Partial weight-bearing following ankle fracture: what's the actual load in early recovery?

PURPOSE: This study investigates the learning efficacy for partial weight load before discharge as well as the impact of biofeedback during the learning process. METHODS: We monitored weight-bearing in 57 patients who had surgery for ankle fractures. Continuous measurements without and with biofeedback were performed in the early postoperative stage in order to, first, assess how well these patients could apply what they have learned before being discharged, and second, to examine the influence of biofeedback. RESULTS: Using conventional teaching methods, only about one-third of patients (36.8% on the ground and 29.2% on the stairs) were able to maintain a satisfactory load. One-fourth of the patients did not place any weight on their leg, which was shown to be due to excessive pain at the time of the measurement (p < 0.05). A further one-fourth loaded inadequately low, while the remainder loaded excessively. Patients benefited significantly from the activation of audio-visual biofeedback in real time. As a result, loads in a target zone between 15 and 30 kg could be significantly increased (p < 0.05). CONCLUSION: We conclude that the majority of ankle fracture patients were unable to learn partial weight bearing in the early postoperative stage using traditional techniques. Additionally, each patient's ability to carry out a given loading varied. Using an audio-visual real-time biofeedback modality led to significantly improved performance. These findings support the proposed utility of audiovisual feedback in early rehabilitation. With the use of outpatient real-time biofeedback systems, therapists will be able to respond specifically to the needs of each individual patient. TRIAL REGISTRATION: Trial registration: DRKS00031136, Registered 01.02.2023 - Retrospectively registered, https://www.drks.de/DRKS00031136.

Continuous real-time biofeedback in orthosis improves partial weight bearing on stairs.

INTRODUCTION: Climbing up and down stairs with crutches is a particular challenge. The current study evaluates a commercially available insole orthosis device for weighing an affected limb and for biofeedback training of gait. This study was done on healthy, asymptomatic individuals before applying to the intended postoperative patient. The outcomes should demonstrate whether a continuous real-time biofeedback (BF) system is more effective on stairs than the current protocol involving a bathroom scale. MATERIALS AND METHODS: 59 healthy test subjects received both crutches and an orthosis and learned to apply a 3-point gait with a partial load of 20 kg using a bathroom scale. Thereafter, the participants were asked to complete an up-and-down course, first without (control group) and then with (test group) an audio-visual real-time biofeedback (BF). Compliance was evaluated using an insole pressure measurement system. RESULTS: Using the conventional therapy technique, 36.6% of the steps up and 39.1% of the steps down in the control group were loaded with < 20 kg. By activating continuous biofeedback, steps with < 20 kg could be increased significantly to 61.1% upstairs (p < 0.001) and 66.1% downstairs (p < 0.001). All subgroups profited from the BF system, independent of age, gender, side relieved, dominant or non-dominant side. CONCLUSIONS: Traditional training without biofeedback led to poor performance for partial weight bearing on stairs, even among young and healthy individuals. However, continuous real-time biofeedback clearly improved compliance, indicating its potential to enhance training and support future research in patient populations.

Supplementation of feedlot lambs with cactus cladodes as strategy to improve testicular function.

The aim of this study was to evaluate the effects of diets containing cactus cladodes genotypes on plasma testosterone levels, testicular histopathological and histomorphometric parameters, and oxidative stress markers in lambs. Thirty-six male, intact Santa Inês lambs (22.0 ± 2.9 kg initial body weight), were to feedlot for 86 days. A completely randomized design was used with three dietary treatments (control diet with Tifton-85 hay as the only roughage; and two more diets with Miúda or OEM cactus cladodes partially replacing hay) and twelve replicates. There was no influence of the diets on the testicular weight (P = 0.414) and gonadosomatic index (P = 0.384) of lambs. The testosterone serum concentrations were almost twice as higher in lambs fed Miúda cactus cladodes compared to control treatment. There was greater incidence and severity of lesions in the testicular parenchyma of animals that received control diet: loosening of germ cell epithelium, germ cell desquamation and vacuolization of Sertoli cells. The seminiferous tubule diameter and height of the seminiferous epithelium were higher in lambs fed OEM cactus cladodes (P = 0.003). The tubular volume and Leydig cells volume were higher in animals fed with cactus cladodes (P < 0.05). The levels of malondialdehyde were higher in the lambs of control group compared to OEM group (P = 0.039) and the testicular concentration of nitric oxide was higher in control group (P = 0.009). The diet containing OEM cactus cladodes increased the levels of superoxide dismutase. Our results indicate that diets containing cactus cladodes promote antioxidant protection to the testicular parenchyma and preserve the spermatogenic process of lambs.

