Upper limb muscular activity and perceived workload during laryngoscopy: comparison of Glidescope(R) and Macintosh laryngoscopy in manikin: an observational study.

BACKGROUND: The interaction between operators and their working environment during laryngoscopy is poorly understood. Numerous studies have focused on the forces applied to the patient's airway during laryngoscopy, but only a few authors have addressed operator muscle activity and workload. We tested whether different devices (Glidescope(®) and Macintosh) use different muscles and how these differences affect the perceived workload. METHODS: Ten staff anaesthetists performed three intubations with each device on a manikin. Surface electromyography was recorded for eight single muscles of the left upper limb. The NASA Task Load Index (TLX) was administered after each experimental session to evaluate perceived workload. RESULTS: A consistent reduction in muscular activation occurred with Glidescope(®) compared with Macintosh for all muscles tested (mean effect size d=3.28), and significant differences for the upper trapezius (P=0.002), anterior deltoid (P=0.001), posterior deltoid (P=0.000), and brachioradialis (P=0.001) were observed. The overall NASA-TLX workload score was significantly lower for Glidescope(®) than for Macintosh (P=0.006), and the factors of physical demand (P=0.008) and effort (P=0.006) decreased significantly. CONCLUSIONS: Greater muscular activity and workload were observed with the Macintosh laryngoscope. Augmented vision and related postural adjustments related to using the Glidescope(®) may reduce activation of the operator's muscles and task workload.

Motor and Cognitive Modulation of a Single Session of Transcutaneous Auricular Vagus Nerve Stimulation in Post Stroke Patients: A Pilot Study.

Objective: The aim of the present study is to explore whether a single session of transcutaneous Vagus Nerve Stimulation (tVNS) can enhance the ipsilesional, and contralesional upper limb motor functions as well as cognitive functions in stroke patients. The effects of the stimulation were evaluated through two different tasks: the box and blocks test (BB), indexing manual dexterity, and the Go/No-go task, a visuomotor paradigm used to assess both motor readiness and response inhibition. Tests were administered without tVNS, during tVNS and during sham tVNS. Results: The BB showed a statistical difference for both contralesional side (p = 0.05) between Basal-Real condition (p = 0.042) and ipsilesional side (p = 0.001) between Basal-Real (p = 0.008) and for Real-Sham (p = 0.005). Any statistical difference was found for the mean latencies in the three conditions of the Go/No-go test. Conclusion: A single session of tVNS seems to improve upper limb motor functions but not cognitive functions in post-stroke patients, despite a positive trend was detected.

Rehabilitation Modulates High-Order Interactions Among Large-Scale Brain Networks in Subacute Stroke.

The recovery of motor functions after stroke is fostered by the functional integration of large-scale brain networks, including the motor network (MN) and high-order cognitive controls networks, such as the default mode (DMN) and executive control (ECN) networks. In this paper, electroencephalography signals are used to investigate interactions among these three resting state networks (RSNs) in subacute stroke patients after motor rehabilitation. A novel metric, the O-information rate (OIR), is used to quantify the balance between redundancy and synergy in the complex high-order interactions among RSNs, as well as its causal decomposition to identify the direction of information flow. The paper also employs conditional spectral Granger causality to assess pairwise directed functional connectivity between RSNs. After rehabilitation, a synergy increase among these RSNs is found, especially driven by MN. From the pairwise description, a reduced directed functional connectivity towards MN is enhanced after treatment. Besides, inter-network connectivity changes are associated with motor recovery, for which the mediation role of ECN seems to play a relevant role, both from pairwise and high-order interactions perspective.

Comparison between directed causal flow metrics for the assessment of resting-state EEG motor network connectivity in subacute stroke patients.

Isolated effective coherence (iCoh) is a measure of neural causal functional connectivity from EEG signals that was proven to overperform the Generalized Partial Directed Coherence (gPDC). However, iCoh sensitivity in the identification of reliable functional neural connections with respect to random links was not investigated. This study aims to compare the sensitivity of iCoh and gPDC with a statistical surrogates' approach. The cerebral motor network topology of a cohort of subjects in sub-acute stage after stroke was investigated. iCoh showed enhanced statistical discriminative power of the relevant connections within the motor network with respect to gPDC. This property influenced the assessment of ipsilesional intra-hemispheric topographic variations occurring in the population after a physical rehabilitation program.

