National Trends and Clinical Outcomes after Scooter Injury in the US: 2016 to 2020.

BACKGROUND: In recent years, the adoption of electric scooters has been accompanied by a surge of scooter-related injuries in the US, raising concerns for their severity and associated healthcare costs. This study aimed to assess temporal trends and outcomes of scooter-related hospital admissions compared with bicycle-related hospitalizations. STUDY DESIGN: This was a retrospective cohort study using the 2016 to 2020 National Inpatient Sample for patients younger than 65 years who were hospitalized after bicycle- and scooter-related injuries. The Trauma Mortality Prediction Model was used to quantify injury severity. The primary outcomes of interest were temporal trends of micromobility injuries. In-hospital mortality, rates of long bone fracture, traumatic brain injury, paralysis, length of stay, hospitalization costs, and nonhome discharge were secondarily assessed. RESULTS: Among 92,815 patients included in the study, 6,125 (6.6%) had scooter-related injuries. Compared with patients with bicycle-related injuries, patients with scooter-related injuries were more commonly younger than 18 years (26.7% vs 16.4%, p < 0.001) and frequently underwent major operations (55.8% vs 48.1%, p < 0.001). After risk adjustment, scooter-related injuries were associated with greater risks of long bone fracture (adjusted odds ratio 1.40, 95% CI 1.15 to 1.70) and paralysis (adjusted odds ratio 2.06, 95% CI 1.16 to 3.69) compared with bicycle-related injuries. Additionally, patients with bicycle- or scooter-related injuries had comparable index hospitalization durations of stay and costs. CONCLUSIONS: The prevalence and severity of scooter-related injuries have significantly increased in the US, thereby attributing to a substantial cost burden on the healthcare system. Multidisciplinary efforts to inform safety policies and enact targeted interventions are warranted to reduce scooter-related injuries.

The diagnostic utility of inspiratory-expiratory radiography for the assessment of phrenic nerve palsy associated with brachial plexus injury.

BACKGROUND: The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury. METHODS: Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis. RESULTS: A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography. CONCLUSION: While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process.

Neuromuscular Weakness and Paralysis Produced by Snakebite Envenoming: Mechanisms and Proposed Standards for Clinical Assessment.

Respiratory and airway-protective muscle weakness caused by the blockade of neuromuscular transmission is a major cause of early mortality from snakebite envenoming (SBE). Once weakness is manifest, antivenom appears to be of limited effectiveness in improving neuromuscular function. Herein, we review the topic of venom-induced neuromuscular blockade and consider the utility of adopting clinical management methods originally developed for the safe use of neuromuscular blocking agents by anesthesiologists in operating rooms and critical care units. Failure to quantify neuromuscular weakness in SBE is predicted to cause the same significant morbidity that is associated with failure to do so in the context of using a clinical neuromuscular block in surgery and critical care. The quantitative monitoring of a neuromuscular block, and an understanding of its neurophysiological characteristics, enables an objective measurement of weakness that may otherwise be overlooked by traditional clinical examination at the bedside. This is important for the initial assessment and the monitoring of recovery from neurotoxic envenoming. Adopting these methods will also be critical to the conduct of future clinical trials of toxin-inhibiting drugs and antivenoms being tested for the reversal of venom-induced neuromuscular block.

Assessment of Safety of a Fully Implanted Endovascular Brain-Computer Interface for Severe Paralysis in 4 Patients: The Stentrode With Thought-Controlled Digital Switch (SWITCH) Study.

