Patients In Arm Research Articles

Remote Ischemic Conditioning in Ischemic Stroke and Myocardial Infarction: Similarities and Differences.

Acute myocardial infarction and ischemic stroke are leading causes of morbidity and mortality worldwide. Although reperfusion therapies have greatly improved the outcomes of patients with these conditions, many patients die or are severely disabled despite complete reperfusion. It is therefore important to identify interventions that can prevent progression to ischemic necrosis and limit ischemia-reperfusion injury. A possible strategy is ischemic conditioning, which consists of inducing ischemia – either in the ischemic organ or in another body site [i.e., remote ischemic conditioning (RIC), e.g., by inflating a cuff around the patient's arm or leg]. The effects of ischemic conditioning have been studied, alone or in combination with revascularization techniques. Based on the timing (before, during, or after ischemia), RIC is classified as pre-, per-/peri-, or post-conditioning, respectively. In this review, we first highlight some pathophysiological and clinical similarities and differences between cardiac and cerebral ischemia. We report evidence that RIC reduces circulating biomarkers of myocardial necrosis, infarct size, and edema, although this effect appears not to translate into a better prognosis. We then review cutting-edge applications of RIC for the treatment of ischemic stroke. We also highlight that, although RIC is a safe procedure that can easily be implemented in hospital and pre-hospital settings, its efficacy in patients with ischemic stroke remains to be proven. We then discuss possible methodological issues of previous studies. We finish by highlighting some perspectives for future research, aimed at increasing the efficacy of ischemic conditioning for improving tissue protection and clinical outcomes, and stratifying myocardial infarction and brain ischemia patients to enhance treatment feasibility.

Effectiveness of Supplemental Upper Extremity Training With Specialty Therapist for Patients With Stroke in Inpatient Rehabilitation

<h3>Research Objectives</h3> To investigate the potential benefits of supplemental training for the upper extremity on patient's arm and hand function during subacute stroke recovery. <h3>Design</h3> Retrospective cohort study over 6 month duration. <h3>Setting</h3> Inpatient Rehabilitation Hospital. <h3>Participants</h3> All participants received conventional occupational therapy (COT) during their inpatient rehabilitation for an admitting diagnosis of stroke. The control group consisted of 34 participants that were not referred to a specialty therapist. The 33 patients in the study group were referred by primary therapist to a specialty therapist for upper extremity motor recovery. <h3>Interventions</h3> Patients treated 1-3x weekly, 60 minute sessions. - Clinical consultation including plan of care recommendations specific to upper extremity impairments. - Treatment by specialty therapist including: 1. Upper extremity robotics 2. Gravity eliminated motor retraining 3. Virtual reality 4. Functional electrical stimulation 5. Constraint induced movement therapy <h3>Main Outcome Measures</h3> Fugl Meyer Assessment - Upper Extremity (FMA-UE), Box and Blocks Test (BBT). <h3>Results</h3> Patients in both groups were stratified into severe, moderate and mild impairment categories using the FMA-UE score collected at inpatient admission. Patients in control group with a severe impairment had an average change score of 8 on FMA-UE and 2 on BBT. Comparatively, the severe experimental group achieved an average change score of 21.9 on FMA-UE and 13.7 on BBT. Effects of supplemental training on mild impairment groups were not seen in FMA-UE. However, the BBT change score for mild control group was 8 versus 16.8 for experimental group. The supplemental training failed to show a significant increase for moderate group in FMA-UE or BBT. <h3>Conclusions</h3> Supplemental upper extremity training along with COT in the subacute phase of stroke recovery may improve gross and fine motor functioning for patients with severe impairment. For patients with mild impairment, supplemental training may serve to improve fine motor function. The effect of specialty therapist intervention on upper extremity function warrants further study due to current small sample size and interaction of selection bias due to reliance on therapist's referral for consultation. <h3>Author(s) Disclosures</h3> None.

