Outcomes of transcutaneous retrobulbar Amphotericin B (TRAMB) as an adjuvant therapy for rhino-orbital-cerebral mucormycosis (ROCM) following COVID-19.

PURPOSE: To assess the outcomes of transcutaneous retrobulbar Amphotericin B (TRAMB) for rhino-orbital-cerebral-mucormycosis (ROCM) post-COVID-19, as an adjuvant to standard systemic antifungal therapy. METHODS: In this prospective cohort study involving ROCM patients with clinical/radiological orbital involvement, 44 eyes with ROCM stage ≥ 3B received TRAMB for 7 consecutive days with liposomal Amphotericin-B (3.5 mg/ml) with a minimum clinical and radiological follow-up of 3 months. All patients received standard systemic antifungal therapy also as per institutional protocol. Data pertaining to demography, systemic status, clinical involvement, imaging, surgical/medical management were also recorded. Potential eyes for exenteration were excluded. Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 12 Given name: [Mahendra Kumar ] Last name [Garg]. Also, kindly confirm the details in the metadata are correct.All author names are presented accurately. Details in the metadata are correct. Thank you. RESULTS: Forty-four eyes of 42 patients were included, out of which 30 had diabetes mellitus & 22 had received steroid/oxygen treatment during COVID-19 infection. Forty eyes showed improvement or stable disease on follow-up on radiology. Four eyes which showed progression of the disease in orbit were reaugmented with TRAMB. No patient required exenteration. Subconjunctival haemorrhage occurred in six eyes and temporary blurring of vision in four eyes after TRAMB which resolved spontaneously. CONCLUSION: TRAMB, as an adjuvant to standard systemic antifungal therapy, is associated with a significant reduction or stabilisation of orbital involvement. TRAMB should be considered as an adjuvant therapy for ROCM to reduce disease progression as well as to preserve globe or sight. It has a promising role in preventing potential orbital exenterations.

TSANZSRS 2023 Australia and New Zealand Society of Respiratory Science and The Thoracic Society of Australia and New Zealand (ANZSRS/TSANZ) Annual Scientific Meeting for Leaders in Lung Health and Respiratory Science

The proceedings contain 360 papers. The topics discussed include: comparison of three methods assessing spirometry bronchodilator responsiveness in children;the quality of spirometry testing: a systematic review;airflow severity in asthma minimally affects within-session oscillometry variability;corrected normative multiple breath washout data in pre-school aged children;prevalence and predictors of tidal expiratory-flow-limitation in healthy adolescents/young adults;impact of change of significant bronchodilator response definition;volume-dependence of reactance as a measure of ventilation inhomogeneity;mechanisms of impaired gas exchange following hospitalization for severe COVID-19;increased shunt and dead space in recovered COVID-19 pneumonitis patients;airway hyperresponsiveness detection in atopic asthma using exhaled nitric oxide;increased conductive ventilation heterogeneity following exposure to coal-mine fire smoke;accuracy of transcutaneous carbon dioxide monitoring during sleep studies;and effect of hematopoietic stem cell transplant on small airways function.

Transcranial and Transcutaneous Stimulation for Pain: What Have We Learned From the COVID-19 Pandemic Shutdown?