Importance: Brain-computer interface (BCI) implants have previously required craniotomy to deliver penetrating or surface electrodes to the brain. Whether a minimally invasive endovascular technique to deliver recording electrodes through the jugular vein to superior sagittal sinus is safe and feasible is unknown. Objective: To assess the safety of an endovascular BCI and feasibility of using the system to control a computer by thought. Design, Setting, and Participants: The Stentrode With Thought-Controlled Digital Switch (SWITCH) study, a single-center, prospective, first in-human study, evaluated 5 patients with severe bilateral upper-limb paralysis, with a follow-up of 12 months. From a referred sample, 4 patients with amyotrophic lateral sclerosis and 1 with primary lateral sclerosis met inclusion criteria and were enrolled in the study. Surgical procedures and follow-up visits were performed at the Royal Melbourne Hospital, Parkville, Australia. Training sessions were performed at patients' homes and at a university clinic. The study start date was May 27, 2019, and final follow-up was completed January 9, 2022. Interventions: Recording devices were delivered via catheter and connected to subcutaneous electronic units. Devices communicated wirelessly to an external device for personal computer control. Main Outcomes and Measures: The primary safety end point was device-related serious adverse events resulting in death or permanent increased disability. Secondary end points were blood vessel occlusion and device migration. Exploratory end points were signal fidelity and stability over 12 months, number of distinct commands created by neuronal activity, and use of system for digital device control. Results: Of 4 patients included in analyses, all were male, and the mean (SD) age was 61 (17) years. Patients with preserved motor cortex activity and suitable venous anatomy were implanted. Each completed 12-month follow-up with no serious adverse events and no vessel occlusion or device migration. Mean (SD) signal bandwidth was 233 (16) Hz and was stable throughout study in all 4 patients (SD range across all sessions, 7-32 Hz). At least 5 attempted movement types were decoded offline, and each patient successfully controlled a computer with the BCI. Conclusions and Relevance: Endovascular access to the sensorimotor cortex is an alternative to placing BCI electrodes in or on the dura by open-brain surgery. These final safety and feasibility data from the first in-human SWITCH study indicate that it is possible to record neural signals from a blood vessel. The favorable safety profile could promote wider and more rapid translation of BCI to people with paralysis. Trial Registration: ClinicalTrials.gov Identifier: NCT03834857.

The epidemiology and management of iliopsoas hematoma with femoral nerve palsy: A descriptive systematic review of 174 cases.

INTRODUCTION: Iliopsoas hematoma with femoral nerve palsy is a rare phenomenon with no consensus treatment algorithm. The objective of this study was to perform a systematic review of all reported cases of femoral nerve palsy secondary to iliopsoas hematoma to better elucidate it's optimal treatment. MATERIALS AND METHODS: Queries of the PubMed, Embase, and Cochrane databases were performed for reports available in English of femoral nerve palsy secondary to iliopsoas, psoas, or iliacus hematoma. 1491 articles were identified. After removal of duplicated publications and review of abstract titles via a majority reviewer consensus, 217 articles remained for consideration. Dedicated review of the remaining articles (including their reference sections) yielded 122 articles representing 174 distinct cases. Clinical data including patient age, sex, medical history, use of pharmacologic anticoagulation, sensory and motor examination at presentation and follow-up, hematoma etiology and location, time to intervention, and type of intervention were collected. Descriptive statistics were generated for each variable. RESULTS: Femoral nerve palsy secondary to iliopsoas hematoma occurred at a mean age of 44.5 years old. A majority of patients (60%) were male, and a majority of hematomas (54%) occurred due to pharmacologic anticoagulation. Most hematomas (57%) were treated conservatively, and almost half (49%) - regardless of treatment modality - resulted in persistent motor deficits at final follow-up. A minority of patients treated surgically (34%) had residual motor deficit at final follow-up, while 66% of those treated medically had resultant motor deficits, although no direct statistical comparison was able to be performed. DISCUSSION AND CONCLUSIONS: The disparate available data on iliopsoas hematoma with femoral nerve palsy precludes the completion of a true metanalysis, and therefore any conclusions on an optimal treatment algorithm. Based on review of the literature, small to moderate hematomas are often treated conservatively, while larger hematomas with progressive neurological symptoms are usually managed with a percutaneous decompression or surgery. LEVEL OF EVIDENCE: IV.

[Clinical-epidemiological profile of patients with thyrotoxic periodic paralysis in two peruvian hospitals]. / Perfil clínico-epidemiológico de pacientes con parálisis periódica tirotóxica en dos hospitales peruanos.