Safe disconnection of 5-fluorouracil elastomeric pumps: The benefit of a closed-system-transfer device designed for cytotoxic drug administration/perfusion.

Occupational exposure to cytotoxic drugs can lead to significant health problems. This study was designed to evaluate the risk of 5-fluorouracil (5-FU) contamination for nurses when disconnecting the infusion line of an elastomeric pump from a non-coring needle, by comparing three configurations: the first one using standard Male and Female Luer lock (Group 1), the second one using a needle-free connector (NFC) and a Male Luer lock (Group 2) and the third one using a closed-system transfer device (CSTD), Qimono® (Group 3). In this in vitro study, 10 elastomeric pumps for each of the three groups were filled with 5-FU and a tissue mimicking the patient's arm was placed below the connection between the infusion line and the tubing of non-coring needle. After 48 h of infusion, disconnection was performed by a nurse with a wipe soaked in a mix of chlorhexidine and isopropyl alcohol in order to mimic care practices. For each pump, the tissue, the pair of gloves and the wipes used during the disconnection were collected for analysis. Median level of overall 5-FU contamination (gloves + wipes + tissues) in group 3 was significantly lower than in group 1 (p = 0.018) and group 2 (p = 0.036). There was no difference between groups 1 and 2. Results per sample type showed no difference in contamination between the three configurations for the gloves as well as for the tissues. Concerning the wipes, the lowest contamination was observed in group 3, representing a mean reduction of 61% compared to group 1 and a mean reduction of 43% compared to group 2. The use of Qimono® appears to significantly reduce 5-FU contamination when disconnecting infusion lines of an elastomeric pump unlike NFC and standard Luer lock.

EFFECT OF UNDERCUFFING ON AUSCULTATORY AND OSCILLOMETRIC BLOOD PRESSURE MEASUREMENT

Abstract Objective: The objective of the present investigation was to identify the effect of using a blood pressure (BP) cuff size smaller than that appropriate for patient's arm circumference (undercuffing) on auscultatory and oscillometric measurements. Design and method: It was a single-centre equivalence trial that recruited 47 adult subjects with upper arm circumferences between 35 and 44 cm. After ten minutes rest, six sequential BP measurements were performed 30 and, at most, 60 seconds apart while seated. First, third and fifth measurements were performed using blinded, simultaneous, two-observer auscultation using a calibrated anaeroid sphygmomanometer and requiring a between-observer agreement equal to or less than 4 mmHg. Second, fourth and sixth were performed with the Omron HBP-1100 oscillometric monitor. The first two measurements (one auscultatory and one oscillometric) were performed using a large adult cuff (16 x 36 cm), which represented appropriate cuffing for the study subjects. Third, fourth, fifth and sixth measurements were performed with a standard adult cuff size (16 × 30 cm). BP differences were calculated using device – observer measurement. A paired t-test was used to identify statistically significant differences between BP readings in each method. Results: 282 complete measurements were available. Mean upper arm circumference size was 38.38 (±2.85) cm. Mean SBP and DBP when the appropriate cuff was used was 115.08 ± 18.32/70.25 ± 12.3 mmHg using the auscultatory method vs. 120.91 ± 17.15/72.57 ± 11.74 mmHg using the oscillometric method (p-value &lt; 0.005). When smaller cuff size was used, mean SBP and DBP was 119.97 ± 15.88/76.78 ± 12.03 mmHg in the auscultatory method vs. 126.95 ± 16.17/74.56 ± 10.97 mmHg in the oscillometric method (p-value &lt; 0.005). The mean device-observer disagreement for SBP (Fig 1) was 5.82 (±9.12) when appropriate cuff size was used and 6.98 (±8.06) with a smaller cuff size (p-value = 0.79). For DBP (Fig 2), the disagreement was 2.31 (±6.28) vs. -2.22 (±5.88) (p-value &lt; 0.005). Conclusions: Using a smaller cuff size overestimates SBP and DBP, in both auscultatory and oscillometric methods and also results in a greater systolic disagreement between these two measurement methods.

