Increased brain activation during motor imagery suggests central abnormality in Neonatal Brachial Plexus Palsy.

Neonatal Brachial Plexus Palsy (NBPP) may lead to permanent impairment of arm function. As NBPP occurs when central motor programs develop, these may be ill-formed. We studied elbow flexion and motor imagery with fMRI to search for abnormal motor programming. We compared the cortical activity of adults with conservatively treated NBPP to that of healthy individuals stratified for hand dominance, using fMRI BOLD tasks of elbow flexion and motor imagery of flexion. Additionally, resting-state networks and regional gray matter volume were studied. Sixteen adult NBPP patients (seven men; median age 29 years) and sixteen healthy subjects (seven men, median age 27 years) participated. Cortical activation was significantly higher in patients during flexion imagery compared to healthy individuals and it increased with lesion extent and muscle weakness. The contralateral and ipsilateral premotor cortex, and the contralateral motor cortex showed stronger activity during imagined flexion in the right-handed NBPP subjects compared to healthy individuals. Activity patterns during actual flexion did not differ between groups. No differences in resting-state network connectivity or gray matter amount were found between the groups. NBPP affected imagined but not actual elbow flexion, suggesting an impairment of motor planning which would indicate abnormal motor programming in NBPP.

Shoulder Function and Bone Mineralization in Children with Obstetric Brachial Plexus Injury After Neuromuscular Electrical Stimulation During Weight-Bearing Exercises.

OBJECTIVE: The purpose of this study was to evaluate the effects of neuromuscular electrical stimulation during weight-bearing exercises on shoulder function and bone mineral density (BMD) in children with obstetric brachial plexus injury (OBPI). DESIGN: This study was a randomized controlled trial. Forty-two children with OBPI were recruited. Their ages ranged from 3 to 5 years. They were randomly assigned either to control group (received a selected program) or study group (received the same program as the control group and neuromuscular electrical stimulation during weight bearing). Mallet grading system and dual-energy x-ray absorptiometry were used to evaluate shoulder function and BMD respectively at entry and after intervention (3 months later). RESULTS: No significant differences of the outcome measures were detected at entry. Significant differences were observed within both groups when the pre and post treatment scores within each group were compared. Finally, significant differences favoring the study group were recorded when their post treatment scores were compared. CONCLUSION: Neuromuscular electrical stimulation during weight bearing exercises is an effective and simple method to improve shoulder function and BMD in children with OBPI.

Therapeutic application of electrical stimulation and constraint induced movement therapy in perinatal brachial plexus injury: A case report.

Infants and children with perinatal brachial plexus injury (PBPI) have motion limitations in the shoulder, elbow, forearm and hand that are dependent on the level of injury and degree of recovery. The injury and subsequent recovery period occur during critical periods of central and spinal neural development placing infants and children at-risk for developmental disregard and disuse of the affected arm and hand. A case report outlines the therapy and surgical interventions provided in the first 2 years of life for a child with global PBPI and a positive Horner's sign. Electrical stimulation and constraint induced movement therapy provided sequentially were effective therapy interventions. Neurosurgery to repair the brachial plexus was performed at an optimal time period.(2) The Assisting Hand Assessment,(12) Modified Mallet(13) and Active Movement Scale(14) are effective outcome measures in PBPI and served as valuable guides for therapy intervention. Oxford Level of Evidence: 3b; Individual Case Control Study.

The epidemiology and management of gynatresia in Lagos, southwest Nigeria.

OBJECTIVE: To document data from patients presenting with gynatresia at 2 tertiary health centers in Lagos, southwest Nigeria. METHODS: In a prospective, descriptive study, clinical history and physical examination data were collected for women who presented with gynatresia between January 2004 and January 2011. Ultrasonography results and abnormality at surgery were also documented. Where possible, the severity of stenosis and surgical outcome were assessed by published scales. RESULTS: Forty-seven patients were included in the study. Eight patients (17.0%) presented with congenital gynatresia, the commonest cause of which was Mayer-Rokitansky-Küster-Hauser syndrome (4 patients, 50%). Thirty-nine patients (83.0%) presented with acquired gynatresia, the main cause of which was herbal pessaries (30 patients, 76.9%). Herbal pessaries were used to treat fibroids (23 patients, 76.7%), uterovaginal prolapse (3, 10.0%), and infertility (2, 6.7%); and to procure abortion (2, 6.7%). The ages of the patients who used herbal pessary ranged from 18 to 50 years (mean 36.10 ± 1.24 years). Other causes of acquired gynatresia were birth injuries (6 patients, 15.4%), and female genital mutilation (2, 5.1%). CONCLUSION: Acquired gynatresia was more common in Lagos than congenital gynatresia. The causes of acquired gynatresia are preventable and could be eliminated by health education.

