Τρίτη, 13 Μαρτίου 2018

Identification of General Patterns of Sex-Biased Expression in Daphnia, a Genus with Environmental Sex Determination

Daphnia reproduce by cyclic-parthenogenesis, where phases of asexual reproduction are intermitted by sexual production of diapause stages. This life cycle, together with environmental sex determination, allow the comparison of gene expression between genetically identical males and females. We investigated gene expression differences between males and females in four genotypes of Daphnia magna and compared the results with published data on sex-biased gene expression in two other Daphnia species, each representing one of the major phylogenetic clades within the genus. We found that 42 % of all annotated genes showed sex-biased expression in D. magna. This proportion is similar both to estimates from other Daphnia species as well as from species with genetic sex determination, suggesting that sex-biased expression is not reduced under environmental sex determination. Among 7453 single copy, one-to-one orthologs in the three Daphnia species, 707 consistently showed sex-biased expression and 675 were biased in the same direction in all three species. Hence these genes represent a core-set of genes with consistent sex-differential expression in the genus. A functional analysis identified that several of them are involved in known sex determination pathways. Moreover, 75 % were overexpressed in females rather than males, a pattern that appears to be a general feature of sex-biased gene expression in Daphnia.



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A Host-Pathogen Interaction Screen Identifies ada2 as a Mediator of Candida glabrata Defences Against Reactive Oxygen Species

Candida glabrata (C. glabrata) forms part of the normal human gut microbiota but can cause life-threatening invasive infections in immune-compromised individuals. C. glabrata displays high resistance to common azole antifungals, which necessitates new treatments. In this investigation, we identified five C. glabrata deletion mutants (ada2, bas1, hir3, ino2 and met31) from a library of 196 transcription factor mutants that were unable to grow and activate an immune response in Drosophila larvae. This highlighted the importance of these transcription factors in C. glabrata infectivity. Further ex vivo investigation into these mutants revealed the requirement of C. glabrata ADA2 for oxidative stress tolerance. We confirmed this observation in vivo whereby growth of the C. glabrata ada2 strain was permitted only in flies with suppressed production of reactive oxygen species (ROS). Conversely, overexpression of ADA2 promoted C. glabrata replication in infected wild type larvae resulting in larval killing. We propose that ADA2 orchestrates the response of C. glabrata against ROS-mediated immune defences during infection. With the need to find alternative antifungal treatment for C. glabrata infections, genes required for survival in the host environment, such as ADA2, provide promising potential targets.



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Correlation of polymorphisms in long non-coding RNAs with the pathogenesis of inflammatory bowel diseases



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Towards a RAS mutation status in a single day for patients with advanced colorectal cancers



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Effectiveness and safety of anti-TNF therapy for inflammatory bowel disease in liver transplant recipients for primary sclerosing cholangitis: a nationwide case series

There is a lack of consensus regarding the treatment of inflammatory bowel disease (IBD) after liver transplantation (LT) forprimary sclerosing cholangitis (PSC).

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Reliability and Validity of HeartSmartKids: A Survey of Cardiovascular Risk Factors in Children

Reliable and valid instruments to measure counseling effectiveness related to eating, activity, and inactivity are lacking. HeartSmartKids (HSK; HeartSmartKids, LLC, Boulder, Colorado) is a bilingual decision-support technology that can be used to assess and counsel families on cardiovascular risk factors in children. The purpose of this study was to establish preliminary test–retest reliability and convergent validity of HSK questions relative to a previously validated questionnaire, HABITS.

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Correlation of polymorphisms in long non-coding RNAs with the pathogenesis of inflammatory bowel diseases



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Towards a RAS mutation status in a single day for patients with advanced colorectal cancers



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Effectiveness and safety of anti-TNF therapy for inflammatory bowel disease in liver transplant recipients for primary sclerosing cholangitis: a nationwide case series

There is a lack of consensus regarding the treatment of inflammatory bowel disease (IBD) after liver transplantation (LT) forprimary sclerosing cholangitis (PSC).

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Patricia Industries signs agreement to acquire Sarnova from company founder and Water Street Healthcare partners

DUBLIN, Ohio — Sarnova Holdings, Inc., parent company to four fast-growing business units: Bound Tree Medical, Cardio Partners, Emergency Medical Products and Tri-anim Health Services, announced today that the company has signed an agreement to be acquired by Patricia Industries, which is part of the Swedish industrial holding company, Investor AB. Patricia Industries will acquire the majority ...

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Reply to Kardos et al.: Estimation of inbreeding depression from SNP data [Biological Sciences]

We thank Kardos et al. (1) for their interest in our study (2), which is about the detection and quantification of inbreeding depression (ID) for complex traits from SNP data. Kardos et al. (1) make a number of points about the utility and interpretation of estimates of ID from runs...

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Editing out five Serpina1 paralogs to create a mouse model of genetic emphysema [Genetics]

Chronic obstructive pulmonary disease affects 10% of the worldwide population, and the leading genetic cause is α-1 antitrypsin (AAT) deficiency. Due to the complexity of the murine locus, which includes up to six Serpina1 paralogs, no genetic animal model of the disease has been successfully generated until now. Here we...

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Rapid regulatory evolution of a nonrecombining autosome linked to divergent behavioral phenotypes [Genetics]

In the white-throated sparrow (Zonotrichia albicollis), the second chromosome bears a striking resemblance to sex chromosomes. First, within each breeding pair of birds, one bird is homozygous for the standard arrangement of the chromosome (ZAL2/ZAL2) and its mate is heterozygous for a different version (ZAL2/ZAL2m). Second, recombination is profoundly suppressed...

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How should we compare different genomic estimates of the strength of inbreeding depression? [Biological Sciences]

Yengo et al. (1) evaluate the ability of genomic measures of inbreeding to quantify inbreeding depression. The authors conclude that a measure of inbreeding based on "runs of homozygosity" (FROH) had low power and upwardly biased estimates of the amount of inbreeding depression compared with FHOM (a measure of homozygosity...

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Assistant Chief Training Officer - Shoshone County EMS Corp.

Shoshone County EMS Corporation is looking for an experienced Paramedic to join our administration team as an Assistant Chief and Training Officer. Shoshone County lies on the eastern side of Idaho's northern panhandle. The county's seven incorporated cities are stretched along the Interstate-90 corridor, from Pinehurst on the western side to the Montana border to the east. This corridor ...

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Automatic application of neural stimulation during wheelchair propulsion after SCI enhances recovery of upright sitting from destabilizing events

The leading cause of injury for manual wheelchair users are tips and falls caused by unexpected destabilizing events encountered during everyday activities. The purpose of this study was to determine the feasi...

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Neuroendocrine neoplasm of pancreas with cystic degeneration mimicking mucinous cystic neoplasm

Abstract

Endoscopic ultrasound is increasingly being used for evaluation of pancreatic diseases and pancreatic tumors. Among various pancreatic cystic lesions, cystic degeneration of pancreatic neuroendocrine neoplasm is of the challenge in making diagnosis. Although unique characteristic of each type of pancreatic cystic lesions has been proposed abundantly, typical morphology of cystic degeneration of pancreatic neuroendocrine neoplasm is still unclear. We, herein, reported a case of 66-year-old woman who was incidentally found to have a cystic lesion in the tail of pancreas upon screening transabdominal ultrasonography. A well-defined cystic lesion with rim calcification was noted on subsequent abdominal computed tomography. Endoscopic ultrasound revealed a markedly thick-wall cystic lesion containing solid nodule inside which was not enhanced following contrast-enhanced study. A mucinous cystic neoplasm was suspected and the patient was proceeded with distal pancreatectomy. A definite diagnosis of neuroendocrine neoplasm was confirmed after staining with synaptophysin and chromogranin A. We performed a meticulous review on current literatures focusing on endoscopic characteristics of pancreatic neuroendocrine neoplasms with cystic degeneration.



