Pre-habilitation before colorectal cancer surgery could improve postoperative gastrointestinal function recovery: a case-matched study.

PURPOSE: While its effect is controverted, multimodal pre-habilitation could be used to improve the postoperative course following colorectal cancer surgery. However, by increasing lean body mass, pre-habilitation could reduce the time needed to recover gastrointestinal (GI) functions. The aim was to assess the impact of pre-habilitation before colorectal cancer surgery on postoperative GI motility recovery. METHODS: This is a matched retrospective study based on a prospective database including patients undergoing colorectal surgery without pre-habilitation (NPH) (2016-2018) and with pre-habilitation (PH group) (2018-2019). The main outcome measure was the time to GI-3 recovery (tolerance to solid food and flatus and/or stools). RESULTS: One hundred thirteen patients were included, 37 underwent pre-habilitation (32.7%). The patient's age, the surgical procedure, the surgical access, the rate of synchronous metastasis, the rate of preoperative chemoradiotherapy, and the rate of stoma were more important in the PH group. Conversely, the rate of patients with an ASA score of > 2 was higher in the NPH group. By matching patients according to age, gender and surgical procedure, 84 patients were compared (61 in the NPH group and 23 in the PH group). The mean of GI-3 recovery was significantly lower in the PH group. The other endpoints were not significantly different but time to GI function recovery and medical morbidity tended to be higher in the NPH group. Compliance with the enhanced recovery program was significantly higher in the PH group. CONCLUSION: Pre-habilitation before colorectal cancer surgery reduced time to GI function recovery and may increase compliance with the enhanced recovery program.

Patch-based 3D U-Net and transfer learning for longitudinal piglet brain segmentation on MRI.

BACKGROUND AND OBJECTIVES: In order to study neural plasticity in immature brain following early brain lesion, large animal model are needed. Because of its morphological similarities with the human developmental brain, piglet is a suitable but little used one. Its study from Magnetic Resonance Imaging (MRI) requires the development of automatic algorithms for the segmentation of the different structures and tissues. A crucial preliminary step consists in automatically segmenting the brain. METHODS: We propose a fully automatic brain segmentation method applied to piglets by combining a 3D patch-based U-Net and a post-processing pipeline for spatial regularization and elimination of false positives. Our approach also integrates a transfer-learning strategy for managing an automated longitudinal monitoring evaluated for four developmental stages (2, 6, 10 and 18 weeks), facing the issue of MRI changes resulting from the rapid brain development. It is compared to a 2D approach and the Brain Extraction Tool (BET) as well as techniques adapted to other animals (rodents, macaques). The influence of training patches size and distribution is studied as well as the benefits of spatial regularization. RESULTS: Results show that our approach is efficient in terms of average Dice score (0.952) and Hausdorff distance (8.51), outperforming the use of a 2D U-Net (Dice: 0.919, Hausdorff distance: 11.06) and BET (Dice: 0.764, Hausdorff distance: 25.91). The transfer-learning strategy achieves a good performance on older piglets (Dice of 0.934 at 6 weeks, 0.956 at 10 weeks and 0.958 at 18 weeks) compared to a standard training strategy with few data (Dice of 0.636 at 6 weeks, 0.907 at 10 weeks, not calculable at 18 weeks because of too few training piglets). CONCLUSIONS: In conclusion, we provide a method for longitudinal MRI piglet brain segmentation based on 3D U-Net and transfer learning which can be used for future morphometric studies and applied to other animals.

Functional, neuroplastic and biomechanical changes induced by early Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (e-HABIT-ILE) in pre-school children with unilateral cerebral palsy: study protocol of a randomized control trial.