Background: Thyrotoxic Periodic Paralysis (PPT) is an uncommon complication of hyperthyroidism, it is the most frequent cause of acute flaccid paralysis in adults. Material and methods: A retrospective observational study was carried out in 2 reference hospitals of the social security in Lima-Peru, which included 22 patients diagnosed with PPT during the period 2014-2021. Results: the average age at diagnosis was 35.77 ± 9.6 years, all of mixed race, in 82% of the patients the diagnosis of hyperthyroidism was established from this entity, the etiology in 95% was autoimmune (Graves-Basedow) except for one whose etiology was toxic multinodular goiter. The triggering event reported in 54% of patients was the intake of copious food high in carbohydrates, followed by exercise (27%), the most frequent presentation time was during the morning (41% of the cases), the main weakness pattern compromised lower limbs (45% paraplegia, 18% paraparesis), only 36% were diagnosed with PPT in their first episode of motor weakness. Conclusions: We consider that this condition should be suspected in any young male patient of any ethnicity with acute muscle weakness, associated with low serum potassium levels and symptoms of thyrotoxicosis, although its absence should not rule out the diagnosis. The precipitating factor should be identified as much as possible and initial therapy with propanolol with or without intravenous or oral potassium replacement should be established, with adequate subsequent monitoring to minimize the risk of rebound hyperkalemia.

Introducción: la paralisis periodica tirotóxica (PPT) es una complicación poco común del hipertiroidismo, corresponde la causa más frecuente de parálisis aguda flácida del adulto. Material y métodos: se realizó un estudio observacional retrospectivo en 2 hospitales referenciales del seguro social en Lima-Perú, que incluyo a 22 pacientes (21 hombres, 1 mujer) diagnosticados con PPT durante el periodo 2014-2021. Resultados: la edad promedio al diagnóstico fue de 35.77 ± 9.6 años, todos de raza mestiza, en 82% de los pacientes el diagnostico de hipertiroidismo fue establecido a partir de esta entidad, la etiología en el 95% fue autoinmune (enfermedad de Graves-Basedow) excepto uno cuya etiología fue bocio multinodular tóxico. El evento desencadenante reportado en 54% de pacientes fue la ingesta de comida copiosa alta en carbohidratos, seguido del ejercicio (27%), el horario más frecuente de presentación fue durante la mañana ( 41% de los casos), el patrón de debilidad principal comprometió miembros inferiores(45% paraplejia, 18% paraparesia), solo 36% fue diagnosticado de PPT en su primer episodio de debilidad motora. Conclusiones: consideramos que se debe sospechar esta condición en cualquier paciente varón joven de cualquier etnia con debilidad muscular aguda, asociado a niveles séricos bajos de potasio y síntomas de tirotoxicosis, aunque su ausencia no debe descartar el diagnostico. Se debe identificar en lo posible el factor precipitante e instaurar terapia inicial con propanolol con o sin reemplazo de potasio endovenoso u oral, con monitoreo posterior adecuado que minimice el riesgo de hiperpotasemia de rebote.

Social inequalities and gender differences in healthcare management of acute ischaemic stroke in France.

BACKGROUND AND PURPOSE: There are regional disparities in access to stroke units in France. Several studies have shown that living in disadvantaged areas is associated with a higher frequency of stroke, worse severity at presentation, increased level of dependency and higher mortality rates. However, few studies have explored the association between an individual's socioeconomic characteristics and stroke care. Our study aimed to determine if living standards are associated with stroke unit access for patients admitted to hospital for acute ischaemic stroke. METHODS: Using the EDP-Santé French administrative database, all patients admitted to hospital for acute ischaemic stroke between 2014 and 2017 were selected. Acute ischaemic stroke corresponded to hospital stay with International Classification of Diseases 10th Revision codes I63 or I64 as the main diagnosis. Multivariate logistic regression was used to identify if standard of living was associated with likelihood of admission to a stroke unit. RESULTS: In all, 14,123 acute care episodes were identified, corresponding to 335,273 episodes in the general population when appropriately weighted. Of these, 52.9% were admitted to a stroke unit. Being in the first (i.e., poorest) living standard quartile was associated with lower likelihood of admission to a stroke unit compared with the fourth (i.e., wealthiest) quartile, and was associated with a higher likelihood of paralysis and language disorder, and death at 1 year. CONCLUSION: A low living standard was associated with lower likelihood of admission to a stroke unit as well as a greater chance of paralysis and aphasia at the end of hospitalization and a higher possibility of death at 1 year after stroke. Greater access to stroke units for disadvantaged people should be promoted.