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The effect of aerobic walking and lower body resistance exercise on serum COMP and hyaluronan, in both males and females

Abstract

Purpose

To compare the serum cartilage oligomeric matrix protein (COMP) and hyaluronan (HA) response to walking (high-repetition loading) and resistance training exercise (low-repetition loading) in males and females.

Methods

15 males (age: 28 ± 6 years; BMI: 24 ± 2; mean ± SD) and 15 females (age: 26 ± 4 years; BMI: 23 ± 2) completed both a 40-min walk at 80% of maximum heart rate and a 40-min lower body resistance training protocol, separated by a minimum of 48 h. Serum COMP and HA were determined at rest, immediately post, and 30-min post exercise. Resting femoral cartilage thickness was also measured using ultrasonography.

Results

COMP increased following walking (28.9%; P < 0.001) and resistance training exercise (26.0%; P < 0.001), remaining above baseline post-exercise following walking (mean difference: +28.3 ng/ml; 95% CI 3.8–52.8 ng/ml; P = 0.02). Although the exercise response did not differ for gender, COMP concentrations were higher in males than in females at all time points (all, P < 0.001). In contrast, HA concentrations did not change following either modality of exercise. However, females demonstrated higher HA pre-exercise (37.7 ± 17.8 vs 26.2 ± 12.8 ng/ml; P = 0.006) and immediately post exercise (38.0 ± 19.0 vs 28.2 ± 15.5 ng/ml; P = 0.033) compared to men. Finally, following adjustment for body size, femoral cartilage thickness was greater in men compared to women (notch: 2.66 vs 1.74 mm, P < 0.001).

Conclusion

The effect of a single bout of lower body exercise on serum COMP and HA is independent of exercise modality in healthy men and women. Furthermore, having thicker femoral cartilage and higher baseline COMP in males does not appear to influence how the cartilage responds to exercise.



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Human Performance in Motorcycle Road Racing: A Review of the Literature

Abstract

Performance in motorcycle road racing is typically considered as the summation of interactions between rider, motorcycle, tires, and environment. Despite the substantial investments made towards the development of motorcycle technology and the business interests of manufacturers, published research focusing on the riders is relatively sparse, and a bike-centered mentality tends to dominate the sport. This manuscript reviews the known human performance aspects of motorcycle road racing and suggests directions for future research. In this sport, riders are exposed to a complex interaction of physiological, mechanical, and psychological stresses, alongside the ever-present potential for injury from crashes or localized muscular overload (i.e., chronic exertional forearm compartmental syndrome). The reviewed literature shows that riders involved in competitive road racing should develop proper levels of body composition, cardiovascular fitness, muscular strength, specific flexibility, and heat tolerance in addition to their all-important technical riding skills. Furthermore, specific resistance to inertial stresses, visual acuity, mental and physical resilience, psychological strategies, and behavioral awareness all appear to be meaningful contributors to successful performance. Further work is needed to profile riders according to their level to create evidence-based methodologies that improve performance. Additionally, future research should aim to improve safety for these athletes and deepen the understanding about the magnitude of metabolic, mental, technical, biomechanical, and muscular demands in relation to anthropometric characteristics, sex, categories of competition, and success rate.



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Meetings Calendar



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Table of Contents



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Letter to the editor regarding “A multicenter cohort study of spinal osteoid osteomas: results of surgical treatment and analysis of local recurrence” by Quraishi et al.

We read the article by Dr Quraishi et al. with great interest. Dr Quraishi and co-authors [1] presented a multicenter study with 84 cases of spinal osteoid osteomas (OO), which is the largest series in this field. They recommended complete resection of the nidus by intralesional resection to achieve local control with a low recurrence rate. Overall, the authors presented delicate surgical techniques and good results. They also provided guidance for the surgical management of spinal OOs. However, there are two issues that we feel should be clarified:

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Table of Contents



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Table of Contents



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Table of Contents



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Editorial Board



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Parturition and the perinatal period: can mode of delivery impact on the future health of the neonate?

Abstract

Caesarean section and instrumental delivery rates are increasing in many parts of the world due to a range of cultural and medical reasons, with limited consideration as to how 'mode of delivery' may impact on childhood and long-term health.

However, babies born particularly by pre-labour caesarean section appear to have a subtly different physiology to those born by normal vaginal delivery, with both acute and chronic complications such as respiratory and other morbidities being apparent. It has been hypothesised that inherent mechanisms within the process of labour and vaginal delivery, far from being a passive mechanical process by which the fetus and placenta are expelled from the birth canal, may trigger certain protective developmental processes permissive for normal immunological and physiological development of the fetus postnatally. Traditionally the primary candidate mechanism has been the hormonal surges or stress response associated with labour and vaginal delivery, but there is increasing awareness that transfer of the maternal microbiome to the infant during parturition and transgenerational transmission of disease traits through epigenetics are also important. Interventions such as probiotics, neonatal gut seeding and different approaches to clinical care have potential to influence parturition physiology and improve outcomes for infants.

This article is protected by copyright. All rights reserved



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Hypercalciuria and nephrolithiasis: Expanding the renal phenotype of Donnai-Barrow syndrome

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Whole exome sequencing detected novel likely pathogenic variants in LRP2 gene in 2 patients presenting with hearing and vision loss, and the Dent disease (DD) classical renal phenotype, that is, low molecular weight proteinuria (LMWP), hypercalciuria and nephrocalcinosis/nephrolithiasis. We propose that a subset of patients presenting as DD may represent unrecognized cases or mild forms of Donnai-Barrow/facio-oculo-acustico-renal (DB/FOAR) syndrome or be on the phenotypic continuum between the 2 conditions.



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Endotracheal tube size to leakage ventilation and tracheal dilatation

Abstract

Purpose

This study analyzed the clinical factors with the aim to determine the relationship between endotracheal tube (ETT) size and leakage ventilation (LV) and tracheal dilatation.

Methods

All patients with ETT intubation and ventilator support for more than 6 months were retrospectively evaluated. The inner tracheal diameter (TD) was measured over image at the starting and 6 months after ventilator initiated. We compared the clinical factors, outcomes and complications between patients with and without LV, as well as with and without a TD enlarging more than 25% after 6 months (TDn). Logistic regression analyses of factors related to the LV and TDn were performed. The cut-off points of the ratio of outer diameter of ETT (OD) to TD were set and evaluated for their accuracy of predicting LV and TDn.

Results

689 patients were enrolled initially and eventually 199 patients were included, of which 52 and 66 patients were identified to have LV and TDn, respectively. Patients with LV had a higher peak inspiratory pressure (PIP), smaller initial ETT OD/TD and higher incidence of pneumonia. Patients with TDn had a higher PIP, larger initial OD/TD and higher incidence of pneumonia. A higher PIP and smaller initial OD/TD were significantly related to LV and a higher PIP and larger initial OD/TD were significantly related to TDn. The incidence of LV and TDn was higher in patients with an initial OD/TD less than 0.51 and more than 0.54, respectively.

Conclusion

The initial ETT OD/TD ratio is a predictor for LV and TDn.



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Isolated Terminal Ileitis: When Is It Not Crohn’s Disease?