Dwarf and tall elephant grass silages: intake, nutrient digestibility, nitrogen balance, ruminal fermentation, and ingestive behavior in sheep.

The objective of this study was to evaluate the exclusive supply of dwarf or tall elephant grass silages, harvested at 60 days of growth, without wilting or the use of additives, on intake, apparent digestibility, nitrogen balance, rumen parameters, and ingestive behavior of sheep. Eight castrated male crossbred sheep (57.6 ± 5.25 kg body weight), fistulated in the rumen, were distributed in two 4 × 4 Latin squares with four treatments and eight animals per treatment and four periods. The treatments consisted of four elephant grass genotype silages (Mott, Taiwan A-146 2.37, IRI-381, or Elephant B). There was no effect of silages (P > 0.05) on dry matter, neutral detergent fiber, and total digestible nutrient intake. The dwarf-sized elephant grass silages provided higher crude protein intake (P = 0.047) and N intake (P = 0.047), while the IRI-381 genotype silage provided higher non-fibrous carbohydrate intake compared to Mott (P = 0.042), without differing from Taiwan A-146 2.37 and Elephant B silages. There were no differences (P > 0.05) among the digestibility coefficients of the evaluated silages. It was observed that silages produced with Mott and IRI-381 genotypes caused a slight decrease in ruminal pH (P = 0.013), and the propionic acid concentration was higher in the rumen fluid of the animals fed with Mott silage (P = 0.021). Therefore, dwarf or tall elephant grass silages, produced with cut genotypes at 60 days of growth and without the use of additives or wilting process, can be used in sheep feeding.

Sugarcane yeast with urea in replace of soybean meal in the diet of Murrah buffaloes does not cause metabolic, endocrine, and mineral disorders.

The aim of this study was to evaluate the effect of the replacement of soybean meal by increasing levels of sugarcane yeast and urea on the energy, enzymatic, protein, mineral, and hormonal profiles of buffalo heifers. Twenty Murrah heifers with an average body weight of 168 ± 2.0 kg and 1 year old were used in a completely randomized design. The treatments consisted of the replacement of soybean meal by increasing levels of sugarcane yeast and urea (0, 33, 67, and 100% dry matter). The animals were weighed at the beginning and end of the experimental period, and blood was collected on the final day. The replacement of soybean meal with sugarcane yeast influenced the performance and metabolic dynamics, with total weight gain (P = 0.005) and average daily gain (P = 0.015), presenting, for both variables, a quadratic effect. Considering the biochemical profile, there was an influence on the serum concentration of triglycerides (P = 0.055), the serum activities of aspartate aminotransferase, gamma-glutamyl transferase, and alkaline phosphatase (P < 0.05), in addition to the serum concentration of phosphorus (P = 0.007) and potassium (P = 0.053), which showed positive linear effects. The hormonal profile was not influenced by diets (P > 0.05). The elements copper, iron, and zinc were able to be quantified at all levels of sugarcane yeast and urea in the diets offered. The use of sugarcane yeast with urea promotes adequate metabolic response of buffalo heifers and can replace up to 100% of soybean meal in the concentrate.

Diets containing cactus cladodes on serum and liver levels of microminerals in sheep and goats.

Two experiments were performed to evaluate the effects of partial replacement of Tifton hay by Miúda cactus cladodes (Nopalea) or Orelha de Elefante Mexicana (O.E.M.) cactus cladodes (Opuntia) on serum and liver concentrations of iron (Fe), copper (Cu), zinc (Zn), and manganese (Mn) in feedlot small ruminants. The experiment 1 (Exp. 1) lasted 86 days, and thirty-six male Santa Inês lambs (22.0 ± 2.9 kg initial body weight-IBW) were used. In experiment 2 (Exp. 2), lasting 100 days, thirty-six male goats of undefined breed (19.0 ± 2.8 kg IBW) were used. In both studies, the animals were distributed in a completely randomized design, with three treatments (diet control-without cactus; and diets with hay partially replaced by Miúda or O.E.M. cactus cladodes) and twelve replicates. Blood samples were collected to quantify serum micromineral levels, and at the end of the feedlot periods, sheep and goats were slaughtered and liver fragments were collected for micromineral dosage. In Exp. 1, lambs fed Nopalea cactus cladodes diet showed greater hepatic Cu accumulation (441.87 mg/kg DM; P = 0.027). The diets containing cactus cladodes tended to increase serum levels of Cu (P = 0.075) and Zn (P = 0.058). In Exp. 2, goats fed diet containing Opuntia cactus cladodes presented higher serum levels of Fe (P = 0.024) and Cu (P = 0.012). In conclusion, the partial replacement of Tifton hay by cactus cladodes increases hepatic concentrations of Cu in lambs and serum levels of Fe and Cu in goats.