Scapular winging due to rhomboid muscle paralysis: clinical assessment of 4 cases and anatomic study of the dorsal scapular nerve.

BACKGROUND: A rare cause of scapular winging is rhomboid muscle paralysis secondary to dorsal scapular nerve (DSN) neuropathy. This paralysis causes winging of the medial border of the scapula with lateral rotation of its inferior angle. We report a series of 4 clinical cases of isolated DSN compression and the results of a specific rehabilitation protocol. METHODS: A continuous clinical series of 4 patients with isolated rhomboid muscle deficiency was analyzed. Two patients were men and 2 were women, with a mean age of 40 years (range, 33-51 years). Three patients were right-handed and 1 was left-handed. Scapular winging always affected the dominant side. Two patients had occupations involving heavy physical work. The sports practiced involved exertion of the arms (dancing, boxing, gymnastics, muscle strengthening). A specific rehabilitation protocol was offered to the patients. In addition, 6 fresh cadaver dissections were performed to reveal possible DSN compression. Potential areas of compression were identified, in particular when the arm was raised. RESULTS: The 4 patients presented with isolated DSN neuropathy were confirmed by electroneuromyographic testing. Total correction of scapular winging was not obtained in any patient. Three patients experienced residual pain with a neuropathic pain by the questionnaire for a Diagnosis of Neuropathic Pain (DN4) score of 2. The mean Quick-Disabilities of the Arm, Shoulder and Hand (DASH) score after treatment was 31.8 of 100. The mean ASES score was 56.2. Only 1 patient agreed to rehabilitation in a specialized center and underwent follow-up electroneuromyography. Signs of rhomboid muscle denervation were no longer present and distal motor latencies had become normal. In all cadaver dissections, the DSN originated from the C5 nerve root and did not pass through the middle scalene muscle. We identified a site of dynamic compression of the DSN by the upper part of the medial border of the scapula when the arm was raised. DISCUSSION: DSN compression is conventionally attributed to the middle scalene muscle, but it is noteworthy that our study reveals the possibility of dynamic compression of the nerve by the proximal part of the medial border of the scapula, which occurs when the arm elevation is above 90°. CONCLUSION: Our study reveals the possibility of dynamic compression of the DSN by the proximal part of the medial border of the scapula, which occurs when the arm is raised above 90°. In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team.

Thyrotoxic periodic paralysis (TPP): assessment in the emergency department.

A male patient aged in his early twenties presented to the emergency department (ED) with quadriparesis. He was ordinarily fit and well and had exercised and eaten a carbohydrate rich meal the evening before. His point-of-care venous blood sample on arrival to the ED showed hypokalaemia of 1.6 mmol/L. (normal range=3.5-5.0 mmol/L). He was put on a cardiac monitor and started on an intravenous infusion of potassium chloride. With the benefit of hindsight, his male sex, particular features in his history and his initial ECG all pointed to a differential diagnosis of thyrotoxic periodic paralysis (TPP), although a differential diagnosis of a first attack of familial hypokalaemic paralysis was considered. As urgent thyroid function tests were sent promptly, there was minimal delay in reaching a diagnosis of TPP and promptly starting propranolol as a safe and more effective means of reversing TPP, followed by definitive treatment with carbimazole.

Improved Assessment of Overall Health in Variably Aged Murine Models of Multiple Sclerosis With a Novel Frailty Index Tool.