BACKGROUND: Transcranial magnetic stimulation (TMS) and transcutaneous magnetic stimulation (tMS) offer a novel noninvasive treatment option for chronic pain. While the recent COVID-19 pandemic caused by the SARS-CoV-2 virus resulted in a temporary interruption of the treatments for patients, it provided an excellent opportunity to assess the long-term sustainability of the treatment, and the feasibility of resuming the treatments after a brief period of interruption as no such data are available in current literature. METHODS: First, a list of patients whose pain/headache conditions have been stably controlled with either treatment for at least 6 months prior to the 3-month pandemic-related shutdown was generated. Those who returned for treatments after the shutdown were identified and their underlying pain diagnoses, pre- and posttreatment Mechanical Visual Analog Scale (M-VAS) pain scores, 3-item Pain, Enjoyment, and General Activity (PEG-3), and Patient Health Questionnaire-9 scores were assessed in 3 phases: Phase I (P1) consisted of a 6-month pre-COVID-19 period in which pain conditions were stably managed with either treatment modality; Phase II (P2) consisted of the first treatment visit period immediately after COVID-19 shutdown; and Phase III (P3) consisted of a 3-4 month post-COVID-19 shutdown period patients received up to 3 sessions of either treatment modality after the P2 treatment. RESULTS: For pre- and posttreatment M-VAS pain scores, mixed-effect analyses for both treatment groups demonstrated significant (P < 0.01) time interactions across all phases. For pretreatment M-VAS pain scores, TMS (n = 27) between-phase analyses indicated a significant (F = 13.572, P = 0.002) increase from 37.7 ± 27.6 at P1 to 49.6 ± 25.9 at P2, which then decreased significantly (F = 12.752, P = 0.001) back to an average score of 37.1 ± 24.7 at P3. Similarly, tMS (n = 25) between-phase analyses indicated the mean pretreatment pain score (mean ± standard deviation [SD]) increased significantly (F = 13.383, P = 0.003) from 34.9 ± 25.1 at P1 to 56.3 ± 27.0 at P2, which then decreased significantly (F = 5.464, P = 0.027) back to an average score of 41.9 ± 26.4 at P3. For posttreatment pain scores, the TMS group between-phase analysis indicated the mean posttreatment pain score (mean ± SD) increased significantly (F = 14.206, P = 0.002) from 25.6 ± 22.9 at P1 to 36.2 ± 23.4 at P2, which then significantly decreased (F = 16.063, P < 0.001) back to an average score of 23.2 ± 21.3 at P3. The tMS group between-phase analysis indicates a significant (F = 8.324, P = 0.012) interaction between P1 and P2 only with the mean posttreatment pain score (mean ± SD) increased from 24.9 ± 25.7 at P1 to 36.9 ± 26.7 at P2. The combined PEG-3 score between-phase analyses demonstrated similar significant (P < 0.001) changes across the phases in both treatment groups. CONCLUSIONS: Both TMS and tMS treatment interruptions resulted in an increase of pain/headache severity and interference of quality of life and functions. However, the pain/headache symptoms, patients' quality of life, or function can quickly be improved once the maintenance treatments were restarted.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh.

BACKGROUND: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh. METHODS: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs. RESULTS: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers. CONCLUSION: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

Remote monitoring and virtual follow-up ventilation clinics in the age of Covid-19

Background: To review the efficacy of long-term non-invasive ventilation (LTV) with virtual follow-up, using assistive technologies and remote monitoring. Objective(s): Compliance greater than 4 hours, correction of hypercapnia and improvements in sleep and quality of life (QoL) were the objectives in improving patient outcome. Method(s): We conducted a retrospective cohort study including patients established on LTV over an 18 month period from the start of the pandemic. Initiation of LTV was established as an inpatient (n= 17;35%), outpatient (n= 28;57%) or from the patient's home (n= 4;8%) and follow-up was by telephone, video consultation or from the patient's own home. LTV was considered successful if compliance achieved was > 4 hours using remote monitoring, corrected hypercapnia (tCO2 < 6.5Kpa) and patient-reported improvements in sleep and QoL. Result(s): Forty-nine patients were included. LTV was initiated for: neuromuscular disease (n=19;39%), obesity hypoventilation or overlap (n=12;24%), chronic obstructive pulmonary disease (n=11;22%) and chest wall deformity (n=6;14%). Compliance > 4 hours was achieved in 69% with effective correction of hypercapnia (tCO2 < 6.5Kpa) in 67% and reported improved sleep and QoL at 63%. Overall success in all 3 objectives was 61%. Patient preference for future follow-up was 45% requesting face-to-face consultations and 33% to continue remotely. A proportion of the most vulnerable (14%) would prefer to be seen at home. Conclusion(s): Successful LTV can be achieved with remote compliance data and transcutaneous carbon dioxide monitoring to support virtual clinics. Patient preference for face-to-face consultations remains important in overall satisfaction.

Clinical usefulness of transcutaneous laryngeal ultrasonography in otolaryngology practice during COVID-19 pandemic: a literature review.

As a consequence of the outbreak of SARS-CoV-2, the clinical practice of otolaryngologists underwent profound transformations. Non-aerosol-generating procedures have been researched and implemented. Transcutaneous laryngeal ultrasonography (TLUSG) provides a rapid and noninvasive method to assess laryngeal function and can support the management of laryngeal disorders. With the aim of investigating the clinical usefulness of TLUSG in otolaryngology practice, a review of the literature published on PubMed, Cochrane Library and Ovid/ Medline databases was performed up to March 2022. 38 studies were eligible to be included in the review. The selected papers were divided into six topics of interest: evaluation of vocal cords function, diagnosis of laryngeal disorders in infants and children, evaluation of swallowing disorders, assessment of laryngeal cancer and other laryngeal lesions, ultrasound-guided cricothyroidotomy, ultrasound-guided laryngeal electromyography. The results of this review demonstrated that TLUSG, applied to ENT practice, can be a valid method for dynamic laryngeal assessment and airway management, since it is time-efficient, non invasive, well tolerated and easily performed.