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Relative Age Effects Across and Within Female Sport Contexts: A Systematic Review and Meta-Analysis

Abstract

Background

Subtle differences in chronological age within sport (bi-) annual-age groupings can contribute to immediate participation and long-term attainment discrepancies; known as the relative age effect. Voluminous studies have examined relative age effects in male sport; however, their prevalence and context-specific magnitude in female sport remain undetermined.

Objective

The objective of this study was to determine the prevalence and magnitude of relative age effects in female sport via examination of published data spanning 1984–2016.

Methods

Registered with PROSPERO (No. 42016053497) and using Preferred Reporting Items for Systematic Reviews and Meta-analysis systematic search guidelines, 57 studies were identified, containing 308 independent samples across 25 sports. Distribution data were synthesised using odds ratio meta-analyses, applying an invariance random-effects model. Follow-up subgroup category analyses examined whether relative age effect magnitudes were moderated by age group, competition level, sport type, sport context and study quality.

Results

When comparing the relatively oldest (quartile 1) vs. youngest (quartile 4) individuals across all female sport contexts, the overall pooled estimate identified a significant but small relative age effect (odds ratio = 1.25; 95% confidence interval 1.21–1.30; p = 0.01; odds ratio adjusted = 1.21). Subgroup analyses revealed the relative age effect magnitude was higher in pre-adolescent (≤ 11 years) and adolescent (12–14 years) age groups and at higher competition levels. Relative age effect magnitudes were higher in team-based and individual sport contexts associated with high physiological demands.

Conclusion

The findings highlight relative age effects are prevalent across the female sport contexts examined. Relative age effect magnitude is moderated by interactions between developmental stages, competition level and sport context demands. Modifications to sport policy, organisational and athlete development system structure, as well as practitioner intervention are recommended to prevent relative age effect-related participation and longer term attainment inequalities.



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The Effects of a Motorized Aquatic Treadmill Exercise Program on Muscle Strength, Cardiorespiratory Fitness, and clinical function in Subacute Stroke Patients -- a Randomized Controlled Pilot Trial

AbstractObjectiveThe aim of this study was to assess the effects of a motorized aquatic treadmill exercise program improve the isometric strength of the knee muscles, cardiorespiratory fitness, arterial stiffness, motor function, balance, functional outcomes and quality of life in subacute stroke patients.DesignThirty-two patients were randomly assigned to 4-week training sessions of either aquatic therapy(n=19) or land-based aerobic exercise(n=18). Isometric strength was measured using an isokinetic dynamometer. Cardiopulmonary fitness was evaluated using a symptom-limited exercise tolerance test and by measuring brachial ankle pulse wave velocity. Moreover, motor function(Fugl-Meyer Assessment[FMA] and FMA-lower limb[FMA-LL]), balance(Berg Balance Scale[BBS]), Activities of daily living(Korean version of the Modified Barthel Index [K-MBI]), and Quality of life(EQ-5D index) were examined.ResultsThere were no inter-group differences between demographic and clinical characteristics at baseline(p>0.05). The results shows significant improvements in peak oxygen consumption (p=0.02), maximal isometric strength of the bilateral knee extensors (p0.05). The results shows significant improvements in peak oxygen consumption (p=0.02), maximal isometric strength of the bilateral knee extensors (p

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When motor unit expansion in aging muscle fails, atrophy ensues

Abstract

Skeletal muscle atrophy is a hallmark of advancing age that contributes to mobility impairment, physical frailty and increased morbidity in the elderly.

This article is protected by copyright. All rights reserved



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Perioperative airway management for aortic valve replacement in an adult with mucopolysaccharidosis type II (Hunter syndrome).

Perioperative airway management for aortic valve replacement in an adult with mucopolysaccharidosis type II (Hunter syndrome).

JA Clin Rep. 2018;4(1):24

Authors: Suzuki K, Sakai H, Takahashi K

Abstract
We herein report anesthetic management during aortic valve replacement for aortic valve regurgitation in a patient with adult mucopolysaccharidosis type II (MPS type 2) (Hunter syndrome). This disorder is rare and related to the accumulation of a mucopolysaccharide in lysosomes. It affects various organs, including the airways, heart, and central nerves. In children with MPS type 2, the risk of airway obstruction during anesthesia/sedation is high, and the degree of difficulty increases with aging. The patient described herein was a 33-year-old male without mental retardation. Before surgery, trismus, megaloglossia, and the disturbance of cervical vertebral excursion were noted, suggesting difficulties with ventilation/intubation. Anesthesia was induced under sedation/spontaneous respiration. A laryngeal deployment was conducted using a video laryngoscope; however, the Cormack grade was III. Nasotracheal fiber intubation was performed, and airway obstruction occurred. A muscle relaxant was administered, facilitating ventilation. However, subglottic stenosis, which was not detected before the surgery, made the tracheal tube insertion difficult. Aortic valve replacement was performed without complications. A detailed postoperative examination of the airways revealed oropharyngeal soft tissue outgrowth, narrowing of the upper airway, subglottic stenosis, and displacement/circumflex of the airway axis. Either awake intubation or rapid induction can be selected for this patient; however, either way have risks of airway obstruction. It is important that strategies under light anesthesia or incomplete neuromuscular blockade should be avoided for such our patient as suggested in the JSA airway management guidelines. A preoperative multidisciplinary airway assessment and simulation are important.

PMID: 29527552 [PubMed]



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Restoration of somatosensory perception via electrical stimulation of peripheral nerves

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Max Ortiz-Catalan




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7. Papillary thyroid cancer in a patient with Morvan’s syndrome

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Susan Walker, Manisha Narasimhan, José Manuel Matamala, Thanuja Dharmadasa, Matthew C. Kiernan, William Huynh
BackgroundMorvan's syndrome is a rare disorder, characterized by peripheral nerve hyperexcitability, dysautonomia and encephalopathy with marked insomnia. About three quarters of patients have voltage gated potassium channel (VGKC) antibodies. A significant proportion of patients have associated tumours and the majority of these are thymomas.IntroductionA 53 year-old man presented with a history of pain, cramps and twitching of the muscles of the chest and limbs, insomnia, hyperhidrosis, hypersalivation and cognitive impairment with hallucinations. Examination revealed fasciculations of the proximal upper limbs, piloerection of the forearms and mild postural hypotension.InvestigationsThe patient underwent a number of electrophysiological studies: (1) EMG demonstrated spontaneous and frequent irregularly occurring neuromyotonic activity as doublet, triplet and multiplet single motor unit discharges firing at a high intraburst frequency (133–200 Hz), consistent with peripheral nerve hyperexcitability. (2) Paired-pulse transcranial magnetic stimulation revealed reduction in the short-interval intracortical inhibition (SICI) suggestive of central hyperexcitability. (3) EEG demonstrated left temporal slowing on an otherwise normal background. (4) autonomic testing showed a generalized sudomotor impairment consistent with autonomic dysfunction. Neuroimaging of the brain with PET demonstrated bilateral temporal lobe hypometabolism. Whole body PET revealed a hypermetabolic thyroid lesion, which was subsequently confirmed histologically to be a multifocal papillary thyroid carcinoma.DiscussionThe clinical and electrophysiological presentation was consistent with a diagnosis of Morvan's syndrome in the context of a paraneoplastic phenomenon secondary to papillary thyroid cancer. The patient underwent a thyroidectomy and adjuvant radiotherapy. In addition, monthly intravenous methylprednisolone and intravenous immunoglobulin was instituted. Subsequently, the patient experienced significant symptomatic improvement with resolution of muscle fasciculations and cramps, hyperhidrosis and visual hallucinations. Insomnia and pain although improved did not completely resolve.ConclusionThis case reviews the clinical and neurophysiological findings of Morvan's syndrome. The case adds to the small number of non-thymomatous tumours associated with this syndrome and highlights the importance of a thorough search for malignancy in this clinical context.