The experimental autoimmune encephalomyelitis (EAE) model is the most commonly used animal model of multiple sclerosis (MS). However, phenotypic characterization of mice based on the traditional 5-point clinical paralysis scale does not fully capture disease progression. The frailty index (FI) conceptualizes frailty as the accumulation of health deficits and it is widely used to assess overall health in aging humans and preclinical models. Here, we adapted an established mouse FI tool for use in EAE mice and determined whether this could evaluate general signs of health in variably aged female EAE mice. The EAE-Clinical FI included 34 items related to clinical signs and deficits characteristic of aging and MS. This tool clearly showed more detailed EAE progression and severity at all ages, highlighting changes in systems other than motor paralysis measured with the traditional 5-point paralysis scale. When we induced disease at 3 and 6 months of age, mice showed typical EAE clinical manifestations with peak disease severity between 17 and 19 days post-induction and mean frailty scores of 0.36 ± 0.04 (3-month-old) and 0.43 ± 0.05 (6-month-old). By contrast, disease severity peaked after 14 days in 12-month-old mice. They showed atypical signs including wobbling, early belly drag, and splayed hindlegs that were better captured with the EAE-Clinical FI. Peak frailty scores also were higher than those of younger animals (0.54 ± 0.04). As MS most often develops in young to middle-aged people, this new tool may have significant value for use in EAE animal studies as a first step toward translation to people with MS.

Patient Self-Assessment and Acoustic Voice Analysis in Screening of Postoperative Vocal Fold Paresis and Paralysis.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the utility of two items in vocal fold paresis and paralysis screening after thyroid and parathyroid surgery: patient self-assessment of voice using the Voice Handicap Index and computer-based acoustic voice analysis using the Multi-Dimensional Voice Program. METHODS: This was a prospective study of 181 patients who underwent thyroid or parathyroid surgery over a 1-year study period (2017). Preoperatively, all patients underwent laryngoscopic vocal fold inspection and acoustic voice analysis, and they completed the Voice Handicap Index questionnaire. Postoperatively, all patients underwent laryngoscopy prior to hospital discharge; 2 weeks after the surgery, they completed the Voice Handicap Index questionnaire a second time. Two weeks postoperatively, patients with vocal fold paresis or paralysis and 20 randomly selected controls without vocal fold paresis or paralysis underwent a follow-up acoustic voice analysis. RESULTS: Fourteen patients had a new postoperative vocal fold paresis or paralysis. Postoperatively, the total Voice Handicap Index score was significantly higher (p = 0.040) and the change between preoperative and postoperative scores was greater (p = 0.028) in vocal fold paresis or paralysis patients. A total postoperative Voice Handicap Index score > 30 had 55% sensitivity, and 90% specificity, for vocal fold paresis or paralysis. In the postoperative Multi-Dimensional Voice Program analysis, vocal fold paresis or paralysis patients had significantly more jitter (p = 0.044). Postoperative jitter > 1.33 corresponded to 55% sensitivity, and 95% specificity, for vocal fold paresis or paralysis. CONCLUSIONS: In identifying postoperative vocal fold paresis or paralysis, patient self-assessment and jitter in acoustic voice analysis have high specificity but poor sensitivity. Without routine laryngoscopy, approximately half of the patients with postoperative vocal fold paresis or paralysis could be overlooked. However, if the patient has no complaints of voice disturbance 2 weeks after thyroid or parathyroid surgery, the likelihood of vocal fold paresis or paralysis is low.

Preoperative electrophysiologic assessment of C5-innervated muscles in predicting C5 palsy after posterior cervical decompression.