Analysis of auditory function using brainstem auditory evoked potentials and auditory steady state responses in infants with perinatal brain injury.

Approximately 2-4 % of newborns with perinatal risk factors present hearing loss. The aim of this study was to analyse the auditory function in infants with perinatal brain injury (PBI). Brainstem auditory evoked potentials (BAEPs), auditory steady state responses (ASSRs), and tympanometry studies were carried out in 294 infants with PBI (586 ears, two infants had unilateral microtia-atresia). BAEPs were abnormal in 158 (27%) ears, ASSRs in 227 (39%), and tympanometry anomalies were present in 131 (22%) ears. When ASSR thresholds were compared with BAEPs, the assessment yielded 92% sensitivity and 68% specificity. When ASSR thresholds were compared with tympanometry results as an indicator of middle-ear pathology, the assessment gave 96% sensitivity and 77% specificity. When BAEP thresholds were compared with tympanometry results, sensitivity was 35% and specificity 95%. In conclusion, BAEPs are useful test for neonatal auditory screening; they identify with more accuracy sensorineural hearing losses. ASSRs are more pertinent for identifying conductive hearing loss associated with middle-ear pathology. The consistency and accuracy of these results could be considered in additional studies.

Stress urinary incontinence: an overview of diagnosis and treatment options.

Giving birth is known to create risk for various degrees of urinary incontinence (UI) at any time after the birth. Environmental and genetic factors predispose many women to pelvic floor disorders. When a woman determines she is incontinent and has approached her provider, she will need an accurate, proper diagnosis and then consider a selected course of treatment. It is imperative that she is informed of all choices so she can choose the treatment with which she is most comfortable, fits her lifestyle, and will improve her quality of life.

Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions.

OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

Birth delivery trauma and malocclusion.

The aim of the investigation was to determine the dynamic of birth delivery and relate to dental occlusion among a group of adult subjects. The group studied was made up of 106 subjects (57 females and 49 males) referred for dental diagnosis and treatment. The average age was 26 with a range 22 to 30 years. In data collection and analysis the following were used as measures: dental occlusion (Angle Class I, II div 1, II div 2 and III) and type of delivery (normal, short, long, caesarean and other). Results showed that among 106 subjects 72 (68%) had malocclusion versus 34 (32%) with normal occlusion; 24 subjects (22.6%) have been normal delivery versus 82 (77.4%) with non-normal delivery. Class I is present in 34 subjects (32%), class II division 1 in 26 (24%), class II division 2 in 22. (20%), class III in 16 (14%), and 8 subjects (6%) fall in the section "other". Among 24 subjects with normal delivery 100% presented class I occlusion. However, among 82 subjects with non-normal delivery 10 subjects had a class I (12.2%) and the 72 (87.8%) had in the other classes, are distributed in the various subgroups of non-normal labor/delivery. None of the subjects with a malocclusion have a normal labor/delivery. Better understanding of the connections among osteopathic theory, craniosacral treatment and the outcomes upon dental occlusion, more rigorous evaluations are warranted.

Evaluation on the therapeutic effects of digital acupoint pressure for obstetric spastic cerebral palsy.