The prevalence of antibodies to human herpesvirus 8 and hepatitis B virus in patients in two hospitals in Tanzania.

The aim of this study was to determine the seroprevalence of human herpesvirus 8 (HHV-8) and the immunization status for hepatitis B virus (HBV) infection in febrile patients in two districts of the United Republic of Tanzania. Between February and March 2007, blood samples were collected in Pemba Island and Tosamaganga from 336 outpatients and sent to the Virology Laboratory in Rome (Italy) for testing. HHV-8 DNA and HBV-DNA were amplified by two in-house molecular methods, anti-HHV-8 antibody titers were determined by an immunofluorescence assay (IFA), and anti-HCV, HBsAg, anti-HBs, and anti-HBc were evaluated by microplate enzyme immunoassay (MEIA). The seroprevalence of HHV-8 was 30.7% (96/313). In Pemba Island, the prevalence was lower than in Tosamaganga (14.4% vs. 46.3%). A higher prevalence of low titers of HHV-8 IgG (<1:80, 81%) was found among those under 5 years of age. HHV-8 DNA was detected in six seropositive patients (6.7%). The prevalence of HBsAg, anti-HBs, and anti-HBc was 4.3%, 37.6%, and 29.3%, respectively. Out of 277 patients, 70 had had a previous infection (25.3%). One case of occult hepatitis was found. The cover of hepatitis B vaccination was higher among children born after 2002 (66.7%) than in patients born before 2002. HHV-8 infection is endemic in Tanzania and the seroprevalence rate was higher in the mainland than on Pemba Island. The 3.9% percentage of HBsAg in children younger than 4 years of age suggests that increased efforts are required in order to achieve universal and compulsory immunization of children against HBV.

Upper-limb actuated exoskeleton for muscular dystrophy patients: preliminary results.

Being able to perform a lost movement is an important experience towards increased independence and self-esteem, particularly for neuromuscular patients, who see their muscles weaken day after day. In this pilot study, preliminary results on the testing of a motorized upper-limb exoskeleton for muscular dystrophy patients are presented. The mechatronic system is a five Degrees of Freedom exoskeleton, which acts at shoulder, elbow, and wrist levels. It is designed to help severely impaired people to regain independence during daily-life activities. While wearing the exoskeleton, the user has the direct control of the system by actively piloting the position of end-effector by means of joystick or vocal control. The usability of the system and a quantitative assessment of arm functionality with and without the exoskeleton are evaluated on five muscular dystrophy patients. According to the objective functional benefit evaluation performed through the PUL scale, all participants strongly increased their range of motion and they were able to perform activities that were not possible without the exoskeleton, such as such as feeding, playing activities at the table, combing hair or using a keyboard. As for the evaluation of self-perceived functional benefit, four patients reflected the effective measured functional improvement. System usability has been evaluated to be good.

Effect of human-robot interaction on muscular synergies on healthy people and post-stroke chronic patients.

Robot-assisted training is a widely used technique to promote motor re-learning on post-stroke patients that suffer from motor impairment. While it is commonly accepted that robot-based therapies are potentially helpful, strong insights about their efficacy are still lacking. The motor re-learning process may act on muscular synergies, which are groups of co-activating muscles that, being controlled as a synergic group, allow simplifying the problem of motor control. In fact, by coordinating a reduced amount of neural signals, complex motor patterns can be elicited. This paper aims at analyzing the effects of robot assistance during 3D-reaching movements in the framework of muscular synergies. 5 healthy people and 3 neurological patients performed free and robot-assisted reaching movements at 2 different speeds (slow and quasi-physiological). EMG recordings were used to extract muscular synergies. Results indicate that the interaction with the robot very slightly alters healthy people patterns but, on the contrary, it may promote the emergency of physiological-like synergies on neurological patients.

The combined action of a passive exoskeleton and an EMG-controlled neuroprosthesis for upper limb stroke rehabilitation: First results of the RETRAINER project.