PURPOSE: To investigate the feasibility of both needle electromyography (EMG) and proximal nerve conduction studies (NCS) in predicting C5 palsy after posterior cervical decompression. METHODS: This study included 192 patients with cervical myelopathy undergoing laminoplasty or laminectomy. Preoperatively, all patients accepted bilateral needle EMG detection and proximal NCS that consisted of supramaximally stimulating Erb's point and recording compound muscle action potential (CMAP) from bilateral deltoid. RESULTS: In the present study, 11 (11/192, 5.7%) patients developed unilateral C5 palsy after operation, and more patients with C5 palsy showed abnormal spontaneous activity in C5-innervated muscles compared to those without C5 palsy (8/11 vs. 16/181, p < 0.05). The sensitivity and specificity of spontaneous activity in C5-innervated muscles in predicting postoperative C5 palsy were 72.7% and 91.2%, respectively. Furthermore, there were significant left-to-right differences of deltoid CMAP amplitudes between the patients with and without C5 palsy (p < 0.05), and this measurement was also demonstrated to be useful for distinguishing patients with C5 palsy from cases without C5 palsy by receiver operating characteristic (ROC) curve analysis (cut-off value: 2.1 mV, sensitivity: 63.6%; specificity: 95.0%). In addition, the sensitivity and specificity of a series application of these two measurements were 63.6% and 100.0%, respectively. CONCLUSIONS: The findings of this study support the hypothesis that pre-existing progressive C5 root injury may be a risk factor for C5 palsy after posterior cervical decompression. Clinically, the estimation of NCS and needle EMG in C5-innervated muscles may provide additional useful information for predicting C5 palsy after cervical spinal surgery. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Improving Paralysis Compensation in Photon Counting Detectors.

Photon counting detectors (PCDs) are classically described as being either paralyzable or nonparalyzable. When the PCD is paralyzed, it is no longer sensitive to the detection of additional flux. A recent strategy in PCD design has been to compensate for detector paralysis by embedding specialized paralysis compensation electronics into the application-specific integrated circuit (ASIC). One such compensation mechanism is the pileup trigger, which places an additional energy bin at very high energy that is triggered only during pileup. Another compensation mechanism is the retrigger architecture, which converts a paralyzable PCD into a nonparalyzable PCD. We propose a third mechanism that modifies the retrigger architecture using dedicated secondary counters. We studied the incremental benefit of these three paralysis compensation mechanisms in simulation. We modeled the spectral response using Monte Carlo simulations and then estimated the variance in basis material decomposition of a single pixel using the Cramér-Rao lower bound (CRLB). In the absence of paralysis compensation, noise in basis material images shows sharp increases at moderate flux (near the characteristic count rate) due to contrast inversion and again at high flux. The pileup trigger reduces noise at high flux but does not eliminate contrast inversion. The retrigger architecture eliminates contrast inversion but does not reduce noise at high flux. Our proposed retrigger architecture with dedicated secondary counters reduce noise at both moderate and high flux.

The paralyzing legal costs of facial nerve injury in head and neck tumors.

PURPOSE: Facial nerve paralysis from head and neck tumors can result from disease progression or iatrogenic causes, leading to litigation. The aim of this study was to investigate lawsuits regarding facial paralysis as a consequence of these tumors to understand and better educate physicians behind the reasons for litigation. METHODS: Jury verdict reviews were obtained from the Westlaw database from 1985 to 2018. Gathered data, including verdicts, litigation reasons, defendant specialties, and amounts awarded, were analyzed via Statistical Package for the Social Sciences. RESULTS: Of the 26 lawsuits analyzed, the leading reason for litigation was failure to diagnose (53.8%), followed by iatrogenic injury (34.6%). The average award was $2,704,470. Otolaryngologists were the most common defendants. Defendants that included an otolaryngologist had shorter delays of diagnosis compared to those that did not (p < 0.05). CONCLUSION: Failure to diagnose parotid injury was the leading cause of litigation. In instances where the jury found for the plaintiff, the amount was material. There were equivalent incidences of cases in favor of plaintiffs and defendants.

Neurological Disturbance of the Upper Extremities After Cervical Laminoplasty: A Morphological Assessment Focused on the Intervertebral Foramen.

STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of this study was to explore the relationship between postoperative neurological disturbance of the upper extremities (NDUE) after cervical laminoplasty and intervertebral foraminal stenosis. SUMMARY OF BACKGROUND DATA: The relationship between foraminal stenosis and neurological disturbance in the C5 segment (C5 palsy) has been reported, but the relationship at other levels has not been examined before. We evaluated foraminal stenosis morphologically using three-dimensional computed tomography (3D-CT), alongside other risk factors for NDUE. METHODS: We retrospectively reviewed patients treated by open-door laminoplasty at the authors' institution between January and June 2016. NDUE was defined as postoperative motor deterioration and/or newly emerged sensory disturbance within 2 weeks of surgery. Radiological measurements were performed in bilateral intervertebral foramina from C5 to C8, using 3D-CT. Investigation using magnetic resonance imaging (MRI) was also performed. RESULTS: Thirty-one patients were reviewed, and 10 (32.3%) developed NDUE. Nineteen NDUE were observed: seven were in the C5 segment, five in the C6 segment, three in the C7 segment, and four in the C8 segment. Four patients (40%) had NDUE from multiple segments. The mean width of the foramen was 2.60 ±â€Š1.26 mm and 3.66 ±â€Š1.66 mm (P = 0.007), and cross-sectional area was 32.8 ±â€Š10.8 mm and 41.6 ±â€Š12.4 mm (P = 0.003), in symptomatic (n = 19) and nonsymptomatic (n = 187) foramina, respectively. The mean transverse diameter of bony spurs and the maximum shift of the spinal cord on MRI was significantly larger in the NDUE group. The odds ratio of having a foraminal cross-sectional area under 28.0 mm in combination with a maximum spinal shift over 3.10 mm was 14.6 (P < 0.001). CONCLUSION: Stenosis of the intervertebral foramen could be a risk factor for NDUE after cervical laminoplasty, and could be aggravated by excessive posterior spinal cord shift. LEVEL OF EVIDENCE: 3.

Assessment of acute flaccid paralysis surveillance performance in East and Southern African countries 2012 - 2019.

INTRODUCTION: polio eradication initiatives started in 1988, this is almost the past 32 years following the WHA resolution 41.8 of eradicating polio by the year 2000. As of 2019, only 3 countries remained to be polio endemic globally, Afghanistan, Pakistan and Nigeria. The east and southern sub-region countries had shown progressive achievement towards polio eradication and to start with the African regional certification. The availability of sensitive AFP surveillance performance is among important strategies in the achievement of polio eradication. We, therefore, decided to conduct this assessment of AFP performance from 2012 to 2019 in the ESA sub-region have evidence documentation and support the certification process of the WHO AFRO region. METHODS: we reviewed all reported acute flaccid paralysis (AFP) cases from 19 countries in the ESA sub region with the date of onset of paralysis from 1 January 2012 to 31 December 2019. The data were run to descriptive analysis based on the personal characteristics and AFP surveillance performance indicators parameters. RESULTS: a total of 46,014 AFP cases were reported from 19 countries in the ESA countries who were paralyzed from 1 January 2012 to 31 December 2019. The most affected age group was children aged 0 to 3 years old where 19,740 children with acute paralysis were reported representing 42.9% of the total reported AFP for the period. The overall assessment of the non-polio AFP rate, there is an increase from a rate of 2.7 in 2012 to 3.5 in 2019 per 100,000 population aged less than 15 years, reflects a significant change with a p-value of 0.040 (95% C.I. ranges from 0.035 to 1.564). Furthermore, the percentage of stool adequacy raised from 86.4% in 2012 to 88.5% in 2019, with an observed 2.1% difference and no significant change over the 8 years. CONCLUSION: we observed an overall increase in the sensitivity of the AFP surveillance performance for the ESA sub-region countries from 2012 to 2019 using the national performance indicators. The COVID-19 pandemic paused an operational challenge for AFP surveillance performances from 2020. A further subnational surveillance performance analysis is suggested.

Design and Implementation of an Analgesia, Sedation, and Paralysis Order Set to Enhance Compliance of pro re nata Medication Orders with Joint Commission Medication Management Standards in a Pediatric ICU.