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10-Effects of non-invasive brain stimulation on motor speech disorder in Parkinson’s disease

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): L. Brabenec, J. Mekyska, Z. Galáž, P. Klobušiakova, M. Koštálová, I. Rektorova
IntroductionHypokinetic dysarthria (HD) is a common symptom of Parkinson's disease (PD) which does not respond well to PD treatments. We investigated short-term effects of repetitive transcranial magnetic stimulation (rTMS) on HD in PD using acoustic analysis of speech.MethodsWe used both high and low frequency rTMS applied over the right posterior superior temporal gyrus (STG), the left orofacial primary motor area, and over the vertex (a control stimulation site) in 15 PD patients using a cross-over design. Resting state seed-based functional connectivity (rs-FC) with the seed located in the stimulation site was used to unravel the neural underpinnings of rTMS-induced behavioural changes.ResultsBoth 1 Hz and 10 Hz rTMS of the right STG induced some positive changes on HD. The major impact was observed for 1 Hz rTMS over the STG. The stimulation improved speech articulation and rhythmicity via modulation of the STG rs-FC with the parahippocampal gyrus and cerebellum. The 10 Hz rTMS of the STG improved articulation while enhancing the rs-FC with the inferior parietal lobule and thalamus.



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Contents

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4





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02-EEG in nonconvulsive status epileptisus (NCSE)

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): H. Krijtová
Nonconvulsive status epilepticus (NCSE) is a serious acute situation in neurology which is not always identified. It covers a heterogenous group of electrophysiological situations. The diagnosis of NCSE requires an electroencephalogram (EEG), since clinical signs and symptoms are often nonspecific. As EEG patterns are not always unequivocal, no reliable diagnostic test exists. To simplify the diagnosis, Salzburg EEG Criteria for NCSE were formulated in 2013, with clinical validation still in progress. According to these criteria there are three possible EEG patterns in NCSE patients without preexisting epileptic encephalopathy: (a) unequivocal finding with rythmic epileptic discharges (EDs) > 2.5/s and (b) two equivocal patterns (periodic EDs ⩽ 2.5/s or rhythmic delta/theta activity exceeding 0.5/s). In those equivocal findings at least one of the additional criteria must be present for diagnosis – clinical and EEG improvements from antiepileptic drugs, subtle clinical phenomena, or typical spatiotemporal evolution. Equivocal patterns are considered to be an ictal-interictal continuum and they may or may not be a correlate of NCSE especially in critically ill patients. For the correct assessment of the importance of these patterns one must be familiar with the new ACNS Standardized Critical Care EEG Terminology which replaces clinically unequivocal terms by neutral descriptive ones.



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3. Characterization of persistent Na+ current in human motor and sensory axons: Exploring the activity at different target levels

Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Yoshimitsu Shimatani, José Manuel Matamala, James Howells, Matthew C. Kiernan
IntroductionAxonal excitability studies are useful clinical tool for the understanding of the physiology of myelinated axons. Across all nerve excitability parameters, the strength-duration time constant (SDTC) has been shown to be related to the activity of persistent Na+ (Nap) current. Nap currents have been implicated in several diseases including ALS, SMA and Kennedy's disease.Because SDTC can also be affected by passive membrane properties, latent addition (LA) is considered a better method, as it is able to separately evaluate Nap and passive membrane properties.Many studies examine the properties of axons recruited at 40% of maximal amplitude, however information about the expression of Nap in different population of axons is still missing.ObjectiveTo characterize Nap currents in motor and sensory axons at different target levels.MethodsMotor and sensory nerve excitability studies were recorded using threshold tracking techniques in 22 healthy controls (mean age 32.3 ± 7.5 years (mean ± S.D.), 11 males). The median nerve was stimulated at the wrist, with CMAPs and CSAPs recorded distally. An axonal excitability protocol was conducted, which included assessment of strength-duration properties and latent addition. These properties were studied in different populations of axons at 10%, 20%, 40%, and 60% of the maximal response for both motor and sensory nerve.ResultsMaximal amplitudes were 8.8 ± 0.7 mV and 81.8 ± 6.6 μV (mean ± SEM) for CMAP and CSAP, respectively. Motor SDTCs were longer at lower target levels (10%: 0.42 ms, 20%: 0.41 ms, 40%: 0.40 ms, 60%: 0.37 ms, F = 9.0, p = 0.002). This relationship was more prominent in sensory axons (10%: 0.69 ms, 20%: 0.65 ms, 40%: 0.58 ms, 60%: 0.54 ms, F = 67.4, p<0.0001). The passive membrane properties were similar for both motor and sensory between different target levels. Threshold changes at 0.2 ms, the best measure of Nap conductance, were higher in sensory axons than in motor (motor vs sensory: 10%: 10.8 vs 17.6, 20%: 10.6 vs 17.2, 40%: 11.9 vs 17.3, 60%: 12.2 vs 17.6), but there was no correlation between Nap and target level in either motor or sensory nerve (motor, F = 1.85, p = 0.18; sensory, F = 0.25, p = 0.78). Regression analyses showed significant relationships between threshold change at0.2 ms and SDTC at all target level for both motor and sensory (R2 (motor) 10%: 0.68, 20%: 0.47, 40%: 0.50, 60%: 0.65, R2 (sensory) 10%: 0.76, 20%: 0.71, 40%: 0.80, 60%: 0.70).ConclusionsThis study provides a comprehensive assessment of Nap current in motor and sensory axons of differing target levels. SDTC was inversely correlated with target level, however threshold change at 0.2 ms was not, suggesting that differences in SDTC between different populations of axons are not fully explained by changes in Nap current.



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Peripheral neuropathies and the vestibular system: Is there a role for vestibular rehabilitation?

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Eleftherios S. Papathanasiou




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11. Studying human neurophysiology using the mouse tail!

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): James Howells, Preet G.S. Makker, Justin G. Lees, José M. Matamala, Susanna B. Park, Matthew C. Kiernan, David Burke, Gila Moalem-Taylor
IntroductionNon-invasive threshold-tracking techniques have been used in vivo to probe the biophysical basis of many neuromuscular conditions in human subjects. However, there are ethical and practical limitations to the study of human subjects, and mouse models provide an alternative and complementary path. Transgenic mouse models and the use of mice during drug development make them attractive targets for axonal excitability studies.AimsThe objective of this study was to develop a mouse model that would allow the valid comparison of the excitability of both motor and sensory axons in mice to that of humans.MethodsAxonal excitability studies were performed in mice by stimulating at the base of the tail using non-polarisable Ag/AgCl ring electrodes and recording CMAP and SNAP responses distally using platinum needle electrodes. The results were compared to human studies, and a mathematical model of the excitability of mouse axons was developed.ResultsForty-nine threshold-tracking studies were performed in mice aged 16–20 weeks with no adverse outcomes (30 M/19F). The excitability waveforms of mice were qualitatively similar to those recorded from human median nerve at the wrist. Mathematical modelling suggested that mouse and human axons are structurally similar, and that the differences are due to smaller Na+, larger fast K+, smaller slow K+ and larger hyperpolarization-activated currents.ConclusionsMotor and sensory excitability studies are readily achievable in mature mice. The results and modelling suggest that, while there are quantitative differences in mouse and human axons, structurally the same channels and morphology underlie their excitability. As is the case in human studies on median nerve at the wrist, the mouse tail provides a valid model of axonal excitability, and this allows the assessment of motor and sensory function. This technique and the mathematical model should be useful for translational studies.