BACKGROUND: Cerebral palsy (CP) causes motor, cognitive and sensory impairment at different extents. Many recent rehabilitation developments (therapies) have focused solely on the upper extremities (UE), although the lower extremities (LE) are commonly affected. Hand-arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) applies the concepts of motor skill learning and intensive training to both the UE and LE. It involves constant stimulation of the UE and LE, for several hours each day over a 2-week period. The effects of HABIT-ILE have never been evaluated in a large sample of young children. Furthermore, understanding of functional, neuroplastic and biomechanical changes in infants with CP is lacking. The aim of this study is to carry out a multi-center randomized controlled trial (RCT) to evaluate the effects of HABIT-ILE in pre-school children with unilateral CP on functional, neuroplastic and biomechanical parameters. METHODS: This multi-center, 3-country study will include 50 pre-school children with CP aged 1-4 years. The RCT will compare the effect of 50 h (two weeks) of HABIT-ILE versus usual motor activity, including regular rehabilitation. HABIT-ILE will be delivered in a day-camp setting, with structured activities and functional tasks that will be continuously progressed in terms of difficulty. Assessments will be performed at 3 intervals: baseline (T0), two weeks later and 3 months later. Primary outcomes will be the Assisting Hand Assessment; secondary outcomes include the Melbourne Assessment-2, executive function assessments, questionnaires ACTIVLIM-CP, Pediatric Evaluation of Disability Inventory, Young Children's Participation and Environment Measure, Measure of the Process of Care, Canadian Occupational Performance Measure, as well as neuroimaging and kinematics measures. DISCUSSION: We expect that HABIT-ILE will induce functional, neuroplastic and biomechanical changes as a result of the intense, activity-based rehabilitation process and these changes will impact the whole developmental curve of each child, improving functional ability, activity and participation in the short-, mid- and long-term. Name of the registry: Changes Induced by Early HABIT-ILE in Pre-school Children With Uni- and Bilateral Cerebral Palsy (EarlyHABIT-ILE). TRIAL REGISTRATION: Trial registration number: NCT04020354-Registration date on the International Clinical Trials Registry Platform (ICTRP): November 20th, 2018; Registration date on NIH Clinical Trials Registry: July 16th, 2019.

Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities.

Pediatric arterial ischemic stroke (AIS) is a severe condition, with long-lasting devastating consequences on motor and cognitive abilities, academic and social inclusion, and global life projects. Awareness about initial symptoms, implementation of pediatric stroke code protocols using MRI first and only and adapted management in the acute phase, individually tailored recanalization treatment strategies, and multidisciplinary rehabilitation programs with specific goal-centered actions are the key elements to improve pediatric AIS management and outcomes. The main cause of pediatric AIS is focal cerebral arteriopathy, a condition with unilateral focal stenosis and time-limited course requiring specific management. Sickle cell disease and moyamoya angiopathy patients need adapted screening and therapeutics.

Adjunct therapies to improve outcomes after botulinum toxin injection in children: A systematic review.

BACKGROUND: Botulinum toxin (BTX) injection alone is not sufficient to treat spasticity in children, notably those with cerebral palsy; thus, there is an emerging trend for adjunct therapies to offer greater outcomes than BTX alone. OBJECTIVE: The aim of this systematic review was to evaluate the general effectiveness of adjunct therapies regardless of their nature in children with spasticity. METHODS: Medline, Cochrane and Embase databases were searched from January 1980 to March 15, 2018 for reports of parallel-group trials (randomized controlled trials [RCTs] and non-RCTs) assessing adjunct therapies after BTX injection for treating spasticity in children. Two independent reviewers extracted data and assessed the risk of bias by using the PEDro scale for RCTs and Downs and Black scale (D&B) for non-RCTs. RESULTS: Overall, 20 articles involving 662 participants met the inclusion criteria. The average quality was good for the 16 RCTs (mean PEDro score 7.4 [SD 1.6]) and poor to moderate for the 4 non-RCTs (D&B score 9 to 17). Adjunct therapies consisted of casting/posture, electrical stimulation, resistance training and rehabilitation programmes. Casting associated with BTX injection improved the range of passive and active motion and reduced spasticity better than did BTX alone (9 studies), with a follow-up of 1 year. Resistance training enhanced the quality and performance of muscles without increasing spasticity. Only 3 rehabilitation programmes were studied, with encouraging results for activities. CONCLUSION: Lower-limb posture with casting in children has a high level of evidence, but the long-term efficacy of short-leg casting needs to be evaluated. A comparison between the different modalities of casting is missing, and studies specifically devoted to testing the different kinds of casting are needed. Moreover, the delay to casting after BTX injection is not clear. Data on electrical stimulation are not conclusive. Despite the small number of studies, resistance training could be an interesting adjunct therapy notably to avoid loss of strength after BTX injection. Rehabilitation programmes after BTX injection still need to be evaluated.