Serum concentrations of folic acid and cobalamin and energy metabolism of ewes as a function of the energy density of the diet, peripartum period, and pregnancy toxemia.

The aim of this study was to determine the serum levels of folic acid, cobalamin, and indicators of energy metabolism during the peripartum period of ewes submitted to different diets and with or without pregnancy toxemia. Forty Santa Inês ewes were divided into three groups, a group of 20 animals fed only roughage-diet with low energy density (G1), a group of 10 ewes submitted to diet containing roughage and concentrate-diet with high energy density (G2), and a group of 10 ewes with diagnosis of pregnancy toxemia (PT) (G3). In the ewes of groups G1 and G2, blood samples were collected -30, -15, -7 days pre-partum, on the day of partum, and 7, 15, and 30 days postpartum; blood samples from G3 animals were collected during the veterinary clinic care. Significant variations were observed in the plasma concentration of glucose and serum folic acid, cobalamin, fructosamine, NEFA, and ß-hydroxybutyrate in the groups fed diets with different energy levels, with and without PT (P < 0.05). A positive correlation of folic acid and cobalamin was observed with plasma glucose and serum NEFA concentrations, in addition to negative correlation of glucose with NEFA and ß-hydroxybutyrate and positive correlation between the latter biomarkers of energy metabolism. The ewes diagnosed with PT showed higher levels of folic acid, NEFA, and ß-hydroxybutyrate (P < 0.05). Ewes fed diet containing roughage and concentrate present higher serum levels of folic acid, cobalamin, and glucose, in the pre-partum period and in the lactation period. The results obtained contribute to better understanding of the application of blood concentration tests for folic acid and cobalamin in the energy metabolism and in PT in ewes.

Kidney changes in lambs fed cactus pear varieties resistant to Dactylopius opuntiae as the only roughage.

This study aimed to evaluate the effects of four varieties of cactus pear resistant to carmine cochineal as exclusive roughage for lambs on the biochemical, histopathological, and histomorphometric parameters of kidneys. Twenty-four castrated male crossbred lambs at eight months of age and an initial body weight of 21.0 ± 0.5 kg were distributed in a completely randomized design, with four treatments and six repetitions. The experimental treatments consisted of four diets containing Miúda cactus pear, IPA-Sertânia cactus pear, IPA-F21 cactus pear, or Orelha de Elefante Mexicana (OEM) cactus pear as the only roughage. Blood samples were collected every two weeks (14 d, 28 d, 42 d, and 56 d) to quantify serum urea and creatinine levels. After 72 days of the introduction of the tested diets, the animals were slaughtered and fragments of the kidneys were collected for histological analysis. The serum urea level was higher in animals fed a diet based on the Miúda variety (49.38 mg dL-1), and the serum creatinine levels were lower in the last two collections (P = 0.009). The most frequent histopathological findings in the kidneys were calcification, congestion, glomerular atrophy, presence of luminal cellular debris, and nephrosis, regardless of the cactus pear variety. The Miúda cactus pear and OEM cactus pear varieties caused more severe damage to the nephron components, while the varieties IPA F-21 and IPA-Sertânia caused less significant injuries. The use of IPA-Sertânia and IPA F-21 cactus pear varieties is suggested in lamb's diets, due to the lower impact on the renal parenchyma. However, there was no expressive impairment of renal function, and there was no difference between the cactus pear varieties tested in this study on the weight gain of the animals, and they can all be used to feed feedlot sheep.

Cactus cladodes cause intestinal damage, but improve sheep performance.

The objective of this study was to evaluate the effect of three varieties of cactus cladodes resistant to carmine cochineal on the animal performance and histology of the large intestine of sheep. Forty lambs (21.0 ± 2.0 kg body weight) were distributed in a completely randomized design, with four treatments and ten repetitions. The experimental treatments consisted of a control diet and three more diets in which part (750 g/kg) of the elephant grass hay, and all the corn were replaced by Miúda cactus cladodes, IPA-Sertânia cactus cladodes, or Orelha de Elefante Mexicana (O.E.M.) cactus cladodes. On the 60th day after the introduction of the tested diets, blood samples were collected to quantify serum magnesium (Mg2+) levels. After 63 days of experiment, the animals were slaughtered and fragments of the cecum and colon were collected for histopathological analysis. The inclusion of the Miúda and O.E.M. cactus cladodes in the diet caused inflammatory lesions in the cecum (100% of the animals) and in the colon (71.43% of the animals) of the sheep. The inflammation in the cecum caused by Miúda and O.E.M. cactus cladodes was considered accentuated (P = 0.009). Less voluntary water intake was observed for animals submitted to diets with cactus cladodes (P < 0.001), as well as higher water content in the feces (P < 0.001). The cactus cladodes, especially the Miúda and O.E.M. varieties, cause lesions in the tissue morphology of the cecum and colon of sheep, but improve productive performance.