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Sensorimotor integration is problematic in amyotrophic lateral sclerosis

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Michael Swash




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06-Diagnostic substantiation and current possibilities of VEPS examination

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): M. Kuba, J. Kremláček, Z. Kubová, J. Szanyi, J. Langrová, F. Vít
The aim of this introductory lecture is to point out that despite the intensive use of modern imagine techniques (MRI, OCT, etc.), the diagnostic applications of visual evoked potentials (VEPs) need not be obsolete, if not preferable in many cases. This objective, fully non-invasive, low-cost electrophysiological method can detect functional problems of the optic pathway and various brain cortical areas even before a development of the first displayable morphological changes.For the increased sensitivity of VEPs, it is necessary to use a larger spectrum of visual stimuli (activating quite selectively different subsystems of the visual pathway and visual cortex) compared to standards recommended by ISCEV or IFCN. It should include not only flash or pattern-related stimuli (pattern-reversal, pattern-on/off) but also motion-related (motion-onset VEPs) and cognitive visual stimulation. Then, not only the early diagnostics of a large spectrum of neuro-ophthalmological and neuro-psychiatric disorders is possible but also the physiological aging of visual information processing or a drug abuse is recognisable.For a better availability of VEPs examination and their long-term monitoring also in home conditions, we have just introduced a "Mobile (wearable), low-cost device for examination of visual evoked potentials (VEPs)", the use of which will be demonstrated during the lecture.Acknowledgements: Supported by the project of Charles University "Progres Q40/07".



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Paradigms for restoration of somatosensory feedback via stimulation of the peripheral nervous system

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Cristian Pasluosta, Patrick Kiele, Thomas Stieglitz
The somatosensory system contributes substantially to the integration of multiple sensor modalities into perception. Tactile sensations, proprioception and even temperature perception are integrated to perceive embodiment of our limbs. Damage of somatosensory networks can severely affect the execution of daily life activities. Peripheral injuries are optimally corrected via direct interfacing of the peripheral nerves. Recent advances in implantable devices, stimulation paradigms, and biomimetic sensors enabled the restoration of natural sensations after amputation of the limb. The refinement of stimulation patterns to deliver natural feedback that can be interpreted intuitively such to prescind from long-learning sessions is crucial to function restoration. For this review, we collected state-of-the-art knowledge on the evolution of stimulation paradigms from single fiber stimulation to the eliciting of multisensory sensations. Data from the literature are structured into six sections: (a) physiology of the somatosensory system; (b) stimulation of single fibers; (c) restoral of multisensory percepts; (d) closure of the control loop in hand prostheses; (e) sensory restoration and the sense of embodiment, and (f) methodologies to assess stimulation outcomes. Full functional recovery demands further research on multisensory integration and brain plasticity, which will bring new paradigms for intuitive sensory feedback in the next generation of limb prostheses.



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Editorial Board

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4





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5. Neurophysiological dysfunction in chemotherapy-treated patients: Comparison of different platinum analogues

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Hannah C. Timmins, Tiffany Li, Peter Grimison, Jenna E. Murray, Keith M. Cox, Lisa G. Horvath, Craig R. Lewis, David Goldstein, Matthew C. Kiernan, Susanna B. Park
ObjectiveChemotherapy-induced peripheral neuropathy is a prominent side effect of treatment with platinum-based chemotherapies cisplatin and oxaliplatin. Progressive abnormalities in sensory axonal excitability have been linked to neuropathy severity in oxaliplatin-treated patients, but not examined in cisplatin-treated patients.MethodsSensory axonal excitability studies were undertaken in median nerve. Neuropathy was assessed via total neuropathy score reduced (TNSr).ResultsClinical severity of neuropathy was greater (TNSr: 6.9 ± 1.2) in oxaliplatin-treated patients (N = 16, Age: 57.1 ± 3 years, cumulative dose: 801 ± 63.5 mg/m2, median 6 months post-completion IQR: 4–12.5) than in cisplatin-treated patients (TNSr: 3.2 ± 0.6, p<.01, N = 17, Age: 48.5 ± 4.3 years, cumulative dose: 316.5 ± 19.3 mg/m2, median 7 months post-completion IQR: 3–30.5). Cisplatin and oxaliplatin-treated patients demonstrated deficits in sensory nerve function compared to controls, with increased threshold change in excitability (TEh90-100 ms Cis: −128.7 ± 4.7%; Ox: −140.9 ± 5.9%; control: −116.6 ± 3.1%, p<.01) and reduced median sensory amplitudes (Cis: 24.4 ± 3.0 μV; Ox: 15.7 ± 3.0 μV; control: 43.9 ± 1.1 μV, p<.01) with greater abnormalities in oxaliplatin-treated patients (p<.01). TEh90-100 ms was correlated to median amplitude (r = .418, p<.05), with patients demonstrating greater excitability abnormalities also demonstrating greater reduction in sensory amplitude.ConclusionsChanges in axonal excitability parameters are consistent between platinum-based chemotherapies and linked to neuropathy severity.SignificancePlatinum analogues demonstrate similar pathophysiological mechanisms of nerve dysfunction. Axonal excitability techniques may provide a marker of axonal dysfunction across different platinum chemotherapies.



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9. Upper motor neuron dysfunction and neuropsychological profile in PLS: Another entrant on the ALS-FTD spectrum

Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Smriti Agarwal, Elizabeth Highton-Williamson, Jose M. Matamala, Jashelle Caga, James Howells, Steve Vucic, Rebekah M. Ahmed, Matthew C. Kiernan
BackgroundPrimary lateral sclerosis (PLS), a rare upper motor neuron disorder, remains a debated entity as an upper motor neuron extreme form of amyotrophic lateral sclerosis (ALS) or a distinct disease. It is now well established that ALS and frontotemporal dementia (FTD) lie on two ends of the frontal neurodegenerative spectrum. While early descriptions of PLS excluded cognitive dysfunction, there is accumulating evidence of varying degrees of frontal lobe deficits accompanying structural and functional changes in the brain in PLS.MethodologyThis study examined the neurophysiological features using transcranial magnetic stimulation (TMS) and neuropsychological profile in a cohort of patients (n = 21) with PLS. Clinical, neuropsychological and TMS findings in PLS patients were compared with two distinct cohorts of patients who had pure ALS (n = 27) and ALSFTD (n = 12). Multivariable regression analysis was used to examine independent predictors of global cognitive function on the Addenbrooke's cognitive examination (ACE) score and motor disability on the ALS functional rating scale (ALSFRS). Kaplan Meier curves were used to determine survival times for the three groups.ResultsMean age in PLS was 60.9 ± 10.4, 47.6% of patients were males and 95% had limb onset disease. The mean survival time was longest in PLS (217.43 ± 22.4 months) and shortest in ALSFTD (38.54 ± 4.5 months). In addition to prominent upper motor neuron (UMN) dysfunction, ACE score was impaired in PLS (mean total ACE score 82.5 ± 13.6), lying intermediately between pure ALS (mean total ACE score 93.4 ± 3.9) and ALSFTD (mean total ACE score 76.3 ± 7.7). Behavioural impairments were not prominent in PLS as indicated by a higher total Motor Neuron Disease Behaviour (MiND-B) score than ALSFTD (PLS 32.1 ± 5.6, ALSFTD 22.4 ± 6.8, p = 0.005). In terms of cortical function, resting motor threshold (RMT) was significantly higher in PLS (93.2 ± 11.7, p < 0.001), indicating lower corticospinal neuronal membrane excitability, compared to ALSFTD (54.2 ± 15.9) and ALS (63.7 ± 14.3). Average short interval intracortical inhibition (SICI) was low in PLS (2.7 ± 11.1), similar to ALS and ALSFTD, while average intracortical facilitation (ICF) was significantly lower, both indicating dysfunction of inhibitory interneurons, in PLS (−10.1 ± 9.1, p = 0.002) compared to ALSFTD (0.38 ± 14.2) and ALS (−0.71 + 6.8). The proportion of patients with a relatively inexcitable cortex was significantly higher in PLS (65%,p < 0.001) compared to ALSFTD (8.3%) and ALS (3.7%) patients.RMT predicted higher global cognition score on the ACE (β = 0.57, p = 0.001), independent of motor progression and clinical upper motor neuron dysfunction. Average SICI predicted motor disability (β = 0.5, p = 0.008), on the ALS functional rating scale (ALSFRS), independent of disease duration and upper motor neuron score across the three groups.ConclusionsThere is a distinctive cognitive profile in PLS which resembles ALSFTD, without the behavioural disturbances typical of the FTD spectrum disorders. Cortical motor neuronal hyperexcitability was associated with poorer global cognitive function, independent of motor disease progression, while dysfunction of inhibitory interneuronal circuits predicted motor disability, across ALS, ALSFTD and PLS. Overall, these findings make a strong case for PLS being on the ALS FTD spectrum and suggest that cortical excitability contributes to neuropsychological and motor dysfunction by distinct pathophysiological mechanisms.