Air-permeable redox mediated transcutaneous CO2 sensor.

Standard clinical care of neonates and the ventilation status of human patients affected with coronavirus disease involves continuous CO2 monitoring. However, existing noninvasive methods are inadequate owing to the rigidity of hard-wired devices, insubstantial gas permeability and high operating temperature. Here, we report a cost-effective transcutaneous CO2 sensing device comprising elastomeric sponges impregnated with oxidized single-walled carbon nanotubes (oxSWCNTs)-based composites. The proposed device features a highly selective CO2 sensing response (detection limit 155 ± 15 ppb), excellent permeability and reliability under a large deformation. A follow-up prospective study not only offers measurement equivalency to existing clinical standards of CO2 monitoring but also provides important additional features. This new modality allowed for skin-to-skin care in neonates and room-temperature CO2 monitoring as compared with clinical standard monitoring system operating at high temperature to substantially enhance the quality for futuristic applications.

Analysis of ophthalmic manifestations of invasive rhino-orbito-cerebral mucormycosis in COVID-19 patients in a medical college

Purpose: To analyze different ophthalmic manifestations of rhino-orbital mucormycosis (ROM) infection in COVID-19 patients. Study Design: Prospective interventional clinical study. Materials and Methods: 20 microbiologically confirmed ROCM cases with ophthalmic involvement hospitalized between May 2021 and July 2021 in our center were included in this study. Results: Among 20 cases there were 9 female and 11 male with a mean age of 57.5 years. All 20 patients had uncontrolled type 2 diabetes with a mean diagnosis duration of 3.67 years. All patients had COVID-19-associated acute respiratory distress syndrome and received corticosteroids. The mean time interval between COVID-19 diagnosis and ROM diagnosis was 3.46 days. 4 patients (20%) had orbital apex syndrome, and 16 patients (80%) presented with orbital cellulitis. CT scan/MRI revealed sino-orbital involvement in all patients, and 3 of these had cerebral involvement at initial presentation. All 20 patients received intravenous amphotericin B and 7 patients received TRAMB and all 20 patients had undergone radical debridement of involved sinuses. Despite all measures, 3 (7.5%) of 20 patients with cerebral dissemination expired. Conclusions: Severe COVID-19 is associated with a significant incidence of ROM with higher mortality rates due to immune dysregulation and the widespread use of steroids. An aggressive multidisciplinary approach can help to reduce mortality. © 2022 Innovative Publication, All rights reserved.

Mucormycosis—The Rising Epidemic in a Pandemic: An Observational Case Study in a Tertiary Care Hospital

Mucormycosis is a rare and ominous fungal disease caused by the order Mucorales fungi. As per Indian data, uncontrolled diabetes is the main risk factor associated with mucormycosis. But during this SARS COV-2 pandemic, a huge rise in the number of mucormycosis cases has been observed in different states in India in last 10-12 months in the second wave. The immune dysfunction caused by this virus and the use of high doses of steroids appears to be a double-edged sword and causes immunosuppression with hyperglycemia, increasing the risk of secondary bacterial and invasive fungal infections (IFIs). Objective We conducted a prospective observational study involving individuals with proven mucormycosis in ABVIMS & Dr RML Hospital, New Delhi. The demographic profile with various clinical presentations, histopathological findings, predisposing factors, management, and final outcomes were recorded. Results We included 53 patients in our study. Rhino-orbital-cerebral mucormycosis was the most common (21/53, 39.6%) presentation followed by rhino-orbital (17/53, 32.0%), rhino-cerebral (10/53, 18.8% ) rhinosinusitis (4/53, 7.5%) and pulmonary involvement in 1/53, (1.8%). The cutaneous involvement was seen in 8 patients (15.0%), disseminated mucormycosis as meningitis in 2 patients (3.7%), and dual fungal infection with aspergillosis was seen in 2 patients (3.7%). The predisposing factors being diabetes mellitus (40/53, 75.4%), with newly diagnosed diabetes in previously undiagnosed (10/ 53, 18.8%), SARS-COV-2 (33/53, 62.2%), steroid intake (30/53, 56.6% ), prolonged hospital stay (29/53, 54.7%), use of oxygen therapy (19/53, 35.8%), and diabetic ketoacidosis in 2 patients (3.7%) Amphotericin B (liposomal form) was the primary therapy in all 53 patients. Hypokalemia (8/53, 15.0%) was seen as side effect of amphotericin-B although renal functions were normal in all patients. Surgical debridement was performed in 43(77.3%) patients and transcutaneous retrobulbar amphotericin-B (TRAMB) was given in 16 patients (30.1%). Total mortality in our study is of 9 patients (16.9%). Conclusions Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis which also includes newly diagnosed diabetes. Hyperglycemia and immune dysregulation by SARS-CoV-2 and high dose corticosteroid use on large scale served a favorable environment for this invasive fungus.