The combined use of Functional Electrical Stimulation (FES) and robotic technologies is advocated to improve rehabilitation outcomes after stroke. This work describes an arm rehabilitation system developed within the European project RETRAINER. The system consists of a passive 4-degrees-of-freedom exoskeleton equipped with springs to provide gravity compensation and electromagnetic brakes to hold target positions. FES is integrated in the system to provide additional support to the most impaired muscles. FES is triggered based on the volitional EMG signal of the same stimulated muscle; in order to encourage the active involvement of the patient the volitional EMG is also monitored throughout the task execution and based on it a happy or sad emoji is visualized at the end of each task. The control interface control of the system provides a GUI and multiple software tools to organize rehabilitation exercises and monitor rehabilitation progress. The functionality and the usability of the system was evaluated on four stroke patients. All patients were able to use the system and judged positively its wearability and the provided support. They were able to trigger the stimulation based on their residual muscle activity and provided different levels of active involvement in the exercise, in agreement with their level of impairment. A randomized controlled trial aimed at evaluating the effectiveness of the RETRAINER system to improve arm function after stroke is currently ongoing.

Indoors man-biting mosquitoes and their implication on malaria transmission in Mpwapwa and Iringa Districts, Tanzania.

Entomological surveys were carried out in six villages at different altitudes in Mpwapwa and Iringa Districts in central Tanzania in March 2002. A total of 1291 mosquitoes were collected. Of these, 887 mosquitoes were collected by light traps and 404 by indoor pyrethrum spray catch technique. Seventy-nine percent (1026) were Anopheles gambiae s.l., 0.2% (N = 3) were An. funestus, and 20.3% (N = 262) were Culex quinquefasciatus. Other species including Cx cinereus, An. coustani and Aedes spp accounted for 0.5% of the mosquito population. In Iringa, more mosquitoes were collected by pyrethrum spray catch than light trapping technique. The light trap catch: spray catch ratio in Iringa and Mpwapwa was 1:1.15 and 2.5:1, respectively. Indoor pyrethrum spray catch gave an overall estimate of An. gambiae density of 8 and 0.6 mosquitoes per room in Iringa and Mpwapwa, respectively, whereas light trap collections gave an overall respective density of An. gambiae of 63.9 and 2.9 mosquitoes per room. The densities of house entering mosquitoes were found to range from 0 to 135 in Iringa and from 2.6 to 3.5 per room in Mpwapwa. An.funestus mosquitoes were collected in Iringa only. None of the dissected An. gambiae collected in the two districts was infected with malaria sporozoites. Despite low mosquito densities and absence of infective mosquitoes in our study, the two districts are malaria epidemic prone, thus a continuous surveillance is critical for a prompt response to any impending outbreak. Further longitudinal studies are required to determine the transmission potential of the malaria mosquitoes in the two districts.

Three-dimensional optical analysis of chest wall motion.

A method for kinematic analysis of chest wall motion is presented, based on a television-image processor that allows a three-dimensional assessment of volume change of the trunk by automatically computing the coordinates of several passive markers placed on relevant landmarks of the thorax and abdomen. The parallel computation used for the image processing allows for a real time recognition of the passive markers with the necessary accuracy. A geometric model also allows the online computation of the contribution to the chest volume by the different parts. For this purpose, the model presented here is based on 54 tetrahedrons that can be grouped into 9 compartments and 3 sections representing 1) upper thorax (mainly reflecting the action of neck and parasternal muscles and the effect of pleural pressure), 2) lower thorax (mainly reflecting the action of diaphragm and the effect of pleural and abdominal pressure), and 3) abdomen (mainly reflecting the actions of diaphragm and abdominal muscles). By this model, the volume can also be split into three vertical sections pointing out asymmetries between the right and left sides. The method is noninvasive, nonionizing, and leaves the subject maximum freedom of movement during the test, thus being suitable for routine clinical analysis. The monitoring of the subject can be prolonged in time and can be performed in different postures: standing, sitting, and supine. The method was tested on 12 healthy subjects showing its good accuracy, reliability, and reproducibility.

Spraying tick-infested houses with lambda-cyhalothrin reduces the incidence of tick-borne relapsing fever in children under five years old.

