Clinical Reasoning: A 60-Year-Old Man With Asymmetric Weakness and Persistent Fever.

Peripheral neuropathies, especially those with atypical features, remain a diagnostic challenge. In this case, a 60-year-old patient presented with acute-onset weakness starting in the right hand then sequentially involving the left leg, left hand, and right leg over 5 days. The asymmetric weakness was accompanied by persistent fever and elevated inflammatory markers. Subsequent development of rashes combined with careful review of the history led us to the final diagnosis and targeted treatment. This case highlights clinical pattern recognition with the help of electrophysiologic studies in peripheral neuropathies, which provide shortcuts to narrow the differential diagnosis. We also illustrate the important pitfalls from history taking to ancillary testing in diagnosing the rare but treatable cause of peripheral neuropathy (eFigure 1, links.lww.com/WNL/C541).

[A man with unilateral erythema of the leg]. / Een man met een rood been.

We report the case of an otherwise healthy 47 year-old man who presented to the dermatology outpatient clinic with asymptomatic, one sided erythema of his leg, without edema. The diagnosis acrodermatitis chronica atrophicans was made based on positive IgG antibodies to Borrelia burgdorferi.

A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia.

Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

A quadriceps femoris motor pattern for efficient cycling.

In cycling, propulsion is generated by the muscles of the lower limbs and hips. After the first reports of pedal/crank force measurements in the late 1960s, it has been assumed that highly trained athletes have better power transfer to the pedals than recreational cyclists. However, motor patterns indicating higher levels of performance are unknown. To compare leg muscle activation between trained (3.5-4.2 W/kgbw) and highly trained (4.3-5.1 W/kgbw) athletes we applied electromyography, lactate, and bi-pedal/crank force measurements during a maximal power test, an individual lactate threshold test and a constant power test. We show that specific activation patterns of the rectus femoris (RF) and vastus lateralis (VL) impact on individual performance during high-intensity cycling. In highly trained cyclists, we found a strong activation of the RF during hip flexion. This results in reduced negative force in the fourth quadrant of the pedal cycle. Furthermore, we discovered that pre-activation of the RF during hip flexion reduces force loss at the top dead center (TDC) and can improve force development during subsequent leg extension. Finally, we found that a higher performance level is associated with earlier and more intense coactivation of the RF and VL. This quadriceps femoris recruitment pattern improves force transmission and maintains propulsion at the TDC of the pedal cycle. Our results demonstrate neuromuscular adaptations in cycling that can be utilized to optimize training interventions in sports and rehabilitation.

Coupling negative pressure wound therapy with instillation and split-thickness skin graft for a large chronic venous leg ulceration: a case report.

INTRODUCTION: Chronic VLUs are quite challenging to heal with many currently available treatment methods. The timing and combination of treatment methods is integral to successful wound healing. OBJECTIVE: This case combined NPWTi coupled with biofilm killing solution, hydrosurgical debridement to prepare the wound bed, and STSG to achieve epithelialization. To the knowledge of the authors of the present study, no previously published case report has combined these methods for treatment of a chronic VLU. CASE REPORT: This case report highlights a chronic VLU on the anteromedial ankle that healed in 2 months using NPWTi and STSG. CONCLUSION: The combination of NPWTi, hydrosurgery, and STSG to treat this patient resulted in successful wound healing, greatly reduced time to healing compared with standard of care, and allowed the patient to return to her normal lifestyle.

Patients' experiences regarding severe leg wound infection associated with coronary artery bypass grafting: A qualitative study.

INTRODUCTION: Coronary artery bypass grafting (CABG) is the most common cardiac surgery throughout the world. The most commonly used graft is the saphenous vein. Wound healing complications related to saphenous vein harvesting are common, with reported surgical site infection rates ranging from 2% to 20%. Surgical site infection can be long-lasting, and the wound healing can be difficult and also presumably troublesome for the patient. CABG patients' experiences of severe infection in the harvesting site have not been studied before. AIM: The aim of this study was to describe patients' experiences associated with acquiring a severe infection in the harvesting site after CABG. METHOD: A qualitative study with descriptive design was conducted at the department of vascular and cardiothoracic surgery in a Swedish university hospital from May to December 2018. Patients diagnosed with a severe surgical site infection in the harvesting site following CABG were included. Data from 16 face-to-face interviews were analysed with inductive qualitative content analysis. RESULT: The main category, varying impact on body and mind, was the core of the patients' experiences of severe wound infection in the harvesting site after CABG. Two generic categories were identified: physical impact and thoughts about the complication. The patients described experiencing different degrees of pain, anxiety, and limitation in daily life. CONCLUSION: These findings indicate that a severe infection in the harvesting site after CABG was experienced as an important issue with varying impact. Overall, the participants experienced pain, anxiety, and limitations in daily life. However, most of them were satisfied with the outcome after the wound had healed. Patients should be advised to seek care at an early stage if symptoms of infection occur. Improved individual pain management is needed for those with severe pain, and varied experiences imply a need for person-centred care.