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13. Threshold-tracking TMS without an MEP

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): James Howells, Terry Trinh, David Burke, Matthew C. Kiernan
IntroductionTranscranial magnetic stimulation (TMS) is a useful tool for quantifying cortical hyperexcitability in ALS. Short-interval intracortical inhibition (SICI) measures the suppression of descending corticomotoneuronal volleys by GABA-ergic inhibitory interneurons. Threshold-tracking TMS (tt-TMS) studies were developed to overcome the marked variability of motor evoked potentials (MEPs); tt-TMS "tracks" the stimulus intensity required to just evoke a small target MEP. Despite the success of studies using the tt-TMS technique, fasciculations can complicate recordings.AimsTo explore the feasibility of using an accelerometer for the measurement of resting motor threshold (RMT), short interval intracortical inhibition (SICI) and intracortical facilitation (ICF).MethodsResting motor threshold (RMT), SICI and intracortical facilitation (ICF) were measured in 6 subjects (3M: 3F) using an accelerometer and compared to results recorded with a MEP. The MEP output was recorded over the thenar eminence and amplified (x1k, 2 Hz to 2 kHz) using a purpose-built amplifier. A natus reusable tremor sensory (6.3 mV/g) was fixed to the distal phalanx of digit 1, and its output was amplified with the same amplifier and settings. For both studies an output of 200 μV was used as the target output measure. RMT in threshold-tracking studies is the magnetic stimulus intensity required to elicit the target MEP (or acceleration). SICI and ICF are measured using a pair of magnetic stimuli with the first stimulus subthreshold (70% of RMT) and the second stimulus tracking the target response. SICI was measured between 1 and 7 ms and ICF between 10 and 30 ms.ResultsA low threshold twitch was easily distinguished using an accelerometer, and was fairly insensitive to the orientation of the accelerometer on the thumb. RMT measured using the accelerometer was 56.5 ± 2.3% and 61.2 ± 2.1% for the MEP, though this was not statistically significant (p = 0.14). Similarly, average SICI (1–7 ms) was lower (11.2 ± 5.0%) when recorded using the accelerometer and 16.8 ± 6.1% for the MEP (p = 0.20). Average ICF(10–30 ms) recorded using the accelerometer was −2.2 ± 3.1% and for MEP 4.7 ± 1.0 (p = 0.02).ConclusionThis pilot study shows that an accelerometer provides an easy to use alternative to MEPs for tt-TMS studies. This may be particularly useful early in MND when fasciculations are common and the diagnostic utility of tt-TMS is most beneficial.



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04-Local synchrony in EEG as a marker of epileptogenic zone

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): R. Mareček, M. Lamoš, M. Mikl, I. Rektor
Approximately a 1/3 of epileptic patients suffer from pharmacoresistant epilepsy. The surgery is often the only possible treatment, which brings a need for finding epileptogenic zone. The task is intricate in non-lesional patients in whom magnetic resonance imaging is uninformative. Our goal is to find a set of non-invasive imaging methods that would find the epileptogenic zone. We show first results with Local Synchrony (LS) method, that evaluates functional connectivity between cortical areas in short distances.We acquired high-density electroencephalography (HD-EEG) data from a set of 25 healthy control subjects (HC) and from a set of epileptic patients. We computed the Corrected Imaginary Coherence (CIC) in source space among all possible pairs of adjacent solution points. The CIC image from each patient was compared with the HC images to reveal regions with increased LS.We performed the analysis for 5 patients. In one patient, the revealed regions matched the neurologist's opinion based on clinical evaluation. In others, increased LS showed regions that might be potential candidates for epileptogenic zone according to clinical evaluation.The evaluation of LS seems to be a useful method that might bring valuable information in the stage of finding the epileptogenic zone in epilepsy patients.AcknowledgementThis study was supported by the project 17-32292A of the Czech Health Research Council and We also acknowledge the core facility MAFIL of CEITEC supported by the Czech-BioImaging large RI project (LM2015062 funded by MEYS CR).



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08-Development of cortical evoked potentials and epileptic after discharges in rats

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): P. Mareš
Cortical interhemispheric responses in rats may serve as an index of maturation. The first two waves monosynaptically elicited by callosal fibres can be reliably evoked since the postnatal day (PD) five. The latency and duration of these evoked potentials markedly shorten after PD7. Paired-pulse stimulations demonstrate fatiguability of immature cortex; potentiation of the second response takes place since the third week. Frequency potentiation appears in the fourth postnatal week.Epileptic afterdischarges (ADs) can be elicited by low-frequency rhythmic stimulation since PD9. Their duration is longest at PD12, then it shortens. If stimulation is repeated, adult animals exhibit postictal refractoriness, i.e. an inability to elicit the second AD. This refractoriness lasting up to 3 min appeared in the fourth postnatal week, animals at PD12 and 15 exhibit marked postictal potentiation – the second, testing AD is significantly longer than the first conditioning AD.The results demonstrate that electrical stimulation induces a purely cortical phenomenon (interhemispheric responses) earlier than the complex cortico-thalamo-cortical epileptic AD. Paired stimulations demonstrate that potentiation appeared earlier in epileptic ADs than in more simple cortical evoked potentials.This study was supported by US-Czech collaborative grants No. LH11015 and LH15032 and a project of Czech Academy of Sciences No. RVO 67985823.