Tick-borne relapsing fever (TBRF) is a major cause of morbidity and mortality of children in central Tanzania. This study assessed the effect of house interior residual spraying with lambda-cyhalothrin on domestic tick infestation and the incidence of TBRF in children under 5 years old. Two neighbouring villages were studied: one was sprayed with insecticide, the other left untreated. Samples of earth from the floors of 50 houses before and after spraying, and 50 houses in the control village, were sieved and ticks counted. The incidence of TBRF was estimated by microscopy of thick blood films taken from all children under 5 years old presenting with fever to the village dispensary or health workers. After 2 cycles of spraying, no tick was found in the treated houses; in the controls, tick numbers remained high. In the treated village there were 29 cases of TBRF among the 960 children under 5 years old in the 4 months before spraying, and one in the 4 months after spraying. In the control village there were 10 and 4 cases in the same periods among the 510 children. There was a significant reduction of 0.09 in the odds ratio of infection after spraying (95% confidence interval 0.01-0.87).

Intrauterine growth in the offspring of epileptic women: a prospective multicenter study.

The aim of the present study was to evaluate the risk of intrauterine growth delay in the offspring of epileptic mothers and to quantify the risks of intrauterine exposure to antiepileptic drugs (AEDs). Data concerning 870 newborns, prospectively collected in Canada, Japan and Italy, using the same study design, were pooled and analyzed. The overall proportion of newborns whose body weight (7.8%) or head circumference (11.1%) at birth were below the 10th percentile was not increased. However, logistic regression analysis showed that the risk of small head circumference was significantly higher in Italian than in Japanese (RR 4.2; 95% CI: 2.2-8.0) or Canadian children (RR 2.6; 95% CI: 1.1-6.5), and in children exposed to polytherapy (RR 2.7; 95% CI: 1.2-6.3), phenobarbital (PB) (RR 3.6; 95% CI: 1.4-9.4) and primidone (PRM) (RR 4.5; 95% CI: 1.5-13.8). Country was also the only factor affecting low body weight, with Italian children having a higher risk than Japanese (RR 5.2; 95% CI: 2.6-10.4) or Canadian (RR 8.8; 95% CI: 2.0-38.1) children. Due to the small categories, the influence of AED doses and plasma concentrations was studied for each individual AED, without adjustment for the other potential confounding factors. A clear dose-dependent effect was found for PB and PRM in terms of both small head circumference and low body weight, and a concentration-dependent effect for PB in terms of small head circumferences. The size of the difference between the Italian and the other two populations, which is only partially explained by differences in therapeutic regimens, suggests that genetic, environmental and ethnic factors also need to be taken into account when considering possible explanations.

Congenital malformations due to antiepileptic drugs.

To identify the major risk factors for the increased incidence of congenital malformations in offspring of mothers being treated for epilepsy with antiepileptic drugs (AEDs) during pregnancy and, to determine the relative teratogenic risk of AEDs, we prospectively analyzed 983 offspring born in Japan, Italy, and Canada. The incidence of congenital malformations in offspring without drug exposure was 3.1%, versus an incidence with drug exposure of 9.0%. The highest incidence in offspring exposed to a single AED occurred with primidone (PRM; 14.3%), which was followed by valproate (VPA; 11.1%), phenytoin (PHT; 9.1%), carbamazepine (CBZ; 5.7%), and phenobarbital (PB; 5.1%). The VPA dose and level positively correlated with the incidence of malformations. This study first determined a cut-off value of VPA dose and level at 1000 mg/day and 70 microg/ml, respectively, to avoid the occurrence of malformations. The incidence of malformations increases as the number of drugs increases, and as the total daily dose increases. Specific combinations of AEDs such as VPA + CBZ and PHT + PRM + PB produced a higher incidence of congenital malformations. The incidence of malformations was not associated with any background factors studied except for the presence of malformations in siblings. These results indicate that the increased incidence of congenital malformations was caused primarily by AEDs, suggesting that malformations can be prevented by improvements in drug regimen, and by avoiding polypharmacy and high levels of VPA (more than 70 microg/ml) in the treatment of epileptic women of childbearimg age.

Intra-amniotic pressure is not affected by amniocentesis between 13 and 18 weeks of gestation.