Методы моделирования и идентификация параметров неоднородных анормальных неврологических движений многокомпонентных нейробиосистемах с когнитивными обратными связями

Разработаны основы математического моделирования и идентификации параметров неоднородных анормальных неврологических движений (АНР) в многокомпонентных нейробиосистемах с обратными когнитивными связями. На основе развитых авторами методов интегральных превращений и спектрального анализа для неоднородных сред предложен новый подход к построению гибридных моделей распространения волнового сигнала, описывающего нежелательные дрожания конечности руки пациента (Т-объекта) в результате самопроизвольного сокращения скелетных мышц. за счет когнитивных воздействий отдельной группы нейронных узлов коры головного мозга (КГМ). Разработана гибридная модель нейробиосистемы, описывающая состояние и поведение Т-объектов, а именно посегментное описание 3D-элементов траекторий АНР Т-объекта с учетом матрицы когнитивных воздействий групп нейроузлов КГМ. На основе гибридных интегральных преобразований Фурье получено высокоскоростное аналитическое векторное решение модели, описывающей элементы траекторий на каждом АНР-сегменте. Предложена новая методика вычисления гибридной спектральной функции, спектральных значений и матрицы когнитивных воздействий нейроузлов КГМ, определяющих гибридное интегральное преобразование построения решения. Сформулированы и решены новые неклассические задачи многопараметрической идентификации нейросистем с обратной связью в неоднородных средах на основе минимизации функционала-невязки между траекториями наблюдения и их модельными аналогами. Построены высокопроизводительные алгоритмы идентификации амплитудно-частотных характеристик систем обратной связи для компонентной оценки влияния когнитивных обратных связей, позволяющих распараллелировать вычисления для многоядерных компьютеров. Выполнено компьютерное моделирование и идентификацию АНР-траекторий нейросистем обратной связи.

A randomized prospective study comparing acute toxicity, compliance and objective response rate between simultaneous integrated boost and sequential intensity-modulated radiotherapy for locally advanced head and neck cancer.

PurposeIntensity-modulated radiotherapy (IMRT) provides higher dose to target volumes and limits the dose to normal tissues. IMRT may be applied using either simultaneous integrated boost (SIB-IMRT) or sequential boost (SEQ-IMRT) technique. The objectives of this study were to compare acute toxicity and objective response rates between SIB-IMRT and SEQ-IMRT in patients with locally advanced head and neck cancer.Materials and MethodsTotal 110 patients with locally advanced carcinoma of oropharynx, hypopharynx, and larynx were randomized equally into the two arms (SIB-IMRT vs. SEQ-IMRT). Patients in SIB-IMRT arm received dose of 66 Gy in 30 fractions, 5 days a week, over 6 weeks. SEQ-IMRT arm’s patients received 70 Gy in 35 fractions over 7 weeks. Weekly concurrent cisplatin chemotherapy was given in both arms. Patients were assessed for acute toxicities during the treatment and for objective response at 3 months after the radiotherapy.ResultsGrade 3 dysphagia was significantly more with SIB-IMRT compared to SEQ-IMRT (72% vs. 41.2%; p = 0.006) but other toxicities including mucositis, dermatitis, xerostomia, weight-loss, incidence of nasogastric tube intubation and hospitalization for supportive management were similar in both the arms. Patients in SIB-IMRT arm showed better treatment-compliance and had significantly less treatment-interruption compared to SEQ-IMRT arm (p = 0.028). Objective response rates were similar in both the arms (p = 0.783).ConclusionConcurrent chemoradiation with SIB-IMRT for locally advanced head and neck cancer is well-tolerated and results in better treatment-compliance, similar objective response rates, comparable incidence of mucositis and higher incidence of grade 3 dysphagia compared to SEQ-IMRT.