To probe the evaluation methods for effects of TCM treatment of cerebral palsy through clinical observation on the digital acupoint pressure in treating obstetric spastic cerebral palsy. From 1998-2003, 40 cases of spastic cerebral palsy were treated with digital acupoint pressure therapy. Ten indexes including intelligence, language, salivation, hand-grasping, thumb-adduction, turnover, sitting, standing, walking, and scissors-gait were divided into the 4 grades of normal, mild abnormal, moderate abnormal, and severe abnormal (dysfunction), respectively marked as 6, 4, 2, and 0 point, with 2 points increased for improving each grade of each item after the treatment. Meanwhile, the ranges were recorded and evaluated before and after the treatment on shoulder-abduction, elbow-extension, wrist-extension, forearm-backward-rotation, hip-abduction, straight-leg-lifting, knee-extension, and ankle-dorsiflexion. Those with the improvement of 10 degrees, 15 degrees, 20 degrees, 25 degrees, and 30 degrees in the range of movement of their contractured joints would obtain respectively 1, 2, 3, 4, and 5 points. There were significant differences before and after the treatment in the 18 items under observation except for intelligence, with obvious improvement shown after the treatment (P<0.01), the effective rate being 92.5%. The therapeutic criteria set in this research are well established in reflecting the functional improvements of the patient.

Central hypoventilation and diaphragmatic eventration: diagnosis and management.

Congenital central alveolar hypoventilation syndrome (CCAHS) is a disorder of ventilatory control that occurs without neuromuscular blockade or pulmonary disease. It is characterized by a lack of response to habitual respiratory stimulants, especially hypercapnia. In this article, the management of this syndrome by diaphragmatic pacing is discussed. Paralysis of the phrenic nerve in small children usually results from injury during birth or during a cardiothoracic operation and results in eventration of the hemidiaphragm. Alternatively, eventration of the diaphragm may be a congenital condition. In both cases it may lead to respiratory distress in the newborn. In this article, we review the diagnosis of these conditions and their management, focusing on the surgical indications. We also discuss outcome.

The hypothalamus.

The hypothalamus is an integral part of the neuroendocrine system. The anatomy, embryologic development, and normal function of the hypothalamus are described here. Pathophysiology of congenital abnormalities and brain injury is discussed and a case study examined. In addition, nursing implications of caring for such an infant are addressed.

Neglected spinal cord, brain stem and musculoskeletal injuries stemming from birth trauma.

OBJECTIVE: A review of the medical literature was undertaken to determine cause, diagnosis, prognosis, treatment and prevention of injuries resulting from birth trauma. The primary focus was the neonate, though infant, child and adult were also considered because the effects of birth trauma can be life-long. DATA SOURCE: A compilation of case studies and review articles were extracted from numerous "MEDLINE" literature searches. Key Terms included: Birth Trauma, Central Nervous System Injuries, Musculoskeletal Injuries, Stillbirth, Sudden Infant Death Syndrome (SIDS), Cerebral Palsy, Brachial Plexus Palsies (Erb's and Klumpke's), Neonatal-Infantile Respiratory Distress, Obstetric Accidents (Forceps, Vacuum Cup and Cesarean Deliveries), Subluxation, Chiropractic Treatment. American, British, Danish and German studies were included to show the universality of the problem. STUDY SELECTION: Findings were selected on the basis of a clear connection between birth trauma and the resulting symptoms, syndromes and/or death. DATA EXTRACTION: Findings were compiled by studying articles from the literature search. The quality and validity were assessed by corresponding references, method of documentation, number of case studies, length of time over which studies took place and presence of follow-up documentation. DATA SYNTHESIS: Inadequacies and source discrepancies were also included with regard to cause and types of obstetric accidents. CONCLUSION: Birth trauma remains an underpublicized and, therefore, an undertreated problem. There is a need for further documentation and especially more studies directed toward prevention. In the meantime, manual treatment of birth trauma injuries to the neuromusculoskeletal system could be beneficial to many patients not now receiving such treatment, and it is well within the means of current practice in chiropractic and manual medicine.

Cephalhaematoma: a 10-year review.

The incidence of cephalhaematoma at the Mercy Maternity Hospital over a 10-year period was 2.5%; of the 1,030 infants 68.4% were born to primiparas, 65.6% were males, the majority (91.1%) were between 37 and 42 weeks' gestation and 3,000 and 4,000 g birth-weight (71.6%). Forceps delivery and vacuum extraction were associated with increased incidences of cephalhaematoma (5.1% and 22.9% respectively), and the incidence was slightly increased (3.8%) when a scalp electrode had been applied. Hyperbilirubinaemia was more prevalent (12.9%) in infants with a cephalhaematoma as was exchange transfusion (0.8%) and the need for phototherapy (4.9%).