BACKGROUND: The use of pro re nata (PRN) medication orders increases nursing flexibility and efficiency of bedside patient care. However, misuse and/or ambiguity of PRN medication orders may increase the propensity for medication errors. The Joint Commission has Medication Management (MM) standards to mitigate such risks. This quality improvement study with a pre-post design aimed to increase compliance of PRN sedative and analgesic orders with use of failure mode and effects analysis (FMEA) and human factors risk assessment methodologies in a pediatric ICU (PICU). METHODS: Staff education and a PICU analgesia, sedation, and paralysis order set, with predefined PRN orders, were implemented to enhance PRN medication compliance with Joint Commission MM standards. The primary goal was to achieve and maintain a weekly average compliance of ≥ 90%. Proportions of compliant PRN analgesic and sedative orders before and after interventions were compared. RESULTS: Weekly average PRN orders compliance increased from 62.0% ± 9.2% to 77.7% ± 10.1% after staff education was implemented (p = 0.013). After order set implementation, weekly average compliance further increased to 93.2% ± 3.6% (p < 0.0001) and remained > 90% until the end of the study period. CONCLUSION: Interdisciplinary synthesis using FMEA and human factors risk assessment is effective for identifying system failure modes associated with Joint Commission MM standard noncompliance. Implementation of an order set with forced functionality to include order information compliant with Joint Commission MM standards can enhance and maintain Joint Commission-compliant PRN medication orders.

A Multicenter Network Assessment of Three Inflammation Phenotypes in Pediatric Sepsis-Induced Multiple Organ Failure.

OBJECTIVES: Ongoing adult sepsis clinical trials are assessing therapies that target three inflammation phenotypes including 1) immunoparalysis associated, 2) thrombotic microangiopathy driven thrombocytopenia associated, and 3) sequential liver failure associated multiple organ failure. These three phenotypes have not been assessed in the pediatric multicenter setting. We tested the hypothesis that these phenotypes are associated with increased macrophage activation syndrome and mortality in pediatric sepsis. DESIGN: Prospective severe sepsis cohort study comparing children with multiple organ failure and any of these phenotypes to children with multiple organ failure without these phenotypes and children with single organ failure. SETTING: Nine PICUs in the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS: Children with severe sepsis and indwelling arterial or central venous catheters. INTERVENTIONS: Clinical data collection and twice weekly blood sampling until PICU day 28 or discharge. MEASUREMENTS AND MAIN RESULTS: Of 401 severe sepsis cases enrolled, 112 (28%) developed single organ failure (0% macrophage activation syndrome 0/112; < 1% mortality 1/112), whereas 289 (72%) developed multiple organ failure (9% macrophage activation syndrome 24/289; 15% mortality 43/289). Overall mortality was higher in children with multiple organ and the phenotypes (24/101 vs 20/300; relative risk, 3.56; 95% CI, 2.06-6.17). Compared to the 188 multiple organ failure patients without these inflammation phenotypes, the 101 multiple organ failure patients with these phenotypes had both increased macrophage activation syndrome (19% vs 3%; relative risk, 7.07; 95% CI, 2.72-18.38) and mortality (24% vs 10%; relative risk, 2.35; 95% CI, 1.35-4.08). CONCLUSIONS: These three inflammation phenotypes were associated with increased macrophage activation syndrome and mortality in pediatric sepsis-induced multiple organ failure. This study provides an impetus and essential baseline data for planning multicenter clinical trials targeting these inflammation phenotypes in children.

Acute Toxicity Assessment: Macroscopic and Ultrastructural Effects in Mice Treated with Oral Tetrodotoxin.

Tetrodotoxin (TTX) is an extremely toxic marine compound produced by different genera of bacteria that can reach humans through ingestion mainly of pufferfish but also of other contaminated fish species, marine gastropods or bivalves. TTX blocks voltage-gated sodium channels inhibiting neurotransmission, which in severe cases triggers cardiorespiratory failure. Although TTX has been responsible for many human intoxications limited toxicological data are available. The recent expansion of TTX from Asian to European waters and diversification of TTX-bearing organisms entail an emerging risk of food poisoning. This study is focused on the acute toxicity assessment of TTX administered to mice by oral gavage following macroscopic and microscopic studies. Necropsy revealed that TTX induced stomach swelling 2 h after administration, even though no ultrastructural alterations were further detected. However, transmission electron microscopy images showed an increase of lipid droplets in hepatocytes, swollen mitochondria in spleens, and alterations of rough endoplasmic reticulum in intestines as hallmarks of the cellular damage. These findings suggested that gastrointestinal effects should be considered when evaluating human TTX poisoning.