Robotic right upper lobectomy: Twelve steps.

Robotic right upper lobectomy: Twelve steps.

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit.

We performed ultrasonographic examinations of the ipsilateral internal jugular vein after placement of peripherally inserted central catheters (PICCs) and found that more than half of malpositions of PICC went to the head through the ipsilateral internal jugular vein. We aimed to reduce malpositions of PICCs in settings where fluoroscopy is not available. This retrospective study had a case-control, single-center study design. From January to June 2018, PICCs were inserted with the patient's arm abducted without the use of ultrasonography to identify the presence of the PICC in the ipsilateral internal jugular vein (procedure A). From July to December 2018, PICCs were inserted in a similar fashion; however, ultrasonography was employed to detect the catheter tip in the ipsilateral internal jugular vein (procedure B). There were 794 placements of PICCs in 650 patients. Procedures A and B were performed in 418 and 376 patients, respectively. Malpositioning of PICC tips occurred significantly less often in procedure B than in procedure A (2.4% vs. 5.7%, P=0.02). In a setting without fluoroscopy, insertions of PICCs can be performed with the arm abducted at 90°. Ultrasound monitoring for the presence of the catheter in the ipsilateral internal jugular vein can help with correct positioning, thereby reducing the occurrence of catheter tip malpositions.

“French Position” for Open Pancreaticoduodenectomy: Coming Back from Laparoscopy to Open Surgery

Introduction: Minimally invasive surgery has arrived slowly in pancreaticoduodenectomy (PD). Even that, most of PDs remains performed Open. Some advantages of laparoscopy can be reintroduced to Open surgery. We propose the “French position” to Open PD, to facilitate the access of the second assistant (usually a Fellow or Resident). Methods: After a pair of conversions of laparoscopic PD to open, we realized that French position (supine with open legs) allows a better performance for the surgical team, specially the second assistant participation. After that, one of the authors (HF) proposed to start open PDs using the advantages of French position. Results: In last 20 Open PDs we start with the patient in French position. Surgeon remains on the right side of the patient, first assistant of the left side and second assistant between de patient legs. We feel that this position allows a better participation of the second assistant and the surgeon have more room to work. In some cases, the surgeon changed the position between the patient's legs, during uncinate process dissection, taking advantage for dissection parallel to mesenteric vessel instead of perpendicular fashion. Another advantage is to get open the patient's arms if is required for the anesthetist. Some limitations: it requires special attention to avoid pressure areas. Conclusion: French position to perform Open PDs can facilitate the disposition of the surgical team and in some cases the surgeon can operate in front of the uncinate process changing the direction in parallel instead of perpendicular.

Directional Local Field Potentials in the Subthalamic Nucleus During Deep Brain Implantation of Parkinson's Disease Patients.

Segmented deep brain stimulation leads feature directional electrodes that allow for a finer spatial control of electrical stimulation compared to traditional ring-shaped electrodes. These segmented leads have demonstrated enlarged therapeutic windows and have thus the potential to improve the treatment of Parkinson’s disease patients. Moreover, they provide a unique opportunity to record directional local field potentials. Here, we investigated whether directional local field potentials can help identify the best stimulation direction to assist device programming. Four Parkinson’s disease patients underwent routine implantation of the subthalamic nucleus. Firstly, local field potentials were recorded in three directions for two conditions: In one condition, the patient was at rest; in the other condition, the patient’s arm was moved. Secondly, current thresholds for therapeutic and side effects were identified intraoperatively for directional stimulation. Therapeutic windows were calculated from these two thresholds. Thirdly, the spectral power of the total beta band (13–35 Hz) and its sub-bands low, high, and peak beta were analyzed post hoc. Fourthly, the spectral power was used by different algorithms to predict the ranking of directions. The spectral power profiles were patient-specific, and spectral peaks were found both in the low beta band (13–20 Hz) and in the high beta band (20.5–35 Hz). The direction with the highest spectral power in the total beta band was most indicative of the 1st best direction when defined by therapeutic window. Based on the total beta band, the resting condition and the moving condition were similarly predictive about the direction ranking and classified 83.3% of directions correctly. However, different algorithms were needed to predict the ranking defined by therapeutic window or therapeutic current threshold. Directional local field potentials may help predict the best stimulation direction. Further studies with larger sample sizes are needed to better distinguish the informative value of different conditions and the beta sub-bands.