Global Perturbation of Initial Geometry in a Biomechanical Model of Cortical Morphogenesis.

Cortical folding pattern is a main characteristic of the geometry of the human brain which is formed by gyri (ridges) and sulci (grooves). Several biological hypotheses have suggested different mechanisms that attempt to explain the development of cortical folding and its abnormal evolutions. Based on these hypotheses, biomechanical models of cortical folding have been proposed. In this work, we compare biomechanical simulations for several initial conditions by using an adaptive spherical parameterization approach. Our approach allows us to study and explore one of the most potential sources of reproducible cortical folding pattern: the specification of initial geometry of the brain.

Laparoscopic adjustable gastric banding in adolescents with severe obesity: Psychological aspects, decision makers of surgery, and 2-year outcomes. A case series.

BACKGROUND: The results of medical treatment of severe obesity in the adolescent population (balanced diet and physical activity) are often unsatisfactory, and bariatric surgery is questioned. The psychological determinants for requesting bariatric surgery in these adolescents are unclear. The objective of this study was to report the psychiatric and psychological aspects as well as the determinants of the medical decision for surgery in a cohort of obese adolescents requesting bariatric surgery by laparoscopic adjustable gastric banding. METHODS: Thirty-five adolescents (12.3-17.7 years of age), were recruited from January 2007 to December 2012. Semistructured interviews were conducted. RESULTS: Fifty-four percent of the adolescents had a psychiatric history and 85% had psychiatric comorbidities. In adolescents undergoing surgery, excess weight loss was 46% after 1 year and 51% after 2years. For patients not receiving surgery, excess weight loss was 0.43% after 1 year (P=0.001). Compliance with medical treatment was the only significant element contributing to the decision to perform surgery. Results in terms of satisfaction and perception 1 and 2years after surgery were encouraging. CONCLUSION: Bariatric surgery is feasible in young patients and produces good results in terms of excess weight loss. We argue that compliance with medical treatment is probably one of the most important elements for making the decision to perform bariatric surgery and in excess weight loss after surgery. We probably need to focus on the compliance of young patients and evaluate how this can be improved.

Vitamin D and the Mechanisms, Circumstances and Consequences of Falls in Older Adults: A Case-Control Study.

OBJECTIVES: To determine i) whether cases of elderly fallers had lower serum 25-hydroxyvitamin D (25OHD) concentration than controls without history of falls; and ii) whether serum 25OHD concentration was associated with specific mechanisms, circumstances and consequences of falls. DESIGN: Case-control study with a 1:2 ratio. SETTING: Geriatric ward of the University Hospital of Angers, France, between February 2012 and March 2014. PARTICIPANTS: 216 inpatients (72 cases and 144 age- and gender-matched controls). MEASUREMENT: Falls were defined as involuntary events causing the person to the ground or other lower level. The main mechanisms, circumstances and consequences of falls were identified using standardized questionnaires. Vitamin D deficiency was defined as serum 25OHD concentration ≤25nmol/L. Age, gender, body mass index, polypharmacy, use antihypertensive drugs, use psychoactive drugs, disability, cognitive performance, serum concentrations of parathyroid hormone, creatinine and albumin, and season of evaluation were used as potential confounders. RESULTS: 216 participants (72 cases and 144 controls) were included in the study. There was no between-group difference in the prevalence of vitamin D deficiency (P=0.176). After adjusting for confounding factors, vitamin D deficiency was positively associated with falls (OR=4.03, P=0.014). Finally, the fallers with vitamin D deficiency exhibited more often orthostatic hypotension (68.8% against 33.3%, P=0.039) and a history of recurrent falls (85% against 50%, P=0.002) than those without vitamin D deficiency. CONCLUSION: This case-control study reported that vitamin D deficiency was associated with falls in older inpatients. There was a greater prevalence of orthostatic hypotension and of the reccurrence of falls among fallers with vitamin D deficiency, suggesting that vitamin D may influence the conditions predisposing to falls rather than the fall by itself.