Static Postural Control during Single-Leg Stance in Endurance, Team and Combat Athletes from the Spanish National Sport Technification Program.

In the context of pediatric physical exercise, the analysis of factors affecting postural control (PC) provides insight into the development of sport-specific motor skills. This study aims to evaluate the static PC during single-leg stance in endurance, team and combat athletes from the Spanish National Sport Technification Program. A total of 29 boys and 32 girls, aged 12 to 16 years old, were recruited. Centre of pressure (CoP) was measured on a force platform in standing position for 40 s under two sensorial and leg dominance conditions. Girls showed lower MVeloc (p < 0.001), MFreq (p > 0.001) and Sway (p < 0.001) values than boys in both sensorial conditions (open and closed eyes). The highest values in all PC variables were observed with eyes closed in both genders (p < 0.001). Sway values were lower in boys combat-athletes compared to endurance athletes in two sensorial conditions and with non-dominant leg (p < 0.05). Young athletes in their teens enrolled in a Sport Technification Program have shown differences in PC when comparing different visual conditions, sport disciplines and gender. This study opens a window to a better understanding of the determinants of PC during single-leg stance as a critical element in the sport specialization of young athletes.

Balance improvements in healthy subjects are independent to postural strategies involved in the training.

BACKGROUND: Adequate postural strategies have a pivotal role in ensuring balance during the performance of daily or sport activities. These strategies are responsible for the management of center of mass kinematics and depend on the magnitude of perturbations and posture assumed by a subject. RESEARCH QUESTION: Are there differences in postural performance after a standardized balance training performed in sitting versus standing posture in healthy subjects? Does a standardized unilateral balance training with the dominant or non-dominant limb improve balance on trained and untrained limbs in healthy subjects? METHODS: Seventy-five healthy subjects reporting a right-leg dominance were randomized into a Sitting, Standing, Dominant, Non-dominant or Control groups. In the Experiment 1, Sitting group performed a 3-week balance training in seated posture, whereas Standing group performed the same training in bipedal stance. In the Experiment 2, Dominant and Non-dominant groups underwent a 3-week standardized unilateral balance training on the dominant and non-dominant limbs, respectively. Control group underwent no intervention and was included in both experiments. Dynamic (Lower Quarter Y-Balance Test with the dominant and non-dominant limbs and trunk and lower limb 3D kinematics) and static (center of pressure kinematics in bipedal and bilateral single-limb stance) balance were assessed before and after the training, and at 4 weeks follow-up. RESULTS: A standardized balance training in sitting or standing posture improved balance without between-group differences, while a unilateral balance training with the dominant or non-dominant limb improved postural stability on the trained and untrained limbs. Trunk and lower limb joints range of motion increased independently to their involvement in the training. SIGNIFICANCE: These results may allow clinicians to plan effective balance interventions even when a training in standing posture is not possible or in subjects with restricted limb weight-bearing.

Association between calf circumference and incontinence in Chinese elderly.

BACKGROUND: The objective of this study was to analyze the association between calf circumference and incontinence in Chinese elderly, and to find out the maximal cut-off point by gender for the use of calf circumference in screening for incontinence. METHODS: In this study, participants were from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). The maximal calf circumference cut-off point and other incontinence-related risk factors were explored using receiver operating characteristic (ROC) curves and logistic regression analysis. RESULTS: The study included 14,989 elderly people (6,516 males and 8,473 females) over 60. The prevalence of incontinence in elderly males was 5.23% (341/6,516), significantly lower than females, which was 8.31% (704/8,473) (p < 0.001). There was no correlation between calf circumference < 34 cm in males and < 33 cm in females and incontinence after adjusting the confounders. We further stratified by gender to predict incontinence in elderly based on the Youden index of ROC curves. We found the association between calf circumference and incontinence was the strongest when the cut-off points were < 28.5 cm for males and < 26.5 cm for females, with an odds rate (OR) value of 1.620 (male, 95%CI: 1.197-2.288) and 1.292 (female, 95%CI: 1.044-1.600) after adjusting the covariates, respectively. CONCLUSIONS: Our study suggests that calf circumference < 28.5 cm in males and < 26.5 cm in females is a risk factor for incontinence in the Chinese elderly population. Calf circumference should be measured in routine physical examination, and timely interventions should be made to reduce the risk of incontinence in subjects with calf circumference less than the threshold.