Design and control of an exoskeleton robot with EMG-driven electrical stimulation for upper limb rehabilitation

PurposeThe purpose of this paper is to design and develop a new robotic device for the rehabilitation of the upper limbs. The authors are focusing on a new symmetrical robot which can be used to rehabilitate the right upper limb and the left upper limb. The robotic arm can be automatically extended or reduced depending on the measurements of the patient's arm. The main idea is to integrate electrical stimulation into motor rehabilitation by robot. The goal is to provide automatic electrical stimulation based on muscle status during the rehabilitation process.Design/methodology/approachThe developed robotic arm can be automatically extended or reduced depending on the measurements of the patient's arm. The system merges two rehabilitation strategies: motor rehabilitation and electrical stimulation. The goal is to take the advantages of both approaches. Electrical stimulation is often used for building muscle through endurance, resistance and strength exercises. However, in the proposed approach the electrical stimulation is used for recovery, relaxation and pain relief. In addition, the device includes an electromyography (EMG) muscle sensor that records muscle activity in real time. The control architecture provides the ability to automatically activate the appropriate stimulation mode based on the acquired EMG signal. The system software provides two modes for stimulation activation: the manual preset mode and the EMG driven mode. The program ensures traceability and provides the ability to issue a patient status monitoring report.FindingsThe developed robotic device is symmetrical and reconfigurable. The presented rehabilitation system includes a muscle stimulator associated with the robot to improve the quality of the rehabilitation process. The integration of neuromuscular electrical stimulation into the physical rehabilitation process offers effective rehabilitation sessions for neuromuscular recovery of the upper limb. A laboratory-made stimulator is developed to generate three modes of stimulation: pain relief, massage and relaxation. Through the control software interface, the physiotherapist can set the exercise movement parameters, define the stimulation mode and record the patient training in real time.Research limitations/implicationsThere are certain constraints when applying the proposed method, such as the sensitivity of the acquired EMG signals. This involves the use of professional equipment and mainly the implementation of sophisticated algorithms for signal extraction.Practical implicationsFunctional electrical stimulation and robot-based motor rehabilitation are the most important technologies applied in post-stroke rehabilitation. The main objective of integrating robots into the rehabilitation process is to compensate for the functions lost in people with physical disabilities. The stimulation technique can be used for recovery, relaxation and drainage and pain relief. In this context, the idea is to integrate electrical stimulation into motor rehabilitation based on a robot to obtain the advantages of the two approaches to further improve the rehabilitation process. The introduction of this type of robot also makes it possible to develop new exciting assistance devices.Originality/valueThe proposed design is symmetrical, reconfigurable and light, covering all the joints of the upper limbs and their movements. In addition, the developed platform is inexpensive and a portable solution based on open source hardware platforms which opens the way to more extensions and developments. Electrical stimulation is often used to improve motor function and restore loss of function. However, the main objective behind the proposed stimulation in this paper is to recover after effort. The novelty of the proposed solution is to integrate the electrical stimulation powered by EMG in robotic rehabilitation.

