until now, it was admitted that motor neurons (MN) in the brain and spinal cord degenerate, leading to muscle weakness and paralysis. However, as ALS symptoms typically begin with muscle weakness or stiffness, a new hypothesis has recently emerged to explain the development of the pathology, that is, the 'dying back hypothesis', suggesting that this degeneration starts at the connections between MN and muscles, resulting in the loss of muscle function. Over time, this damage extends along the length of the MN, ultimately affecting their cell bodies in the spinal cord and brain. While the dying back hypothesis provides a potential framework for understanding the progression of ALS, the exact mechanisms underlying the disease remain complex and not fully understood. In this review, we are positioning the role of extracellular vesicles as new actors in ALS development.

Applications, impacts and consequences of botulinum toxin usage in medicine

Introduction Botulinum toxin is a neurotoxin produced by the gram-positive bacteria Clostridium botulinum. Botulinum toxin has found great interest in the field of aesthetic medicine, but it has many other applications in other areas of medicine. Aim of the study The aim of this comprehensive review is to provide an overview of the usage of botulinum toxin in medicine, with a focus on specific areas of medicine. Attention will be paid to the safety of the use of this substance, taking into account its molecular structure and mechanism of action. Materials and methods An analysis of the scientific articles available in the Pubmed, Google Scholar and web of science databases was performed. Recent publications which most appropriately encompassed the issues under discussion have been selected for the purpose of this study. The process of search was carried out with the following keywords: neurotoxin, botulinum toxins, botulism, muscle paralysis. Summary Despite numerous studies, there is ample room for further research into the safety of using botulinum toxin in patients as well as new therapies with this substance. Botulinum toxin is a neurotoxin that is widely used in medicine, but has many side effects.

Случай тяжелого пищевого ботулизма у ребенка: трудности диагностики и тактика терапии

Practitioners’ alertness of botulism in children decreases due to the rarity of its cases. Early diagnosis is based on clinical symptoms though the clinical manifestations may also escalate rapidly and further lead to misdiagnosis. Patients with suspected botulism require immediate hospitalization due to the high risk for paralysis of respiratory muscles and the need for mechanical ventilation. The timely administration of the antitoxin is crucial. However, maximum allowable time of its administration counting from the onset is still a subject to discussion among physicians. Authors represent a clinical case of late diagnosis of severe foodborne botulism in a 5 y/o pediatric patient with the development of tetraplegia, paralysis of cranial nerves, mechanical ventilation for 148 days, the beginning of motor recovery on the 10th day and antitoxin administration on the 18th day counting from the onset of paralysis that all let to the full motor recovery after 20 months. The difficulties of diagnosis in the acute period and both laboratory and instrumental studies are described. The questions of the duration and the necessity of the administration of botulinum antitoxin in this particular clinical case of late diagnosis are discussed as well.

Oriented artificial nanofibers and laser induced periodic surface structures as substrates for Schwann cells alignment.

People with injuries to the peripheral nervous system suffer from paralysis of the facial muscles, fingers and hands or toes and feet, often for the rest of their lives, due to its poor functional regeneration. Therefore, to improve patients' quality of life, there is an urgent need for conduits that effectively support the healing of large defects in nerve pathways through specific guidance of nerve cells. This paper describes two specific methods for achieving directed growth of Schwann cells, a type of glial cells that can support the regeneration of the nerve pathway by guiding the neuronal axons in the direction of their alignment. One method uses aligned polyamide-6 (PA-6) nanofibers produced via electrospinning on a very fast rotating structured collector, which enables easy nanofiber detachment, without additional effort. The other method implies the exposure of a poly(ethylene terephthalate) (PET) foil to a KrF* laser beam, that renders a nanorippled surface topography. Schwann cell growth on these substrates was inspected after one week of cultivation by means of scanning electron microscopy (SEM). For both methods we show that Schwann cells grow in a certain direction, predetermined by nanofiber and nanoripple orientation. In contrast, cells cultivated on randomly oriented nanofibers or unstructured surfaces, show an omnidirectional growth behavior. These two methods can be used to produce nerve conduits for the treatment of injuries to the peripheral nervous system.