The Effect of a Knee Brace on Muscle Forces during Single-Leg Landings at Two Heights.

Single-leg landing is one of the maneuvers that has been linked to non-contact anterior cruciate ligament (ACL) injuries, and wearing knee braces has been shown to reduce ACL injury incidence. The purpose of this study was to determine whether wearing a knee brace has an effect on muscle force during single-leg landings at two heights through musculoskeletal simulation. Eleven healthy male participants, some braced and some non-braced were recruited to perform single-leg landings at 30 cm and 45 cm. We recorded the trajectories and ground reaction forces (GRF) using an eight-camera motion capture system and a force platform. The captured data were imported into the generic musculoskeletal model (Gait2392) in OpenSim. Static optimization was used to calculate the muscle forces. The gluteus minimus, rectus femoris, vastus medialis, vastus lateralis, vastus medialis medial gastrocnemius, lateral gartrocnemius, and soleus muscle forces were all statistically significant different between the braced and non-braced participants. Simultaneously, increasing the landing height significantly affected the gluteus maximums, vastus medialis, and vastus intermedia muscle forces. Our findings imply that wearing a knee brace may alter muscle forces during single-leg landings, preventing ACL injuries. Additionally, research demonstrates that people should avoid landing from heights due to the increased risk of knee injuries.

Intra- and inter-session reliability and repeatability of an infrared thermography device designed for materials to measure skin temperature of the triceps surae muscle tissue of athletes.

Background: Infrared thermography devices have been commonly applied to measure superficial temperature in structural composites and walls. These tools were cheaper than other thermographic devices used to measure superficial human muscle tissue temperature. In addition, infrared thermography has been previously used to assess skin temperature related to muscle tissue conditions in the triceps surae of athletes. Nevertheless, the reliability and repeatability of an infrared thermography device designed for materials, such as the Manual Infrared Camera PCE-TC 30, have yet to be determined to measure skin temperature of the triceps surae muscle tissue of athletes. Objective: The purpose was to determine the procedure's intra- and inter-session reliability and repeatability to determine skin temperature within the Manual Infrared Camera PCE-TC 30 thermography device in the triceps surae muscle tissue of athletes, which was initially designed to measure the superficial temperature of materials. Methods: A total of 34 triceps surae muscles were bilaterally assessed from 17 healthy athletes using the Manual Infrared Camera PCE-TC 30 thermography device to determine intra- (at the same day separated by 1 h) and inter-session (at alternate days separated by 48 h) reliability and repeatability of the skin temperature of the soleus, medial and lateral gastrocnemius muscles. The triceps surae complex weas measured by a region of interest of 1 cm2 through five infrared thermography images for each muscle. Statistical analyses comprised intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimum detectable change (MCD), systematic error of measurement, correlation (r), and Bland-Altman plots completed with linear regression models (R 2). Results: Intra- and inter-session measurements of the proposed infrared thermography procedure showed excellent reliability (ICC(1,2) = 0.968-0.977), measurement errors (SEM = 0.186-0.232 °C; MDC = 0.515-0.643 °C), correlations (r = 0.885-0.953), and did not present significant systematic error of measurements (P > 0.05). Adequate agreement between each pair of measurement moments was presented by the Bland-Altman plots according to the limits of agreement and non-significant linear regression models (R 2 = 0.000-0.019; P > 0.05). Conclusions: The proposed procedure to determine skin temperature within the Manual Infrared Camera PCE-TC 30 thermography device presented excellent intra- and inter-session reliability and repeatability in athletes' triceps surae muscle tissue. Future studies should consider the SEM and MDC of this procedure to measure the skin temperature of soleus, medial, and lateral gastrocnemius muscles to promote triceps surae muscle prevention and recovery in athletes.

Identifying the Optimal Arm Priming Exercise Intensity to Improve Maximal Leg Sprint Cycling Performance.