Design of an upper limb elevation cushion for hand surgery

Upper limb injury is a common disease in hand surgery. After surgery, it is necessary to raise the patient's arm to reduce limb swelling and promote recovery. In clinic, clothes or pillows are usually placed under the arm to raise it, but in this way the arm cannot be fixed well and easily slide down, without ideal raising effect. Therefore, the upper limb raising pad for assisting the raising of the affected limb is specially designed. The device is composed of shell, mounting plate, strut, elastic band and spring. The position of the strut is adjusted by squeezing or lifting the spring, so as to change the inclination angle of the mounting plate and to adjust the raising height of the upper limb. After the height is determined, the affected limb is placed comfortably and then fixed with the elastic band. The device can freely adjust the raising height of the affected limb and effectively fix the affected limb to reduce its swelling, thus promoting recovery. This device is worthy to be clinically popularized and applied.

Measurement of Outlet Pressures Favors Rib Resection for Decompression of Thoracic Outlet Syndrome

When conservative therapy for thoracic outlet syndrome fails, scalenectomy with or without first-rib resection (FRR) is the treatment of choice. We measured pressure in the costoclavicular space before and after FRR at time of neurogenic thoracic outlet syndrome release to evaluate whether FRR is required to completely decompress the costoclavicular space. Using a supraclavicular exposure for anterior-middle scalenectomy with FRR, costoclavicular space pressures were measured using a balloon catheter with the patient's arm in neutral anatomic position, secondarily, the arm abducted and externally rotated. Pressures were recorded in both arm positions before scalenectomy, after scalenectomy, and after FRR. Paired Student's t test was used to compare differences in group means for paired samples. Patient-reported outcomes were reported using the Derkash classification and quick disabilities of the arm, shoulder, and hand (qDASH) questionnaire. Fifteen patients (16 cases) surgically treated for neurogenic thoracic outlet syndrome were included in this retrospective study. There was no significant difference in pressure change between arm positions before scalenectomy (161.56 ± 71.65 mm Hg difference) or after scalenectomy (148.5 ± 80.24 mm Hg difference). There was a significant difference in pressure change between post-scalenectomy and post-FRR arm positions; mean pressure change between arm positions after FRR was 50.56 ± 40.28 mm Hg. Mean postoperative qDASH score was 20 ± 23.2. All patients reported improvement in symptoms and functional status. Supraclavicular first rib resection for management of neurogenic thoracic outlet syndrome can be safely performed with favorable outcomes. The pressure increase in the costoclavicular space caused by arm abduction and external rotation was significantly reduced only after FRR, raising concerns about potential incomplete costoclavicular space decompression with scalenectomy alone for neurogenic thoracic outlet syndrome management.

Improving Healthcare Access: A Preliminary Design of a Low-Cost Arm Rehabilitation Device

AbstractA low-cost continuous passive motion (CPM) machine, the Gannon Exoskeleton for Arm Rehabilitation (GEAR), was designed. The focus of the machine is on the rehabilitation of primary functional movements of the arm. The device developed integrates two mechanisms consisting of a four-bar linkage and a sliding rod prismatic joint mechanism that can be mounted to a normal chair. When seated, the patient is connected to the device via a padded cuff strapped on the elbow. A set of springs have been used to maintain the system stability and help the lifting of the arm. A preliminary analysis via analytical methods is used to determine the initial value of the springs to be used in the mechanism given the desired gravity compensatory force. Subsequently, a multibody simulation was performed with the software simwise 4D by Design Simulation Technologies (DST). The simulation was used to optimize the stiffness of the springs in the mechanism to provide assistance to raising of the patient's arm. Furthermore, the software can provide a finite element analysis of the stress induced by the springs on the mechanism and the external load of the arm. Finally, a physical prototype of the mechanism was fabricated using polyvinyl chloride (PVC) pipes and commercial metal springs, and the reaching space was measured using motion capture. We believed that the GEAR has the potential to provide effective passive movement to individuals with no access to postoperative or poststroke rehabilitation therapy.