Clinical Efficacy Analysis of Acupuncture Treatment in the Acute Phase of Peripheral Facial Paralysis

Peripheral facial paralysis, caused by damage to the lower motor neurons of the facial nerve, is a neurological disorder characterized by partial or complete loss of facial expression. It typically manifests suddenly with symptoms such as post-auricular pain, diminished taste, excessive tearing, difficulty speaking, and facial muscle twitching. Depending on the underlying cause, this condition can be categorized into spontaneous facial nerve palsy, peripheral facial paralysis induced by Guillain-Barré syndrome, and peripheral facial paralysis caused by brainstem lesions. Among these, the most common type is Bell’s palsy, which usually presents as sudden unilateral facial muscle paralysis. The incidence rate is approximately 20 to 40 cases per 100,000 people annually, with patients ranging in age from young to old, although it is most prevalent in those aged 20 to 40, and it tends to occur more frequently in men than in women. Conventional treatments for peripheral facial nerve paralysis include hormone therapy, antiviral medication, and surgical intervention. However, hormone therapy may not be effective for some patients due to its side effects, the efficacy of antiviral therapy remains controversial, and surgery is costly and may lead to postoperative complications. Traditional Chinese Medicine (TCM) acupuncture therapy, with a long-standing history, has been widely used to treat such facial nerve disorders as documented in the "Huangdi Neijing · Suwen."

The effects of anaesthesia on the cardiovascular, respiratory and nervous systems during inhalational anaesthesia: A case report.

Our understanding of the effects of anaesthesia is incomplete. Anaesthesia works primarily by causing widespread depression of the central nervous system. This article will consider the anaesthesia provided for a patient undergoing a hysteroscopy, endometrial ablation and biopsy for abnormal uterine bleeding. The relationship between physiology and the effects of anaesthesia is discussed. Several effects of anaesthesia are observed during the case. Relating to the respiratory system, preoxygenation increased end tidal oxygen by 39%, delaying desaturation during apnoea. Propofol had a profound effect on the patient's respiratory rate by inhibiting the ventilatory drive, resulting in apnoea. The cardiovascular system was affected by tracheal intubation. Stimulation of the sympathetic nervous system caused a 96% increase in heart rate. Induction of anaesthesia resulted in hypotension, treated with the administration of ephedrine, causing vasoconstriction. Modified rapid sequence induction required an increased dose of rocuronium, resulting in an increased duration of action at the neuromuscular junction. The prolonging muscle paralysis required sugammadex as a reversal agent. This case demonstrated the effects of anaesthesia on the respiratory, cardiovascular and nervous systems.

Biomechanical significance of intervertebral discs on growthplate stresses in scoliotic trunks following unilateral muscle weakening: A hybrid approach of finite element and musculoskeletal modeling.

This study aimed to ascertain the relevance of intervertebral discs (IVD) in the stress distribution on growthplates (GPs) of a trunk model with adolescent idiopathic scoliosis (AIS) following a unilateral weakening of muscles. A thoracolumbar spine finite element (FE) model of a young female healthy and an AIS spine comprising GPs linked to the T12 through sacrum vertebrae. Two scenarios of including (FEI) and excluding (FEE) IVDs were considered. Then, using optimization-driven musculoskeletal models of the AIS and healthy trunks, the FE models were examined under subject-specific muscle forces and gravity loads. Results of this study demonstrate that when IVDs included in the FE model, an increase, ranging from 0.2 to 1.7 MPa, with the highest value occurring at the apex of the AIS model, in the von Mises stresses in the GPs. The ratio of 1.5 was found for the maximum von-Mises stress value on the most tilted GP in the FEI over the FEE model. Unilateral paralysis of muscles caused a reduction of 50% and 63% in the von Mises stress ratio of the concave-over-convex side of the most tilted GP in the FEI and FEE models of the AIS spine with healthy muscles, respectively. The intradiscal pressures, found for FEE and FEI models, assented to recent in-vivo investigations. Nonetheless, employing IVDs in the simulations provides an indispensable tool to anticipate the effects of neuromuscular disorders on GP stresses in an AIS spine and predict deformity progression during growth.

Understanding renal tubular acidosis.

Renal tubular acidosis is a group of disorders characterised by metabolic acidosis, hyperchloraemia, normal anion gap, and potassium imbalance. Genetic mutations, drugs or acquired disorders disrupt the function of various transport proteins and enzymes in the renal tubules, causing diminished bicarbonate reabsorption or inability to excrete hydrogen ions, leading to proximal (type 2) and distal (type 1) renal tubular acidosis, respectively. These conditions are typically associated with hypokalaemia, which, if severe, can cause muscle paralysis and dangerous cardiac arrhythmias. A rare mixed variant (type 3), including features of both type 1 and type 2 renal tubular acidosis, has also been described. On the other hand, aldosterone deficiency or resistance leads to the hyperkalaemic form of renal tubular acidosis (type 4). If untreated, renal tubular acidosis can lead to long-term severe complications such as growth retardation, osteoporosis, rickets, osteomalacia, and renal calculi. Moreover, renal tubular acidosis might be the initial presentation of a more severe underlying pathology, such as autoimmune disease or plasma cell dyscrasias. A better understanding of the condition can help physicians diagnose and treat it early and prevent adverse outcomes.