Priming exercises improve subsequent motor performance; however, their effectiveness may depend on the workload and involved body areas. The present study aimed to estimate the effects of leg and arm priming exercises performed at different intensities on maximal sprint cycling performance. Fourteen competitive male speed-skaters visited a lab eight times, where they underwent a body composition measurement, two V̇O2max measurements (leg and arm ergometers), and five sprint cycling sessions after different priming exercise conditions. The five priming exercise conditions included 10-minute rest (Control); 10-minute arm ergometer exercise at 20% V̇O2max (Arm 20%); 10-minute arm ergometer exercise at 70% V̇O2max (Arm 70%); 1-min maximal arm ergometer exercise at 140% V̇O2max (Arm 140%); and 10-min leg ergometer exercise at 70% V̇O2max (Leg 70%). Power outputs of 60-s maximal sprint cycling, blood lactate concentration, heart rate, muscle and skin surface temperature, and rating of perceived exertion were compared between the priming conditions at different measurement points. Our results showed that the Leg 70% was the optimal priming exercise among our experimental conditions. Priming exercise with the Arm 70% also tended to improve subsequent motor performance, while Arm 20% and Arm 140% did not. Mild elevation in blood lactate concentration by arm priming exercise may improve the performance of high-intensity exercise.

Underwater Surface Electromyography for the Evaluation of Muscle Activity during Front Crawl Swimming: A Systematic Review.

This systematic review is aimed to provide an up-to-date summary and review on the use of surface electromyography (sEMG) in evaluating front crawl (FC) swim performance. Several online databases were searched by different combinations of selected keywords, in total 1956 articles were retrieved, and each article was assessed by a 10-item quality checklist. 16 articles were eligible to be included in this study, and most of the articles were evaluating the muscle activity about the swimming phases and focused on assessing the upper limbs muscles, only few studies have assessed the performance in starts and turns phases. Insufficient information about these two phases despite the critical contribution on final swimming time. Also, with the contribution roles of legs and trunk muscles in swimming performance, more research should be conducted to explore the overall muscle activation pattern and their roles on swimming performance. Moreover, more detailed description in participants' characteristics and more investigations of bilateral muscle activity and the asymmetrical effects on relevant biomechanical performance are recommended. Lastly, with increasing attention about the effects of muscles co-activation on swimming performance, more in-depth investigations on this topic are also highly recommended, for evaluating its influence on swimmers.

Motor Overflow during Reaching in Infancy: Quantification of Limb Movement Using Inertial Motion Units.

Early in life, infants exhibit motor overflow, which can be defined as the generation of involuntary movements accompanying purposeful actions. We present the results of a quantitative study exploring motor overflow in 4-month-old infants. This is the first study quantifying motor overflow with high accuracy and precision provided by Inertial Motion Units. The study aimed to investigate the motor activity across the non-acting limbs during goal-directed action. To this end, we used wearable motion trackers to measure infant motor activity during a baby-gym task designed to capture overflow during reaching movements. The analysis was conducted on the subsample of participants (n = 20), who performed at least four reaches during the task. A series of Granger causality tests revealed that the activity differed depending on the non-acting limb and the type of the reaching movement. Importantly, on average, the non-acting arm preceded the activation of the acting arm. In contrast, the activity of the acting arm was followed by the activation of the legs. This may be caused by their distinct purposes in supporting postural stability and efficiency of movement execution. Finally, our findings demonstrate the utility of wearable motion trackers for precise measurement of infant movement dynamics.

Segmental Tissue Resistance of Healthy Young Adults during Four Hours of 6-Degree Head-Down-Tilt Positioning.

(1) Background: One effect of microgravity on the human body is fluid redistribution due to the removal of the hydrostatic gravitational gradient. These fluid shifts are expected to be the source of severe medical risks and it is critical to advance methods to monitor them in real-time. One technique to monitor fluid shifts captures the electrical impedance of segmental tissues, but limited research is available to evaluate if fluid shifts in response to microgravity are symmetrical due to the bilateral symmetry of the body. This study aims to evaluate this fluid shift symmetry. (2) Methods: Segmental tissue resistance at 10 kHz and 100 kHz was collected at 30 min intervals from the left/right arm, leg, and trunk of 12 healthy adults over 4 h of 6° head-down-tilt body positioning. (3) Results: Statistically significant increases were observed in the segmental leg resistances, first observed at 120 min and 90 min for 10 kHz and 100 kHz measurements, respectively. Median increases were approximately 11% to 12% for the 10 kHz resistance and 9% for the 100 kHz resistance. No statistically significant changes in the segmental arm or trunk resistance. Comparing the left and right segmental leg resistance, there were no statistically significant differences in the resistance changes based on the side of the body. (4) Conclusions: The fluid shifts induced by the 6° body position resulted in similar changes in both left and right body segments (that had statistically significant changes in this work). These findings support that future wearable systems to monitor microgravity-induced fluid shifts may only require monitoring of one side of body segments (reducing the hardware needed for the system).

Determination of the adequate vascular perfusion time of cross-leg free latissimus dorsi myocutaneous flaps in reconstruction of complex lower extremity defects.