Association of adverse perinatal events with an empty sella turcica in children with growth hormone deficiency.

High-resolution computed tomography (HR-CT) of the hypothalamo-pituitary region was performed in 26 consecutive children presenting with growth hormone deficiency (GHD) at one clinic. 58% had an empty sella turcica (ES) and 42% a full sella turcica (FS). There was no difference between the ES and FS groups for mean (+/- 95% confidence limits) presentation age (ES 6.7 (+/- 1.8) years, FS 5.6 (+/- 2.2) years), height standard deviation score (SDS) (ES -3.9 (+/- 0.8), FS -3.3 (+/- 0.5] nor head circumference SDS (ES -1.9 (+/- 1.1), FS -0.7 (+/- 1.1]. There were significant associations between the ES group and a history of adverse perinatal events (p less than 0.001) and multiple pituitary deficiency (p = 0.014). Growth hormone response to an acute growth hormone releasing factor test showed no association with HR-CT diagnosis. Sella turcica volumes were calculated from the HR-CT scans. All sella volumes were small; mean SDS for height was -2.6 (+/- 0.2). There was no difference in sella volume SDS between the ES and FS groups (ES -2.9 (+/- 0.3), FS -2.5 (+/- 0.4]. Adverse perinatal events may cause an ES and GHD by compromising the blood supply to the pituitary gland or infundibulum.

[Stunted growth]. / Minderwuchs.

According to recent investigations more than half of all growth disorders are due to growth hormone (GH) deficiency. I. The cause of the classic hypothalamo-pituitary dwarfism is: 1. perinatally acquired lesions of the hypothalamus; 2. suprasellar tumours; 3. brain malformations; 4. hereditary disturbances of GH-synthesis. - II. Constitutional delay of growth and adolescent development is clinically characterised by harmonious delay of growth, skeletal development and sexual maturation. The typical aspect of the pituitary dwarf is missing. Whereas provocation tests for GH do not show reliable deviations, assessment of the spontaneous GH secretion during sleep usually demonstrates a significant GH-deficit. - III. Impairments of GH synthesis with production of a hormone which reacts in the RIA but exhibits reduced biological effectivity causes the same clinical picture as constitutional delay. The disorders I--III can successfully be treated by GH. - IV. Familial short stature is based on the summation of hereditary anlages of the parents. In principle, it is no endocrine disorder. However, the combination with disorders II and III occurs frequently ("Small/Delay" acc. to Tanner). - V. Intrauterine growth retardation is caused by maternal, placental or fetal factors. With most of the "small for dates" growth prognosis is good. However, if teratogenic agents, particularly alcohol is involved, and if the damage occurs in the first months of gestation, the prognosis is unfavorable. - VI. A great number of genetic disorders is connected with pre- and/or postnatal growth retardation, combined with typical malformations. Apart from few exceptions these syndromes are rare. Endocrine deviations are missing. - The therapeutic possibilities of GH and anabolics are thoroughly discussed.

"Nautral" canine model of infantile hydrocephalus.

A review of the current knowledge about a variety of aspects of infantile hydrocephalus suggests that one cause of this problem is subarachnoid blood from birth trauma interacting with an anatomically immature cerebrospinal fluid-absorbing system. To test this hypothesis and to create a model that could be used to devise various methods of prophylaxis and therapy, we injected autologous blood into the cisterna magna of puppies, followed the size of their ventricles with serial computerized tomographic (CT) scans, and evaluated the scanning electron microscopic (SEM) appearance of the ventricular walls and subarachnoid space. By injecting blood until the dogs were just at the point of apnea, we obtained a 46% incidence of hydrocephalus with a 13% mortality rate. The amount of blood accepted was variable. The size of the ventricles was followed with CT scans; the time course of hydrocephalus was variable, and in some cases it resolved. SEM revealed significant regional, free cell aggregation and calcification, especially over the base of the brain, which was most marked in the animals that developed hydrocephalus. This suggests a more marked reaction or a lesser ability to clear the subarachnoid blood in those animals, although the reason for this is not clear. Possible uses for this model are suggested.