A COMPREHENSIVE STUDY ON NERIVIO MIGRA

Migraine is one among the foremost prevalent and disabling disorders, characterized by recurrent headache attacks with nausea, vomiting, photophobia, and phonophobia. Nerivio Migra may be a breakthrough device for acute treatment of migraines. Attached to the patient's arm (below the shoulder), it's a clinically-tested wearable suited to be worn everywhere and at any time. Non steroidal anti inflammatory drugs (NSAIDs) and triptans, commonly used for acute migraine treatment3, may be ineffective, poorly tolerated, contraindicated, and if used in excess, may lead to medication overuse headache there is a great unmet need for alternative acute migraine treatments that are both effective and well tolerated. Non-invasive neuromodulation is safe, well tolerated, and may have fewer adverse effects than drugs. Remote electrical neuromodulation (REN) may be a novel acute migraine treatment that stimulates upper arm peripheral nerves to induce conditioned pain modulation (CPM)-an endogenous analgesia mechanism during which conditioning stimulation inhibits pain in remote body regions.

Minimally Invasive Surgical Considerations for the Obese Patient

Video Objective This objective of this video is to review surgical considerations for the obese patient undergoing minimally invasive surgery. Setting The obese patient is the patient considered. This video addresses risks of laparoscopic surgery, differences in patient counseling, prophylactic measures, patient positioning, laparoscopic entry, management of the panniculus, and prevention of conversion to an open procedure. Interventions Interventions for prophylactic measures include placement of an orogastric/nasogastric tube prior to intubation, increased dose of antibiotic prophylaxis, and optimization of hemoglobin A1c for diabetic patients. Interventions for optimizing patient positioning include allotting extra time for procedures, utilizing bariatric beds and stirrups, anti-skid material and padding during surgery, tucking the patient's arms, and applying a chest strap. Interventions for laparoscopic entry include utilization of bariatric trocars, placing trocars more laterally and cephalad, left upper quadrant or supraumbilical entry, and inserting ports at a 90 degree angle to the abdomen. Interventions for panniculus management and prevention of conversion to an open procedure include limiting the use of steep Trendelenberg, decreasing the insufflation pressure, mechanically retracting the panniculus, and performing a tilt test. Conclusion Gynecologic surgeons will inevitably be operating on more obese patients with coming years given the rising prevalence of obesity. Thus, they should be prepared for preoperative evaluation of the obese patient, surgical preparation, patient counseling, and surgical optimization to prevent conversion to an open procedure, all of which are addressed in this video. Preventing conversion is a balancing act between improving surgical visualization and maintaining stable cardiac and respiratory status of the patient. With increasing volume of cases, gynecologic surgeons can become proficient at minimally invasive surgery for the obese patient, thus, decreasing their operative morbidity and post-surgical quality of life.

Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction.

In patients with global brachial plexus injury and lack of biological treatment alternatives, bionic reconstruction, including the elective amputation of the functionless hand and its replacement with a prosthesis, has recently been described. Optimal prosthetic function depends on a structured rehabilitation protocol, as residual muscle activity in a patient's arm is later translated into prosthetic function. Surface electromyographic (sEMG) biofeedback has been used during rehabilitation after stroke, but has so far not been used in patients with complex peripheral nerve injuries. Here, we present our rehabilitation protocol implemented in patients with global brachial plexus injuries suitable for bionic reconstruction, starting from identification of sEMG signals to final prosthetic training. This structured rehabilitation program facilitates motor relearning, which may be a cognitively debilitating process after complex nerve root avulsion injuries, aberrant re-innervation and extra-anatomical reconstruction (as is the case with nerve transfer surgery). The rehabilitation protocol using sEMG biofeedback aids in the establishment of new motor patterns as patients are being made aware of the advancing re-innervation process of target muscles. Additionally, faint signals may also be trained and improved using sEMG biofeedback, rendering a clinically "useless"muscle (exhibiting muscle strength M1 on the British Medical Research Council [BMRC] scale) eligible for dexterous prosthetic hand control. Furthermore, functional outcome scores after successful bionic reconstruction are presented in this article.