BACKGROUND: Lower limb defects may be present due to various causes including infections, vascular diseases, tumor resections, and crush or avulsion injuries. Management of lower leg defects is a complex problem, especially when they are large with deep soft tissue loss. These wounds are difficult to be covered with local skin flaps, distant skin flaps or even conventional free flaps because of the compromised recipient vessels. In such cases, the vascular pedicle of the free flap could be anastomosed to the recipient vessels of the contralateral healthy leg temporarily and then divided after adequate neo-vascularization of the flap from the wound bed. The ideal time to divide such pedicles should be investigated and accurately assessed to have the maximum success rate possible for these challenging conditions and procedures. METHODS: Sixteen patients who did not have a suitable adjacent recipient vessel for free flap reconstruction had been operated with cross leg free latissimus dorsi flap between February 2017 and June 2021. The mean soft tissue defect dimension was 12 × 11 cm (the smallest 6 × 7 cm; the largest 20 × 14 cm). Gustilo type 3B tibial fractures were present in 12 patients, while no fractures were present in the other 4 patients. Preoperatively, arterial angiography was performed on all patients. After the fourth week post-operatively, non-crushing clamp was applied around the pedicle for 15 minutes. The clamping time was increased by 15 minutes on each consequent day (average 14 days). On the last 2 days, the pedicle was clamped for 2 hours, and bleeding was assessed by a needle prick test. RESULTS: Clamping time was assessed in each case to reach a scientific calculation of the adequate vascular perfusion time needed for full flap nourishment. All flaps survived completely except two cases of distal flaps necrosis. CONCLUSION: Cross-leg free latissimus dorsi can provide a solution for large soft-tissue defects in lower extremities especially with absence of any suitable recipient vessels or when the use of vein grafts would not be feasible. However, ideal time before dividing the cross vascular pedicle should be identified to have the maximum success rate possible.

Predictive simulation of single-leg landing scenarios for ACL injury risk factors evaluation.

The Anterior Cruciate Ligament (ACL) rupture is a very common knee injury during sport activities. Landing after jump is one of the most prominent human body movements that can lead to such an injury. The landing-related ACL injury risk factors have been in the spotlight of research interest. Over the years, researchers and clinicians acquire knowledge about human movement during daily-life activities by organizing complex in vivo studies that feature high complexity, costs and technical and most importantly physical challenges. In an attempt to overcome these limitations, this paper introduces a computational modeling and simulation pipeline that aims to predict and identify key parameters of interest that are related to ACL injury during single-leg landings. We examined the following conditions: a) landing height, b) hip internal and external rotation, c) lumbar forward and backward leaning, d) lumbar medial and lateral bending, e) muscle forces permutations and f) effort goal weight. Identified on related research studies, we evaluated the following risk factors: vertical Ground Reaction Force (vGRF), knee joint Anterior force (AF), Medial force (MF), Compressive force (CF), Abduction moment (AbdM), Internal rotation moment (IRM), quadricep and hamstring muscle forces and Quadriceps/Hamstrings force ratio (Q/H force ratio). Our study clearly demonstrated that ACL injury is a rather complicated mechanism with many associated risk factors which are evidently correlated. Nevertheless, the results were mostly in agreement with other research studies regarding the ACL risk factors. The presented pipeline showcased promising potential of predictive simulations to evaluate different aspects of complicated phenomena, such as the ACL injury.

Radiological features accompanying peroneus brevis split rupture revealed on magnetic resonance imaging - a cohort study.

BACKGROUND: Peroneal split tears are an underrated cause of ankle pain. While magnetic resonance imaging (MRI) is useful for diagnosis, split tears are challenging to identify. The aim of the study was to investigate the association of peroneus brevis split rupture with abnormalities of the superior peroneal retinaculum (SPR), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), joint effusion, morphology of the malleolar groove, presence of the bone marrow oedema and prominent peroneal tuberculum. METHODS: Ankle MRI cases were assessed by independent observers retrospectively in two groups: one with peroneus brevis split tears (n = 80) and one without (control group, n = 115). Two observers evaluated the soft tissue lesions, and three graded the bone lesions. Fisher's exact test and Pearson correlation were used for analysis. The Bonferroni-Holm method (B-H) was used to adjust for multiple comparisons. RESULTS: Only bone marrow edema in the posterior part of the lateral malleolus was significantly (p < 0.05) more common in the split tear group after applying B-H. SPR total rupture was seen only in the experimental group. No differences in incidence of ATFL and CFL lesions or other SPR lesions were noticed (p < 0.05). CONCLUSION: Bone marrow edema in the posterior part of the lateral malleolus is associated with peroneus split tears on MRI.