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12-Distinct between-network functional connectivity changes in Parkinson’s disease related to cognition: A follow-up study

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): P. Klobusiakova, R. Marecek, I. Rektorova
IntroductionPatients with Parkinson's disease (PD) show abnormal functional connectivity in large-scale brain networks. We explored resting state connectivity among the main networks, including the default mode network (DMN), dorsal attentional network (DAN), frontoparietal control network (FPCN) and visual network (VN) in PD patients with and without cognitive impairment (PD-MCI and PD-NC).Methods51 healthy controls (HC), 17 PD-NC and 24 PD-MCI were enrolled. Participants underwent cognitive testing and MRI examination at the baseline and at one year follow-up. Resting-state fMRI data were analysed and the inter-network connectivity was calculated between the FPCN and other networks. Spearman correlations with attention and executive domain z-scores were calculated.ResultsFPCN-DAN, FPCN-VN and FPCN-DMN connectivities were significantly reduced in PD-NC as compared to HC. The connectivities decreased in the order HC > PD-MCI > PD-NC. At one-year follow-up, significant increases in FPCN-VN and FPCN-DMN connectivities were observed in the merged PD group, while no changes were detectable in the HC group.ConclusionDecreased connectivity between the FPCN and other networks was observed already in PD-NC. PD-MCI tend to compensate for their cognitive deficit by increasing between-network connectivities. Moreover, the between-network connectivities were increased at the follow-up in the PD-all group, while no changes were found in HC.Acknowledgement:Supported by the EU Joint Programming initiative within Neurodegenerative Diseases, funded by the Norwegian Strategic Research Council (APGeM—Preclinical genotype-phenotype predictors of Alzheimer's disease and other dementias, grant agreement number 3056-00001). We acknowledge also the core facility MAFIL of CEITEC supported by the MEYS CR (LM2015062 Czech-BioImaging).



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2. Craniopharyngioma presenting as bilateral carpal tunnel syndrome

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): P. Joshi, I. Rosemergy
A 35 year-old Caucasian information technology professional developed bilateral hand paraesthesia, increasing in severity over two months. He reported recent onset photophobia. He was obese with a weight of 138 kg and body mass index of 47.5 kg/m2. Visual acuity was 6/6 on the right and 6/18 on the left. Visual fields were normal to confrontation. There was no relative afferent pupillary defect and optic discs were normal. There was mild weakness of abductor pollicis brevis and mild sensory disturbance affecting his fingers in the median distribution bilaterally. Phalen's test was positive. The remaining neurological examination was normal. Nerve conduction studies showed bilaterally prolonged median distal motor latencies (6.5 ms on left, 6.9 ms on right), bilaterally absent sensory potentials at digit two, and prolonged median lumbrical motor latencies compared to the ulnar interosseus, consistent with severe carpal tunnel syndrome (CTS).Blood tests performed in view of the rapid onset of symptoms showed normal haemoglobin A1c and vitamin B12 levels. Thyroid function tests showed a low thyroxine of 3.4 pmol/L (normal range 10–21) and inappropriately normal thyroid stimulating hormone of 3.3 mIU/L (normal range 0.4–4.0), suggestive of secondary hypothyroidism. Further pituitary function tests confirmed panhypopituitarism. MRI brain showed a suprasellar cystic mass with an enhancing wall, suggestive of a craniopharyngioma. Visual field testing was consistent with compression of the optic chiasm. The patient was started on hydrocortisone and thyroxine and underwent transsphenoidal resection of the tumour. His hand paraesthesia and visual symptoms resolved within two weeks. Repeat nerve conduction studies after five months showed significant electrophysiological improvement.Craniopharyngiomas are cystic suprasellar tumours arising from remnants of the craniopharyngeal duct (Levy, 2004). They commonly present with headache, visual field defects, panhypopituitarism and hypothalamic dysfunction resulting in obesity and somnolence. CTS has not previously been reported in this context. There is a modest association between hypothyroidism and CTS (Shiri, 2014). A combination of hypothyroidism and obesity likely predisposed this patient to CTS. Routine screening for thyroid disease is not recommended in patients with CTS due to low yield.



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4. Median/ulnar nerve ultrasound cross-sectional area ratio in ALS

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Publication date: April 2018
Source:Clinical Neurophysiology, Volume 129, Issue 4
Author(s): Jun Tsugawa, Yu-ichi Noto, Thanuja Dharmadasa, Nidhi Garg, Matthew C. Kiernan
BackgroundIt has been shown that hand muscle wasting in amyotrophic lateral sclerosis (ALS) preferentially affects the thenar muscles, with relative sparing of the hypothenar muscles. This so-called "split-hand" is clinical sign that can be used to differentiate ALS from mimic disorders, and is thought to be caused by a difference in nerve excitability between median and ulnar nerve. The split-hand phenomenon has been largely discussed in regard to neurophysiological finding, but no studies performed comparing median and ulnar nerve size using ultrasound. We therefore sought to compare nerve size between the median and ulnar nerves in ALS using ultrasound in order to determine whether this may give further insight into the split-hand phenomenon.ObjectiveTo identify whether nerve ultrasound results might reflect the clinical split-hand sign in ALS patients and whether these findings can be used to differentiate ALS from other neuromuscular disorders.MethodsUltrasound was used to image both the median and ulnar nerves of 98 patients with ALS and 82 patients with other neuromuscular disorders (non-ALS). The nerve cross-sectional area (CSA) was measured at the wrist, the forearm, and the upper arm bilaterally. Nerve CSA values and median/ulnar nerve CSA ratios were compared at different locations between the two groups.ResultBoth the median and ulnar nerve CSA values were smaller in the ALS group than in the non-ALS group, except for the median nerve at the wrist. The median/ulnar nerve CSA ratio was comparatively decreased in the upper arm segment. There was a significant difference between the two groups at the wrist on the left side and at upper arm on the right side (Left wrist (IQR) ALS: 2.00 (1.67,2.33) vs non-ALS: 1.63 (1.35,2.18) p = 0.003, Right upper arm (IQR) ALS: 1.29 (1.12,1.50) vs non-ALS: 1.37 (1.16,1.69) p = 0.003).ConclusionWe observed that the median/ulnar nerve CSA ratio was decreased in ALS patient at the upper arm segment. Overall, these findings suggest that there is preferential involvement of the median nerve compared to the ulnar nerve in ALS, which is consistent with the clinical findings of the split hand in these patients. This adds further support to the involvement of peripheral mechanisms underlying this phenomenon. Therefore, ultrasound may be a useful non-invasive tool to objectively detecting changes. Further studies assessing cortical contribution to the clinical and ultrasound findings are warranted to elucidate this pathology further.



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Epidemiology of general anesthesia prior to age 3 in a population-based birth cohort

Summary

Background

Utilization of general anesthesia in children has important policy, economic, and healthcare delivery implications, yet there is little information regarding the epidemiology of these procedures in the United States.

Aims

The primary objective of this study was to describe in a geographically defined population the incidence of procedures requiring general anesthesia up to the child's third birthday, and the patient characteristics associated with receiving these procedures. A secondary objective was to determine the proportion of children in the population who meet the risk criteria promulgated by the Food and Drug Administration (FDA).

Methods

A retrospective cohort of children born from 1994 to 2007 in Olmsted County, MN was established. Birth certificate information and receipt of general anesthesia before age 3 were collected. Proportional hazard regressions were performed to evaluate the association between characteristics of children and incidence of general anesthesia.

Results

Among the 20 922 children in the cohort, 3120 (14.9%) underwent at least 1 general anesthesia before age 3. In multivariate regression, factors independently associated with receiving at least 1 procedure included prematurity, male sex, lower birth weight, cesarean delivery, a non-Hispanic mother, and a White mother, controlling for multiple gestation, number of children previously born, age, education, and marital status of the mother. Seven hundred and twenty-three children (3.5%) had at least 1 subsequent procedure. Estimated gestational age <32 weeks and low birth weight were independently associated with receiving repeated anesthesia. Eight hundred and twenty children (3.9%) had a single prolonged exposure above 3 hours, multiple exposures prior to age 3, or both.

Conclusion

Approximately 1 in 7 children were exposed to at least 1 episode of general anesthesia before age 3, and approximately 1 in 4 children who received general anesthesia fall within the high-risk category as defined by the recent FDA warning. The apparent disparities in surgical utilization related to race and ethnicity in this study population deserve further exploration.