[Long term outcome of perinatal stroke]. / Devenir neurodéveloppemental après un infarctus cérébral artériel néonatal.

Neonatal Arterial Ischemic Stroke (NAIS) affects 6-17 newborns on 100 000-birth term neonates, most of these children keeping long-term motor and cognitive impairments. Based on a literature review, the objectives of this paper are to describe motor and cognitive outcomes after a NAIS and to propose a consensual monitoring of these children to improve their management. About 30 % of children after a NAIS will develop a unilateral cerebral palsy requiring a management by a team with expertise in physical medicine and rehabilitation. Unlike adults, especially after a left NAIS, children will not present aphasia but between 50 and 90 % will present disorders of speech and language in expression and/or reception. After NAIS, the global intellectual efficiency is usually preserved except when the size of the lesion is very important or when severe epilepsy occurs. Several studies are also in favor of vulnerability in visuospatial functions. To quantify impairments, activity limitations and participation restrictions resulting from this NAIS, early and at least yearly evaluations with reliable tools must be carried out systematically until puberty. A multidisciplinary team with a longitudinal follow-up, in all the different developmental dimensions, must conduct these evaluations in term of motor skills, cognitive impairment, behavior, autonomy, quality of life, and participation. Consequences on family functioning need to be evaluate in order to help children and family coping with this event.

[Brain plasticity and early rehabilitative care for children after neonatal arterial cerebral infarction]. / Plasticité cérébrale et prise en charge rééducative précoce des enfants après infarctus cérébral artériel néonatal.

Currently, in the literature of the evidence based medicine, little data are available to confirm the benefit and the specific procedures of an early intervention for a neonatal arterial ischemic stroke. However, data about the effect of an early physical rehabilitation program on the cerebral plasticity, and preliminary results of clinical studies in children with cerebral palsy strongly suggest the benefit of an early rehabilitation with a multidisciplinary approach. The type of the rehabilitation and its frequency must be determined because a wide variability in the practices exists. A comprehensive care, of the children and his family is necessary to limit the orthopaedics but also the social consequences of a neonatal stroke.

Perspectives in neonatal and childhood arterial ischemic stroke.

INTRODUCTION: Over the last decade considerable advances have been made in the identification, understanding and management of pediatric arterial ischemic stroke. Such increasing knowledge has also brought new perspectives and interrogations in the current acute and rehabilitative care of these patients. Areas covered: In developed countries, focal cerebral arteriopathy is one of the most common causes of arterial ischemic stroke in childhood and imaging features are well characterized. However, there are ongoing debates regarding its underlying mechanisms, natural evolution and proper management. The implementation of thrombolytic therapy in acute pediatric stroke has been shown to be efficient in anecdotal cases but is still limited by a number of caveats, even in large tertiary centers. Finally, neonatal stroke represents a unique circumstance of possible early intervention before the onset of any neurological disability but this appears meaningful only in a selective group of neonates. Expert commentary: While perinatal stroke, a leading cause of cerebral palsy, appears to be multifactorial, a large number of childhood ischemic stroke are probably essentially triggered by infectious factors leading to vessel wall damage. Current research is aiming at better identifying risk factors in both conditions, and to define optimal acute and preventive therapeutic strategies in order to reduce significant long-term morbidity.

[Neonatal arterial ischemic stroke: Review of the current guidelines]. / Accidents vasculaires cérébraux ischémiques artériels néonatals : synthèse des recommandations.

Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.

Pain during injections of botulinum toxin in children: Influence of the localization technique.

OBJECTIVE: In this study, we consider two localization techniques used in injections of botulinium toxin in children: electrical stimulation and ultrasound. The hypothesis of this work was that injections performed without stimulation would be less painful. PATIENTS AND METHODS: Monocentric prospective study, with 107 sessions of lower limb injections. Two groups of children were compared: localization by ultrasound only (60 children), detection by stimulation only or by stimulation combined with ultrasound (47 children). Pain assessment was performed by the child or an accompanying party using the Visual Analog Scale (VAS) and by a health care team using the Face, Legs, Activity, Cry, Consolability (FLACC). RESULTS: A significant difference between the two groups was found in both self-report and by means of the behavioral observational pain scale. Indeed, VAS average and FLACC average were significantly higher with detection by stimulation than with ultrasound alone: 4.5cm±2.54 versus 2.7cm±2.27; P<0.001 for VAS scale and 3.7±2.1 versus 2.7±2.3; P<0.05 for FLACC scale. CONCLUSION: When compared to ultrasound detection, localization by electrostimulation appears to increase the overall pain caused during injections of botulinum toxin in children.