Surgical wound coverage with platelet rich fibrin and an elastic polymer sheet

Background Platelet-rich fibrin (PRF) can be prepared from the patient's peripheral blood. It releases several signal molecules, such as PDGF, TGF-b, and VEGF, which promote tissue regeneration. It is likely that covering the surgical wound with PRF stimulates healing. However, PRF alone does not have enough mechanical strength to be sutured on the surgical wound. Aim/Hypothesis This study aims to evaluate the effect of the combination of the low speed centrifuged platelet-rich fibrin (PRF) and thin elastic polymer mesh on the surgical wound for widening keratinized mucosa around the implant at the second surgery. Material and Methods In total, 8 patients aged 40–65 (mean 50.7) years, 4 male and 4 females, were included in this study. In these patients, the width of KM around the implants at the lower jaw was less than 3 mm. Smokers and patients with systemic diseases that could interfere with the healing, were excluded from this clinical study. Under local anesthesia, a partial-thickness flap was raised from the periosteum. The vestibular flap is apically displaced and sutured to the periosteum. Immediately after peripheral blood was obtained from the patient's arm vein, the blood in the plastic tube was centrifuged at low speed (283 g, 8 minutes). The upper layer was transferred and combined with a thermoplastic olefin elastomer (TPO) thin mesh in the flat glass container. The combined material of PRF and the mesh was placed on the wound dehiscence and sutured. The combined material was removed together with other stitches at 10–14 days after the surgery. The surgical site was observed and photographed up to 6 weeks. Results The combined material of PRF and TPO mesh was easily placed and sutured on the surgical wound. The application of the combined material to the surgical wound was clinically effective, increasing the width of keratinized mucosa around the implants in all the cases. Notably, the patients did not feel any distinct pain after the surgery. The average length of KM of all patients is 6.17 mm. Conclusion and Clinical Implications The combined material of PRF and TPO mesh is useful for surgical wound coverage. TPO protects the wound and stabilizes the PRF around implants. PRF is contributed to angiogenesis by participating in cell-cell cross talk and expressing various signaling molecules. PRF and TPO combination shows a synergistic effect. TPO can be clinically useful for soft tissue healing. However, further studies are necessary to figure out the effect on TPO on peri-implant biology.

Peri‐operative brachial plexus injury following self‐positioning for stereotactic radiofrequency ablation

A 71-year-old woman with a known accessory cervical rib and distinct scoliosis was scheduled for elective, percutaneous stereotactic radiofrequency ablation of a non-resectable intrahepatic cholangiocellular carcinoma. Patient positioning and fixation using a Bluebag fixation system (Medical Intelligence, Schwabmünchen, Germany) and a dedicated adjustable armrest were customised in the patient while awake. In order to provide safe conditions for mask ventilation and tracheal intubation, the patient was returned to standard supine positioning without changing the position of the armrest. Following the induction of general anaesthesia, the patient's arm was returned to the previously defined position. Upon completion of the procedure and emergence from anaesthesia, the patient immediately reported symptoms of severe brachial plexus damage. Therefore, we suggest that awake positioning according to current recommendations does not completely preclude the possibility of neurologic injury.

Spur Gears Transmission Analysis on Countinous Passive Motion Machine Design for Shoulder Joint

An analysis of gear transmission on a countinous passive machine (CPM) from the 3-dimensional design has been carried out using Solidworks software. Analysis of the strength of the gear structure is affected by the weight of the patient's arm. Analysis of gear transmission that is affected by the load of the passive arm uses static simulation, by entering the patient's arm load. The facilities used are static simulation with the condition of fixed geometry in the parts related of the shaft, the effect of gravity of 10 m/s 2 , making mesh, and running simulation. The maximum stress that occurs in gear 3 z = 100 is 4.5524e + 006 N/m 2 , the maximum stress on gear 2 z = 80 is 4.81729e + 006 N/m2, the maximum stress on gear 100 z = 20 is 9.08982e + 006 N/m 2