Efficacy of transcutaneous posterior tibial nerve stimulation in functional constipation.

Most children with functional constipation (FC) improve with conventional treatments. However, a proportion of children have poor treatment outcomes. Management of intractable FC may include botulinum toxin injections, transanal irrigation, antegrade enemas, colonic resections, and in some cases sacral nerve stimulation (SNS). SNS is surgically placed, not readily available and expensive. Posterior tibial nerve stimulation (PTNS) allows transmission of electronic impulses and retrograde stimulation to the sacral nerve plexus in a portable, simple and non-invasive fashion. To assess the efficacy and safety of transcutaneous PTNS for the treatment of FC in children. Single-center, prospective interventional study. Children 4-14 years with Rome IV diagnosis of FC received ten daily PTNS (30 min/day) sessions. Electrodes placed over skin of ankle. Strength of stimulus was below pain threshold. Outcomes were assessed during treatment and 7 days after. Twenty-three subjects enrolled. Two children excluded (acute gastroenteritis, COVID-19 contact). Twenty completed the study (4-14 years), (8.4 ± 3.2 years, 71.4% female). We found significant improvement in the consistency of bowel movements (BM) (p = 0.005), fecal incontinence (FI) (p = 0.005), abdominal pain presence (p = < 0.001) and intensity (p = 0.005), and a significant for improvement in blood in stools (p = 0.037). There was 86.3% improvement in abdominal pain. 96.7% reported treatment satisfaction. Only one child required rescue therapy. CONCLUSION: We found significant improvement in stool consistency, FI, abdominal pain, and hematochezia. This suggests that transcutaneous PTNS could be a promising noninvasive treatment for FC in children. Large studies are needed. WHAT IS KNOWN: • Functional constipation is one of the most common disorders in children. • Current management of functional constipation consists of an integrative approach that includes medications, diet and behavioral strategies. WHAT IS NEW: • Posterior tibial nerve stimulation is a novel noninvasive and easy to use therapy that can improve stool consistency, fecal incontinence and blood in stools.

Transcutaneous electrical nerve stimulation for at-home treatment of nocturnal enuresis in children: Determining optimal pad placement

Introduction: Nocturnal enuresis (NE) is a common problem encountered in children that can be recalcitrant to currently available treatment options. Neuromodulation techniques are used to treat various urologic disorders but can be limited by convenience and compliance. Transcutaneous electrical nerve stimulation (TENS) is a neuromodulator that can be used at home to treat various conditions. The aim of this study was to determine if TENS can be offered as an effective at-home option that shows durability for NE in children, and to determine which pad placement is the most efficacious. Materials & Methods: A randomized clinical trial including 90 patients aged 5-18 years presenting with monosymptomatic NE was performed. After one month of behavioral therapy, they were treated with TENS therapy after randomization to three groups based on pad placement: suprapubic (SP), parasacral (PS), and ankle/posterior tibial (PT). TENS therapy was performed nightly for one month. Voiding diaries recording the number of wet nights, wet scale severity score (0-3), TENS compliance, quality of life (QOL) questionnaires, and any adverse reactions were collected monthly at baseline, during TENS therapy, and after TENS for durability assessment, and statistically analyzed after study completion. Results: No patient was cured of NE, and our study failed to show a statistical difference between the study arms in enuresis frequency during TENS. The only statistically significant improvement was QOL during TENS therapy (2.95 improvement for the PT group versus 1.2 and 1.5 regression for SP and PS groups, respectively, p=0.003). PT TENS therapy also showed improvements for enuresis frequency with 2.7 less episodes/month (versus 4.1 and 8.2 more episodes/month in the SP and PS groups, respectively, p=0.06) and the severity of wetness each night with a 0.17 improvement (versus 0.06 and 0.13 regression in the SP and PS groups, respectively, p=0.06) after TENS therapy was completed, however these did not meet statistical significance. Patients were compliant with using TENS therapy (90% or more in all groups) and there were no adverse events. Discussion: This study found that patients who used the PT pad placement for TENS showed significant improvements in QOL during therapy, however we were unable to show a significant difference in enuresis frequency during TENS between groups. The major limitation of our study was the high number of patients lost to follow-up during the COVID-19 pandemic. Conclusion: TENS therapy when combined with behavioral techniques can be an easy and safe tool that can be used at home to help treat NE, however, further studies are needed to optimize this type of therapy to show a clinically significant benefit.