Design and construction of a GAP-43 reporter system for potential identification of effective therapeutics for peripheral nerve regeneration

Background: Peripheral nerve injury (PNI) is a condition that can result in muscle paralysis and sensory disturbances. Electrical stimulation and/or the application of exogenous neurotrophic factors and cytokines are effective at enhancing nerve regeneration and is mediated via the expression of regeneration associated genes (RAGs) such as the growth associated protein GAP-43. Therapeutic upregulation of GAP-43 has potential use as a treatment for improving recovery from PNI. Few studies have investigated the potential of increasing GAP-43 for PNI therapeutic purposes and current methods for measuring GAP-43 expression are limited. Aims and Objectives: The broader aim of this work was to construct a motor neuron-like cell model with a GAP-43 reporter system. Such a model would have potential use in screening for novel therapeutics that upregulate GAP-43 and in the optimisation of electrical stimulation treatment in combination with these therapies. The key aim of the work was to design and construct a Cas9 expressing plasmid bearing a gRNA that targets GAP-43 cleavage and a donor plasmid bearing a reporter GFP or Neo cassette flanked with 5’ and 3’ GAP-43 homology arms (HAs) to facilitate the insertion of the reporter immediately 3’ of the GAP-43 promoter via CRISPR/Cas9 homology directed repair (HDR). Such an insertion would enable quantitative measurement of endogenous expression of the GAP-43 gene. Methods and Results: To guide the Cas9 nuclease to the target location, GAP-43 gRNA oligomers were designed and cloned downstream of the U6 promoter in the Cas9 expression plasmid px330, which also expresses the Cas9 gene and the cloned gRNA when transfected into cells. For CRISPR/Cas9 HDR, the 5’ and 3’ GAP-43 HAs were amplified from mouse genomic DNA and cloned into the donor plasmid using Gibson Assembly so that they flanked the reporter cassette. Results: This work successfully constructed the Cas9 gRNA expressing plasmid to target cleavage of the GAP-43 gene in mouse cell lines and has provided the complete design and construction foundation for generation of the reporter system for the endogenous GAP-43 gene in mice.

Effects of Combined Respiratory Physiotherapy with High-Flow Nasal Cannula and Venturi Mask in Spinal Cord Injury: A Single-Subject Research Study and Literature Review.

The level of spinal cord injury affects the severity of respiratory impairment and the alteration of respiratory pattern and gas exchanges. Lesions at the C3-C5 level (phrenic nerve nucleus) cause disruption of descending input with paralysis of the main inspiratory muscle, often requiring tracheostomy and prolonged mechanical ventilation. Oxygen therapy is essential to switch from ventilatory support to removal of the endotracheal tube to correct residual difficulties in oxygenation management. A 58-year-old man had tracheostomy and tetraparesis as complication of tonsillectomy and adenoidectomy treatment for a history of obstructive sleep apnea. A respiratory rehabilitation program with protocol of oxygen therapy with high flow cannula alternated with a low-flow system by Venturi mask during daytime hours only was started. The patient was constantly monitored with capillary partial oxygen saturation to obtain adequate oxygenation (≥ 94%) and registered every 15 minutes in the clinical chart. There was gradual improvement of respiratory function. Oxygen by Venturi mask was gradually reduced due to improvement of partial pressure oxygen values. Over the course of days, the optimal results of respiratory parameters led to a gradual weaning from the Venturi mask until the complete discontinuation of the low-flow system during daytime and decreased of the high-flow fraction of inspired oxygen to the maximal tolerated level during nighttime. Implementing a combined protocol of nighttime oxygen with high flow cannula and daytime Venturi mask improves intensive motor training of patients by promoting the acquisition of ability to perform chair/bed transitions and to be able to achieve standing and begin gait training. More research is needed whether or noted to determine the role of this promising approach in patients with severe SCI and in other critically ill patients. This is a presentation of a new respiratory training protocol of combined oxygen therapy by high flow cannula and Venturi mask in a patient with cervical spinal cord injury and respiratory failure.Due to this new respiratory training, from the weaning of ventilation devices the patient had greater independence and improved quality of life, with more intensive motor training in the gym, improvement of the motor program and the patient tolerance to training.Oxygen therapy with high flow cannula and Venturi mask could be valid and reliable combined respiratory training to improve the respiratory pattern in severely hypoxemic and hypercapnic patients, without adverse events.