Quality of life and functional outcome in early school-aged children after neonatal stroke: a prospective cohort study.

BACKGROUND: Quality of life (QoL) is recognized internationally as an efficient tool for evaluating health interventions. To our knowledge, QoL has not been specifically assessed in children after neonatal arterial ischemic stroke (AIS). AIM: To study the QoL of early school-aged children who suffered from neonatal AIS, and QoL correlation to functional outcome. METHOD: We conducted a multicenter prospective cohort study as part of a larger study in full-term newborns with symptomatic AIS. Participating families were sent anonymous QoL questionnaires (QUALIN). Functional outcome was measured using the Wee-FIM scale. Healthy controls in the same age range were recruited in public schools. Their primary caregivers filled in the QUALIN questionnaires anonymously. We used Student's t-test and a rank test to compare patients and controls' QoL and functional outcomes. RESULTS: 84 children with neonatal AIS were included. The control group was composed of 74 children, of which ten were later excluded due to chronic conditions. Mean ages and QUALIN median scores did not differ between patients and controls. Median Wee-FIM scores were lower in hemiplegic children than in non-hemiplegic ones (p < 0.001). QoL scores did not seem correlated to functional outcome. INTERPRETATION: Those results could support the presence of a "disability paradox" in young children following neonatal AIS.

Translation and validation of the French Movement Imagery Questionnaire - Revised Second Version (MIQ-RS).

INTRODUCTION: Motor imagery can be defined as a dynamic state during which the representation of a movement is internally rehearsed in the absence of voluntary movements. There are two strategies to mentally simulate the movements, either a visual representation of the movements (visual imagery), or kinesthetic feeling of the movement (kinetic imagery). In stroke rehabilitation, studies indicate that motor imagery associated with physical therapy results in cortical reorganization and correlative functional improvements. AIM: The aim of this study is to provide to the French-speaking community a valid and reliable version of the Movement Imagery Questionnaire - Revised Second Version (MIQ-RS). METHOD: We examined the test-retest, inter-rate reliability and the internal consistency of the visual and kinesthetic items of our French version of MIQ-RS in 153 healthy subjects. RESULTS: Results showed the internal consistency (Cronbach α=0.90) and test-retest reliability (intraclass correlation coefficient for visual items=0.68 and for kinesthetic items=0.78) of the French version of MIQ-RS were satisfactory; the two-factor structure was supported by confirmatory factor analysis. CONCLUSION: The French version of MIQ-RS is a valid and reliable instrument in French-speaking population and therefore useful as a measure for motor imagery ability.

Social functioning and self-esteem in young people with disabilities participating in adapted competitive sport.

AIMS: The aim of this study was to investigate social functioning quality of life and self-esteem in young people with disabilities taking part in adapted competitive sport. METHOD: A sample of 496 athletes (mean age 16 years 4 months, range: 9 years to 20 years 9 months) was obtained from the 540 participants (91.8%) involved in a French national championship. The main outcome measurements were a social functioning inventory (PedsQL 4.0 social functioning) and a self-esteem inventory in physical areas (physical self inventory 6 PSI-6). RESULTS: The mean PedsQL SF score was 74.6 (SD: 17.7). Comparisons of PedsQL SF according to gender, age, self mobility and training revealed no significant differences between the groups. PedsQL SF was weakly but significantly correlated with all subscales of the PSI-6 in the total population. PSI-6 scores were significantly different between boys and girls, with better self-esteem for boys on general self-esteem (7.7 vs. 6.9, P=0.018), physical condition (6.8 vs. 6.0, P=0.023) and attractive body subscores (6.5 vs. 5.1, P<0.001). CONCLUSION: Social functioning scores were significantly higher in this population than in the samples of young people with disabilities available in the literature. Interactions between self-concept, social functioning quality of life and participation in adapted sport activities require further studies.