Changes in amniotic fluid pressure before and after amniocentesis fell within the range of +/- 5 mmHg, except when uterine contractions were present. Intra-amniotic pressure is not affected by amniocentesis between 13 and 18 weeks of gestation. Amniotic fluid pressure was recorded in 82 pregnancies of patients undergoing genetic amniocentesis to determine whether sampling of amniotic fluid between 13 and 18 weeks changed intra-amniotic pressure. Pressures were recorded through a needle and saline filled catheter with a zero-level at the needle tip. Amniotic fluid pressure was unrelated to gestational age (P = 0.962) during the weeks we performed our measurements. Fluid samples of 12.6% of the total volume in a group of early genetic amniocentesis (n = 65) and of 7.5% of the total volume in a group of late genetic amniocentesis (n = 17) did not change significantly amniotic fluid pressure values. An increase in pressure of more than 5 mmHg only occurred in cases where uterine contractions were present. Other than these cases, all pressure change values fell within the range of +/- 5 mmHg. No difference in pregnancy outcome were present within the two groups. An argument for a standard method for stationing pressure is presented.

A neurophysiological method for the evaluation of motor performance in spastic walking patients.

Intrathecal baclofen is at present the best treatment for severe spasticity of various etiologies. In walking patients affected by severe spasticity a careful evaluation of the motor performance is needed for a correct indication for this treatment. The examination should focus on the delicate balance between spasticity and voluntary muscle activation which is crucial for an improvement of motor performance during gait. Seven patients have been neurophysiologically evaluated by the use of a Cibex apparatus measuring torque and movement velocity of the lower limbs simultaneously with static and dynamic recordings of the EMG.

[Preliminary study on the physician-patient relation in acupuncture]. / Studio preliminare del rapporto medico-paziente in agopuntura.

A preliminary attempt to analyse and interpret the doctor-patient relationship in acupuncture is presented. The study was based on questionnaires completed by doctors and patients and patients' pictures of the acupuncture session. Early data reveal the importance of the doctor's personality and the doctor-patient relationship as well as the influence of the needle as a particular therapeutic medium with magic, symbolic and menacing connotations. What emerges is that the doctor must be aware of his role and personal dynamics as well as of the symbolic connotations of the needle if the is to obtain optimum therapeutic results.

[Benign cancers of the stomach: radiological and endoscopic correlation on ten cases (author's transl)]. / I tumori benigni dello stomaco: considerazioni radiologiche ed endoscopiche su dieci casi.

The Authors refer to their experience on 10 cases of benign cancer of the stomach studied either radiologically or endoscopically before the surgery intervention. Moreover the authors emphasize the importance of the association between the radiological investigation and the fibroscope in the determination of the benign characters of the gastric neoplasm and the possibility given by the endoscope to effect an extemporaneous biopsy in the cases of uncertain interpretation.

[Primary malignant neoplasms of the duodenum. Considerations on 4 cases]. / Sulle neoplasie maligne primitive del duodeno. Considerazioni su 4 casi.

Starting from four primitive malignant neoplasias of the duodenum observed during the course of the last two years, the Authors briefly outline the clinical aetiopathological and especially the radiological characteristics of duodenal primitive malignant neoplasias. They stress the importance of the radiological investigation for early diagnosis of such disturbances, as can clearly by deduced from illustration of the radiological pictures concerning the four cases, all male patients aged from 55 to 68 years. A localisation in the duodenal bulb, with ulceration, is to be considered very rare; the other localisations were two at the 2nd and one at the 1st duodenal portion.

Selective neuromuscular blocks and chemoneurolysis in the localized treatment of spasticity.

Selective neuromuscular blocks and chemoneurolysis are currently the most widespread therapies for treating localized or locoregional spasticity. Both procedures present advantages and disadvantages. The main advantages of BTX-A are its relative ease of use, low incidence of side effects, reversibility and elevated efficacy. Its disadvantages are the limited maximum dose, which does not permit the treatment of many muscles simultaneously, especially if they are large, and its relatively high cost. Phenol neurolysis has a low cost, elevated efficacy in the control of pathologic muscle overactivity, and long duration of effect. Its disadvantages are the risk of injury to the vascular and sensory structures and the difficulty in performing the procedure. The risks associated with neurolysis have led to an increasing interest in and use of BTX-A, making it one of the most widely used therapies in treating localized spasticity. From the perspective of a balanced benefit-risk analysis, a viable option for some cases may be to combine phenol neurolysis for treating spasticity in large proximal muscles and BTX-A for treating hypertonia in small distal muscles.