Non-Migraine Head Pain and Botulinum Toxin.

Botulinum toxin A (BT-A), a potential neurotoxin produced by the bacterium Clostridium botulinum, is known for its ability to prevent the release of acetylcholine at the neuromuscular synapse, leading to temporary muscle paralysis. BT-A is used for a wide range of therapeutic applications. Several studies have shown mechanisms beyond the inhibition of acetylcholine release for pain control. BT-A inhibits the release of neurotransmitters associated with pain and inflammation, such as glutamate, CGRP, and substance P. Additionally, it would be effective in nerve entrapment leading to neuronal hypersensitivity, which is known as a new pathogenesis of painful conditions. BT-A has been applied to the treatment of a wide variety of neurological disorders. Since 2010, BT-A application has been approved and widely used as a chronic migraine prophylaxis. Moreover, due to its effects on pain through sensory modulation, it may also be effective for other headaches. Several studies using BT-A, at different doses and administration sites for headaches, have shown beneficial effects on frequency and severity. In this review, we provide an overview of using BT-A to treat primary and secondary headache disorders.

Paradoxical metabolic acidosis after vomiting in children with spinal muscular atrophy: A report of 9 patients

BackgroundSpinal muscular atrophy (SMA) is a hereditary neuromuscular disease that progresses toward restrictive respiratory failure due to muscle paralysis. We observed that SMA patients presented with a specific clinical and laboratory profile, consisting of severe metabolic acidosis following an episode of mild vomiting. This is an unusual, little-known, and life-threatening situation for these patients, as hyperventilation induced by metabolic acidosis can lead to exhaustion and to death by mixed acidosis. ObjectiveThe aim of our study was to describe this paradoxical acidosis after vomiting in SMA patients and to discuss the physiological basis of this condition. MethodsWe conducted a retrospective single-center study reviewing the clinical and laboratory data of SMA patients who were hospitalized in the intensive care unit for severe metabolic acidosis after vomiting. ResultsOur cohort comprised 11 cases. On arrival, the median pH of the patients was 7.23 with a median bicarbonate concentration of 11.7 mmol/L and almost half of them (45 %) had ketone bodies in the blood and/or urine. The median correction time was 24 h for pH and 48 h for bicarbonate concentrations after receiving intravenous hydration with a glucose solution. ConclusionsWe suggest that SMA patients are particularly sensitive to ketoacidosis induced by fasting, even after a few episodes of mild vomiting. Moreover, they have a low buffering capacity due to their severe amyotrophy, which favors metabolic acidosis. They must be quickly hydrated through a glucose-containing solution to avoid exhaustion, mixed acidosis, and death.

Structural determinants of tendon multiscale mechanics and their sensitivity to mechanical stimulation during development in an embryonic chick model

There is an abrupt increase in the multiscale mechanical properties and load-bearing capabilities of tendon during development. While prior work has identified numerous changes that occur within the collagenous structure during this developmental period, the primary structural elements that give rise to this abrupt increase in mechanical functionality, and their mechanobiological sensitivity, remain unclear. To address this knowledge gap, we used a shear lag model along with ultrastructural imaging, biochemical/thermodynamic assays, and multiscale mechanical testing to investigate the dynamic structure-function relationships during late-stage embryonic chick development and to establish their sensitivity to mechanical stimulation. Mechanical testing and modeling suggested that the rapid increase in multiscale mechanics can be explained by increases in fibril length, intrafibrillar crosslinking, and fibril area fraction. To partially test this, we inhibited collagen crosslinking during development and observed a drastic reduction in multiscale mechanical behavior that was explained by a reduction in both fibril modulus and length. Using muscle paralysis to investigate mechanosensitivity, we observed a significantly impaired multiscale mechanical response despite minimal changes in fibril diameter and fibril area fraction. Additionally, the shear lag model found a trend toward lower fibril lengths with paralysis and experimental data found decreased crosslinking and fibril modulus values following flaccid paralysis. Together, these data suggest that both intrafibrillar crosslink formation and fibril elongation are critical to the formation of load-bearing capabilities in tenogenesis and are sensitive to mechanical loading. These findings provide critical insights into the biological and structural mechanisms that give rise to tensile load-bearing soft tissue. Statement of SignificanceDespite prior work investigating the structural and mechanical changes that occur during tendon development, there has not been a comprehensive analysis of how these simultaneous changes in structure and function are connected. In this study, we performed a comprehensive battery of mechanical and structural assessments of embryonic chick tendons and input these data into a shear lag model to estimate the individual importance of each structural change to the tendon mechanical properties. Additionally, we inhibited muscle activity in the embryos to evaluate the impact of mechanical stimulation on these evolving structure-function relationships during tendon development. These data provide insight into the primary structural elements that produce the tensile load-bearing capabilities of tendon, which will inform efforts to produce tissue engineered tendon replacements.