Outcomes of Transcutaneous Retrobulbar Amphotericin B in Rhino-Orbital-Cerebral Mucormycosis Among Patients Recovering From COVID-19: A Preliminary Experience.

Background In this study, we aimed to assess the outcomes of transcutaneous retrobulbar injection of amphotericin B (TRAMB) in rhino-orbital-cerebral mucormycosis (ROCM) among patients recovering from coronavirus disease 2019 (COVID-19). Methodology This retrospective study was conducted at a tertiary care center in eastern India from May 29th to July 31st, 2021, and included post-COVID-19 patients admitted with stage 3 and 4a ROCM who underwent TRAMB. The details of the ophthalmic examination, laboratory investigations, and radiological examination were retrieved from patients records. Patients were given TRAMB (3.5 mg/mL) on alternate days till they underwent debulking surgery and resumed from the second postoperative day alternatively till the patients showed clinical stabilization or improvement. Results In total, 45 eyes of 41 patients were included in the study. The median number of injections given was six (minimum = 3; maximum = 10). Following was the distribution of number of injection needed in each eye: eight eyes (three injections), six eyes (four injections), seven eyes (five injections), three eyes (six injections), eight eyes (seven injections), 11 eyes (eight injections), and one eye had received nine and ten injections each. Overall, 21/32 (65.62%) eyes had improvement in proptosis whereas 9/32 (28.12%) had improvement in ptosis. Six patients had improvement in extraocular movement. In total, 25 eyes had no improvement whereas seven eyes had improvement in vision. Four eyes underwent exenteration. All nine patients with limited orbital disease had good improvement with fewer injections (median = 4). None of the patients undergoing TRAMB had an intracranial extension of disease. Moreover, 8.88% (4/45) of the eyes had post-TRAMB transient inflammation which resolved without any intervention. Finally, 3/41 of the patients died. Conclusions TRAMB can be considered as an useful therapeutic adjunct in managing ROCM. Further, it can halt the progression of the disease while awaiting definitive surgical intervention.

Transcutaneous auricular vagal nerve stimulation releases extrapineal melatonin and reduces thermal hypersensitivity in Zucker diabetic fatty rats.

Type 2 diabetes (T2D) is the most common comorbidity of COVID-19, and both are related to the lack of circulating melatonin. In addition, chronic pain is a common sequela of both COVID-19 and T2D. Using a neuropathic pain model produced by sciatic nerve chronic constriction injury in Zucker diabetic fatty rats, a verified preclinical genetic T2D neuropathy animal model, this study aimed to show that transcutaneous auricular vagal nerve stimulation (taVNS) could elevate plasma melatonin concentration, upregulate the expression of melatonin receptors (MTRs) in the amygdala, and relieve peripheral neuropathic pain. Furthermore, taVNS would restore melatonin levels and relieve pain even in pinealectomized rats. On the contrary, intraperitoneally injected luzindole, a melatonin receptor antagonist, would attenuate the antinociceptive effects of taVNS. In conclusion, the mechanism of the therapeutic effect of taVNS on chronic pain involves the release of extrapineal melatonin and the positive regulation of the expression of central MTRs. This beneficial efficacy should be considered during COVID-19 rehabilitation in individuals with diabetes.

Post-Covid Cerebral Mucormycosis, Varied Presentations and Surgical Strategies of a Newer Epidemic: An Institutional Experience.