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Corrigendum



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Nil Per Os Consideration for Emergency Procedures: Cornerstone of Safety or an Obstacle to Patient Care?

No abstract available

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Patients at High Risk for Obstructive Sleep Apnea Are at Increased Risk for Atrial Fibrillation After Cardiac Surgery: A Cohort Analysis

BACKGROUND: Patients with obstructive sleep apnea (OSA) experience intermittent hypoxia, hypercarbia, and sympathetic activation during sleep, which increases risk for paroxysmal atrial fibrillation and other cardiac arrhythmias. Whether patients with OSA experience increased episodes of atrial fibrillation after cardiac surgery is unclear. We examined whether patients at increased risk for OSA, assessed by the STOP-BANG (snoring, tired during the day, observed stop breathing during sleep, high blood pressure, body mass index more than 35 kg/m2, age more than 50 years, neck circumference more than 40 cm, and male gender) questionnaire, had a higher incidence of new-onset postoperative atrial fibrillation after cardiac surgery. Because both postoperative atrial fibrillation and OSA increase resource utilization, we secondarily examined whether patients at increased OSA risk had longer duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay. METHODS: With institutional review board approval, this retrospective observational study evaluated adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass between 2014 and 2015 with preoperative assessment of OSA risk using the STOP-BANG questionnaire. Patients with a history of atrial fibrillation were excluded. The association between the STOP-BANG score and postoperative atrial fibrillation was examined using a multivariable logistic regression model. Secondarily, we estimated the association between the STOP-BANG score and duration of initial intubation using multivariable linear regression and ICU length of stay using Cox proportional hazards regression. We also descriptively summarized the percentage of patients requiring tracheal reintubation for mechanical ventilation. RESULTS: Of 4228 cardiac surgery patients, 1593 met inclusion and exclusion criteria. An increased STOP-BANG score was associated with higher odds of postoperative atrial fibrillation (odds ratio [95% confidence interval {CI}], 1.16 [1.09–1.23] per-point increase in the STOP-BANG score; P

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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Use of Survey and Delphi Process to Understand Trauma Anesthesia Care Practices

BACKGROUND: Few trauma guidelines evaluate and recommend anesthesiology practices and there are no trauma anesthesia-specific guidelines. There is no information on how anesthesiologists perceive clinical practice patterns. Our objective was to understand the perceptions of anesthesiologists regarding trauma anesthesia practices. METHODS: A survey assessing anesthesia management of trauma patients was distributed to 21,491 anesthesiologists. A subset of 10 of these questions was subsequently reviewed by a trauma anesthesiology focus group through a 3-round web-based Delphi process. A question was deemed to have respondent consensus if the response with the highest percentage of agreement was unchanged between rounds 1 and 2. RESULTS: A total of 2360 anesthesiologists (11% response rate) responded to the survey. Results demonstrated that the practitioners' answers conflicted with existing surgical trauma society recommendations (ie, when to transfuse component therapy), and several areas that lacked any guidelines, resulted in response variability among anesthesiologists where not 1 answer achieved >75% agreement (ie, intubation technique of choice for patients with uncleared cervical spine). Thirteen trauma anesthesiologists participated in round 1 (response rate 100%), and 12 responded in rounds 2 and 3 (response rate 92%) of the Delphi process. None of the questions received 100% agreement. Consensus was achieved on 9 of 10 statements pertaining to trauma anesthesia care. Consensus was not reached on the intubating technique in a hemodynamically unstable patient with an uncleared cervical spine with deficits. Delphi participant opinion conflicted with existing guidelines on 2 statements: the use of cricoid pressure, and when to begin blood component therapy. CONCLUSIONS: There are several important areas of trauma anesthesia practice where guidelines do not exist and several where existing guidelines are not endorsed by the majority of practitioners who completed our survey. The lack of consensus on trauma anesthesia management and the variation in survey responses demonstrate a need to develop evidence-based trauma anesthesia guidelines. Accepted for publication December 20, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Catherine M. Kuza, MD, Department of Anesthesiology, Keck School of Medicine of USC, 1520 San Pablo St, Suite 3451, Los Angeles, CA 90033. Address e-mail to catherine.kuza@med.usc.edu. © 2018 International Anesthesia Research Society

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The Effectiveness of Applying Soft Tissue Bonding Adhesive Composed of 2-Ethyl Cyanoacrylate to Epidural Catheter Fixations Using Film Dressings: An Open-Label, Randomized, Parallel-Group Comparative Study

BACKGROUND: Insufficient fixation of an epidural catheter may result in migration of the catheter and eventual catheter failure. However, the best fixation method remains to be established. Aron Alpha A (2-ethyl cyanoacrylate) adhesive is approved for clinical use and can be used for surgical adhesion to both skin and blood vessels. We hypothesized that the addition of Aron Alpha A adhesive to film dressing would result in consistent and dependable catheter fixation. METHODS: In this study, 58 women who were scheduled for cesarean delivery under spinal and epidural anesthesia were recruited. Patients were randomly assigned to a control or treatment group. In the control group, the catheter was fixed solely by film dressing. In the treatment group, a small amount of Aron Alpha A was applied at 2 sites along the catheter. The fixation area was then covered by film dressing. The catheter insertion length was recorded after fixation (T0), immediately postoperatively (T1), on postoperative day 1 (T2), and when the catheter was removed (T3). The change in insertion length from T0 to T3 between the 2 groups was the primary outcome measure. The incidence of catheter failure was also recorded. For all comparisons, P

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The Anesthesiologist-Informatician: A Survey of Physicians Board-Certified in Both Anesthesiology and Clinical Informatics

All 36 physicians board-certified in both anesthesiology and clinical informatics as of January 1, 2016, were surveyed via e-mail, with 26 responding. Although most (25/26) generally expressed satisfaction with the clinical informatics boards, and view informatics expertise as important to anesthesiology, most (24/26) thought it unlikely or highly unlikely that substantial numbers of anesthesiology residents would pursue clinical informatics fellowships. Anesthesiologists wishing to qualify for the clinical informatics board examination under the practice pathway need to devote a substantive amount of worktime to informatics. There currently are options outside of formal fellowship training to acquire the knowledge to pass. Accepted for publication January 29, 2018. Funding: Departmental. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). This study was presented in part at the Annual Meeting of the American Society of Anesthesiologists, Chicago, IL, October 22–26, 2016 (Abstract 16A3714ASAHQ). Reprints will not be available from the authors. Address correspondence to Richard H. Epstein, MD, Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami, 1400 NW 12th Ave, Suite 3075, Miami, FL 33136. Address e-mail to repstein@med.Miami.edu. © 2018 International Anesthesia Research Society

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Hypothermia During Cesarean Delivery

No abstract available

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In Response

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Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial

BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55–4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26–3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89–6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability. Accepted for publication December 22, 2017. Funding: This study was supported by the Australian National Health and Medical Research Council; Australian and New Zealand College of Anaesthetists; Heart and Stroke Foundation of Quebec; Heart and Stroke Foundation of Ontario, Canada; and General Research Fund of the Research Grant Council, Hong Kong Special Administrative Region, China. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Trial Registration: ClinicalTrials.gov (NCT00430989). ANZCA Clinical Trials Network for the ENIGMA-II investigators is listed in Appendix. Reprints will not be available from the authors. Address correspondence to W. Scott Beattie, MD, PhD, FRCPC, Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada; and Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada, 200 Elizabeth St, Eaton 3-402, Toronto, Ontario M5G 2C4. Address e-mail to scott.beattie@uhn.ca. © 2018 International Anesthesia Research Society

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