Endoscopic transorbital approach for recurrent spheno-orbital meningiomas: single center case series

Endoscopic transorbital approaches (ETOAs) are finding wide application for skull base lesions, particularly for spheno-orbital meningiomas (SOMs). These tumors have high recurrence rates, and second surgery can often represent a challenge. In this study we analyze our experience of management of recurrent SOMs through a slightly modified eyelid crease approach. Between May 2016 and September 2023, in the Department of Neurosurgery of Fondazione IRCCS Policlinico San Matteo (Pavia, Italy), five consecutive recurrent SOMs have been treated using an endoscopic transorbital approach. Demographic data, preoperatory deficits, lesions characteristics, histology, grade of resection, eventual adjuvant treatments, complications, outcome in terms of symptoms improvement and cosmesis, and hospitalization are described. One patient maintained a right lateral rectus muscle palsy that was already present in the preoperatory, no cerebrospinal fluid (CSF) leaks were reported. All patients had postoperative periorbital edema, but no other systemic complication was found. All patients had proptosis improvement, two had visual acuity improvement, and best cosmetic outcome was obtained in all cases. Hospitalization varied between 4 and 6 days. ETOAs in the management of recurrent SOMs are safe and have good outcome. Right selection of patients is mandatory, but when feasible, endoscopic surgery can allow a virgin route to a previously operated tumor, guaranteeing a good strategic option.

Azolla as a Safe Food: Suppression of Cyanotoxin-Related Genes and Cyanotoxin Production in Its Symbiont, Nostoc azollae.

The floating freshwater fern Azolla is the only plant that retains an endocyanobiont, Nostoc azollae (aka Anabaena azollae), during its sexual and asexual reproduction. The increased interest in Azolla as a potential source of food and its unique evolutionary history have raised questions about its cyanotoxin content and genome. Cyanotoxins are potent toxins synthesized by cyanobacteria which have an anti-herbivore effect but have also been linked to neurodegenerative disorders including Alzheimer's and Parkinson's diseases, liver and kidney failure, muscle paralysis, and other severe health issues. In this study, we investigated 48 accessions of Azolla-Nostoc symbiosis for the presence of genes coding microcystin, nodularin, cylindrospermopsin and saxitoxin, and BLAST analysis for anatoxin-a. We also investigated the presence of the neurotoxin β-N-methylamino-L-alanine (BMAA) in Azolla and N. azollae through LC-MS/MS. The PCR amplification of saxitoxin, cylindrospermospin, microcystin, and nodularin genes showed that Azolla and its cyanobiont N. azollae do not have the genes to synthesize these cyanotoxins. Additionally, the matching of the anatoxin-a gene to the sequenced N. azollae genome does not indicate the presence of the anatoxin-a gene. The LC-MS/MS analysis showed that BMAA and its isomers AEG and DAB are absent from Azolla and Nostoc azollae. Azolla therefore has the potential to safely feed millions of people due to its rapid growth while free-floating on shallow fresh water without the need for nitrogen fertilizers.

Development of Ocular Muscle Stimulation Systems and Optimization of Electrical Stimulus Parameters for Paralytic Strabismus Treatment.