Context: During the challenging second wave of the COVID-19 pandemic, we encountered a most dreadful fungal infection in the form of COVID-associated mucormycosis (CAM), with a varied pattern of presentation from previous experience. Patients presented with simple fungal sinusitis or more complicated brain abscesses, and newer manifestations such as skull osteomyelitis. We report our findings and innovative treatment strategies used to manage this morbid condition. Objectives: To study the various presentations and surgical strategies in treating post-COVID rhino-orbito-cerebral mucormycosis (ROCM). Settings and Design: Observational cross-sectional study. Methods and Materials: From May to October 2021, 270 patients with CAM were admitted to Andhra Medical College Department of Neurosurgery, King George Hospital, Visakhapatnam, India. A cohort of 61 cases with intracranial involvement was studied in detail. The varied presentations and different or innovative treatment modalities were analyzed. Results: The death rate was 30/270 in the whole cohort, and three deaths (4.9%) occurred in 61 cases with cranial involvement. Thirty-three (54.1%) of the 61 cases were treated surgically: 17 patients required bone excision (for focal osteomyelitis) and 16 cases required abscess drainage/excision. Conclusions: Post-COVID mucormycosis (especially with intracranial involvement) is a highly challenging entity. A multidisciplinary approach with early and aggressive anti-fungal medication combined with timely surgical interventions offers some hope of overcoming this complex infection in CAM patients. We identified some novel techniques during regular follow-up that have proven helpful in combatting this devastating condition.

Abstracts from the IFESS 2021 conferences

The proceedings contain 53 papers. The topics discussed include: evoked sensations with sinusoidal transcutaneous electrical stimulation at different frequencies;IMU triggered FES for robotic gait training;trans-spinal electrical stimulation for improving trunk and sitting function in tetraplegics with cervical cord injury;a combined approach to CNS excitation for hand rehabilitation: a case study using spinal stimulation and BCI;analysis of the movements generated by a multi-field FES device for upper extremity rehabilitation;and neuromuscular and functional electrical stimulation for motor recovery after COVID-19: systematic review.

Microneedle-based two-step transdermal delivery of Langerhans cell-targeting immunoliposomes induces a Th1-biased immune response.

Novel Coronavirus is affecting human's life globally and vaccines are one of the most effective ways to combat the epidemic. Transcutaneous immunization based on microneedle (MN) has attracted much attention because of its painlessness, rapidity, high efficiency and good compliance. In this study, CD11c monoclonal antibody-immunoliposomes (OVA@CD11c-ILP) actively targeting to Langerhans cells (LCs) were successfully prepared and were delivered by the microchannels of skin produced by MN to induce an immune response in vivo. OVA@CD11c-ILP could be targeted to LCs by conjugating CD11c monoclonal antibody to the surface of the ILP. OVA@CD11c-ILP promoted the maturation of dendritic cells (DCs) and the uptake and endocytosis of antigen by LCs. Moreover, OVA@CD11c-ILP immunization can significantly inhibit tumor growth and prolong overall survival. Furthermore, a higher antibody's titer ratio of IgG1/IgG2a indicated that the immune response stimulated by this immunization method was Th1-biased and the liposomes showed Th1-type adjuvant effect. In conclusion, the combination delivery system of immunoliposomes and microneedle can significantly improve the efficiency of antigen presentation and effectively activate cellular immune responses in the body, which is expected to be a promising transdermal immune strategy.

Analysis of COVID-19-associated rhino-orbital-cerebral mucormycosis patients in a tertiary care center in Northern India.

Purpose: An unprecedented surge has been noted in rhino-orbital-Cerebral mucormycosis (ROCM) in times of current COVID-19 pandemic. The present prospective study aims to evaluate clinico-epidemiological profile, risk factors, management, and outcome of the cases of ROCM that presented to our tertiary care center during the study period from April to June 2021. Methods: All patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were staged and were treated with intravenous liposomal amphotericin B (AMB) and sino-nasal debridement of local necrotic tissue. Transcutaneous retrobulbar AMB (TRAMB), orbital decompression, and exenteration were instituted as indicated. All patients were followed up for a minimum of 6 months before arriving at the final outcome. Statistical analysis was performed. Results: A total of 49 patients presented during the study period, with a mean age of 42.2 years. The major risk factors included uncontrolled diabetes (89.8%), COVID-19 positivity (51.02%), and concurrent steroid use (38.77%). The most common presenting symptom was facial pain/swelling (43.65%), while the most common presenting sign was deterioration in vision (75.51%). Intravenous liposomal AMB was given to all patients along with sino-nasal debridement (85.71%), TRAMB (57.14%), orbital decompression (14.28%), and exenteration (12.24%). Overall, mortality at 6 months was 22.45% (11 patients). Age more than 60 years, intracranial extension, and HbA1c of more than 8.0% were observed to be statistically significant indicators of mortality. Conclusion: Early suspicion and timely diagnosis of mucormycosis at rhino-orbital stage is warranted in order to salvage life as well as visual function. TRAMB may prove as potentially favorable treatment modality in cases with limited orbital involvement.