Paralysis of the extraocular muscles can lead to complications such as strabismus, diplopia, and loss of stereopsis. Current surgical treatments aim to mitigate these issues by resecting the paralyzed muscle or transposing the other recti muscles to the paralyzed muscle, but they do not fully improve the patient's quality of life. Electrical stimulation shows promise, while requiring further in vivo experiments and research on various stimulation parameters. In this study, we conducted experiments on rabbits to stimulate the superior rectus (SR) muscles using different parameters and stimulation waveforms. To provide various types of electrical stimulation, we developed the ocular muscle stimulation systems capable of both current controlled stimulation (CCS) and high-frequency stimulation (HFS), along with the chip that enables energy-efficient and safe switched-capacitor stimulation (SCS). We also developed electrodes for easy implantation and employed safe and efficient stimulation methods including CCS, SCS, and HFS. The in vivo animal experiments on normal and paralyzed SR muscles of rabbits showed that eyeball abduction angles were proportional to the current and pulse width of the stimulation. With the decaying exponential stimuli of the SCS system, eyeball abductions were 2.58× and 5.65× larger for normal and paralyzed muscles, respectively, compared to the rectangular stimulus of CCS. HFS achieved 0.92× and 0.26× abduction for normal and paralyzed muscles, respectively, with half energy compared to CCS. In addition, the continuous changes in eyeball abduction angle in response to varying stimulation intensity over time were observed.

Krait bite: A Diagnostic Dilemma

In Nepal, fatalities resulting from snakebites are alarmingly common, yet the issue remains inadequately addressed, prompting experts to characterize it as an imminent but overlooked crisis. Among the venomous snakes, the Common Krait stands out for its exceptionally lethal venom, rich in neurotoxins that induce muscle paralysis. Particularly in rural areas, snakebites pose a significant threat to public health. However, the diagnostic challenge posed by patients with obscure medical histories devoid of known snakebite incidents is seldom documented in medical literature. In this context, we present the case of a 22-year-old male patient presenting with nonspecific symptoms and an indistinct medical background.

One- vs Two- vertical muscle surgery in the management of unilateral superior oblique muscle palsy with hypertropia over 20 PD

ABSTRACT Purpose: To compare the surgical outcomes of One- versus Two-vertical muscle surgery in patients with unilateral superior oblique muscle palsy (SOP) with primary position hypertropia (HT) over 20 PD. Patients in Group 1 underwent inferior oblique anterior transposition plus resection (IOATR), while patients in Group 2 underwent inferior oblique anterior transposition (IOAT) along with contralateral inferior rectus (IR) recession. Methods: Medical data of all SOP patients treated by either procedure from 2000 to 2023 in our strabismus center were recruited. We compared surgical outcomes between Group 1 and Group 2 by analyzing HT correction, rate of under-correction, and over-correction. Results: The study included 33 patients in Group 1 and 23 in Group 2. Both groups were similar in age, sex, etiology, affected side, diplopia, and head tilt. Group 2 achieved higher HT correction in all measured gazes. Group 1 had a higher risk of under-correction (18.18% in Group 1 vs 8.69% in Group 2) while Group 2 had a higher rate of over-correction (21.73% vs 0% in Group 1). Conclusion: In patients with severe unilateral SOP, Two-vertical muscle surgery achieved higher amounts of HT correction in all gazes despite a significantly higher risk of over-correction.

Transplantation of embryonic spinal motor neurons into peripheral nerves enables functional reconstruction of a denervated diaphragm

Respiratory muscle paralysis due to trauma or neurodegenerative diseases can have devastating consequences. Only a few studies have investigated the reconstruction of motor function in denervated diaphragms caused by such conditions. Here, we studied the efficacy of transplanting E14 embryonic spinal motor neurons (SMNs) into peripheral nerve grafts for functionally reconstructing a denervated diaphragm in a rat model. The diaphragms of 8-week-old male Fischer 344 rats were first denervated by transecting the phrenic nerves. Subsequently, peripheral nerve grafts taken from the lower limb were used for neurotization of the denervated diaphragms. One week later, fetal E14 SMNs were transplanted into the peripheral nerve grafts. After 3 months, we observed functional contraction of the diaphragm following neuromuscular electrical stimulation (NMES) of the peripheral nerve graft. Additionally, we confirmed that SMN transplantation into the peripheral nerve graft had an inhibitory effect on diaphragm muscle atrophy. The SMNs transplanted into the peripheral nerve grafts formed a structure similar to the spinal cord, and the neuromuscular junction of the denervated diaphragm was reinnervated. These findings suggest the establishment of an ectopic motor neuron pool in the peripheral nerve graft. Free peripheral intra-nerve SMN transplantation in combination with NMES, which can be applied for diaphragmatic pacing, offers novel insights into the development of neuroregenerative therapies for treating life-threatening and intractable respiratory muscle paralysis caused by severe nerve damage and degenerative diseases.