Facilitators and Barriers to Implementation of a Transcutaneous Electrical Nerve Stimulation Intervention in a Pragmatic Clinical Trial

Fibromyalgia TENS in Physical Therapy (PT) Study (FM-TIPS) is testing feasibility and efficacy of Transcutaneous Electrical Nerve Stimulation (TENS). We present our experience for implementing TENS into PT clinics and virtual training to participants on TENS in a pragmatic clinical. FM-TIPS is a pragmatic, cluster-randomized clinical trial examining if the addition of TENS to routine PT improves movement-evoked pain in fibromyalgia (FM). FM patients (n=600) will be enrolled from 35 PT clinics across six Midwest healthcare systems into either a TENS or no-TENS group. All subjects randomized by TENS clinics receive TENS starting on Day 1. The no-TENS clinics start after completion of the primary outcome on Day 60. In the TENS group, Physical therapists (PTs) provide TENS education in person, while in the no-TENS group, study staff provide TENS education virtually. To facilitate implementation, we selected a study-specific TENS unit that provides mixed frequency TENS with intensity as the only adjustable parameter. All PTs were trained in proper use of the TENS unit in-person. While most PTs embraced the addition of TENS, some had not used TENS and had difficulty adapting practice to include TENS. For virtual visits in the no-TENS group, a standardized procedure was developed and completed by study staff PTs. TENS units were shipped to subject's and zoom visits were scheduled at the subject's convenience within a 10-day window. Most subjects completed virtual TENS training and implementation without difficulties. Technology limitations provided a significant barrier for some subjects. Most clinics have adopted and incorporated TENS intervention. Implementing virtual TENS training in a pragmatic trial can be successful for participant intervention. Due to the current COVID-19 pandemic, participants are more aware of the need to complete interventions via virtual mechanisms. Barriers to virtual TENS instruction are often due to internet and device limitations. FM-TIPS work is supported by the National Institutes of Health (NIH) through the NIH HEAL Initiative under award number UG3AR076387 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. This work also received logistical and technical support from the PRISM Resource Coordinating Center under award number U24AT010961 from the NIH through the NIH HEAL Initiative. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or its HEAL Initiative.

Transcutaneous laryngeal ultrasonography in vocal fold assessment before and after thyroid surgery in light of recent studies.

Transcutaneous laryngeal ultrasonography (TLUS) has become a cheap, convenient, and novel method in vocal fold (VF) assessment. The gold standard method of VF examination is laryngoscopy. It requires ear, nose, and throat specialist consultation and additional equipment. Moreover, laryngoscopy causes distress to patients, and during the COVID-19 pandemic it is a high-risk, aerosol-producing procedure. The aim of the paper was to review publications on the role of TLUS in VF evaluation. Considered aspects included VF visibility, factors affecting them, and different variables measured during TLUS examination. The visibility of VFs in TLUS ranged from 72.8 to 100%. Among men it was significantly lower (17-100%) in comparison to women (83-100%). All but 2 authors concluded that TLUS is a viable tool that can be an alternative to laryngoscopy in diagnosing VFs. Obesity, age, male gender, height, calcified thyroid, and incision close to the thyroid cartilage were independent factors for inaccessible vocal folds. VF displacement velocity (VFDV) is the most objective parameter measured by Doppler, and it is proportional to the velocity of the wave causing the vibrations of the VFs. After VF paralysis, this parameter is reduced. Valsalva manoeuvre, low-frequency transducer, and different transducer positions can improve images obtained on USG. TLUS in a majority of cases can adequately assess whether the function of the VFs is intact or paresis/paralysis has occurred. It is noninvasive and rapid, it adds no extra cost, and it can be a part of the preoperative examination of the thyroid gland. TLUS can usually be a convenient alternative to laryngoscopy.