Shoulder function after helical long PHILOS plate.

BACKGROUND: In order to minimize the risk of damaging the radial nerve while using a long PHILOS plate for proximal humerus fractures, recent studies have proposed twisting the plate in a helical form. This implies a modified surgical approach being yet unclear whether it leads to different middle to long-term shoulder function. This study compares the one-year shoulder functional outcomes of both techniques (helical vs. control). METHODS: In this retrospective comparative study, we analyzed 30 patients that fit the inclusion criteria, being 14 treated with a helical plate and 16 with a conventional straight long PHILOS plate. The primary endpoint was the normalized constant score after a minimum follow up of one year. RESULTS: Both groups had a good one-year shoulder function, and no significant difference between the normalized constant scores was seen. There was no significant difference in the surgical complications as well. CONCLUSION: Opting for a helical long PHILOS plate in order to avoid radial nerve damage provided a safe treatment with similarly good one-year shoulder function compared to straight PHILOS plates. LEVEL OF EVIDENCE: Level 3, Retrospective Cohort Study.

Interventionist videothermometry: a new model of cardiac ischemia evaluation.

BACKGROUND: The purpose of the present study was to evaluate, through videothermometry, the temperature variation in the hearts of rabbits, that underwent induced myocardial ischemia and reperfusion. RESULTS: A total of 20 female rabbits were divided into two groups: a treated group and a sham group, the treatment group underwent 5 min of cardiac arrest and reperfusion, using the inflow occlusion technique. Throughout the experiment, the animals were monitored by videothermometry, observing the thermal variations of the myocardial tissue. During the experiment, at different times, blood gas tests and tests to evaluate the lactate concentrations were performed. At the end of the experiment, each heart was submitted to histopathological evaluation. In the treated group, there was a reduction in temperature of the myocardial tissue during the circulatory arrest compared to the sham group. Additionally, a colder area next to the caudal vena cava ostium and the right atrium was observed. Notably, despite the 5 min of cardiac arrest in the treated group, both the lactate and bicarbonate levels were maintained without significant variation. However, there was an increase in PaCO2 and pH reduction, featuring respiratory acidosis. In relation to the histopathological study, the presence of hydropic degeneration in the myocardium of animals in the treated group was observed. CONCLUSIONS: Based on these results, the videothermometry was efficient in identifying the range of myocardial tissue temperature, suggesting that the first areas to suffer due to cardiac arrest were the caudal vena cava ostium and the right atrium. However, in regard to the angiographic coronary thermography, the study was not feasible due to the small size of the coronary. There was no variation between the groups regarding the presence of myocardial infarction, myocardial congestion, myocardial edema and myocardial hemorrhage.

Comparing iatrogenic radial nerve lesions in humeral shaft fractures treated with helical or straight PHILOS plates: a 10-year retrospective cohort study of 62 cases.

BACKGROUND: Humerus shaft fractures are common and often treated surgically with a proximal humerus internal locking system like the long PHILOS® plate. Due to its close anatomical proximity to the humerus, the radial nerve is particularly susceptible to traumatic and iatrogenic damage. The iatrogenic radial nerve damage associated with internal locking systems is described in about 7% of the cases. In order to avoid this lesion, helical plates have been suggested since 1999. This technique continues to not being used as standard as there is still a clear lack of evidence. This study aimed to understand if twisting a long PHILOS plate can reduce the rate of iatrogenic radial nerve damage in humerus shaft fractures. METHODS: In this 10-year retrospective comparative study, patients with primary traumatic proximal humerus shaft fracture treated with a straight or twisted helical PHILOS® plate were analyzed and compared. Among the 62 patients meeting the inclusion criteria between 2008 and 2018, 33 received a conventional straight plate, while 29 were treated with a helical plate. The primary endpoint was iatrogenic radial nerve damage immediately after surgery with a follow-up of at least 3 months. RESULTS: No case of radial nerve damage was reported in the helical group. In the control group, iatrogenic radial nerve damage occurred in two cases (6%), which was not statistically significant when comparing both groups (p = 0.18). CONCLUSION: Manually twisting long PHILOS® plates is a safe procedure to avoid radial nerve lesion in humerus shaft fractures. Even though the group size did not allow a statistically relevant difference, we underline that only the helical group showed no iatrogenic radial lesion. This technique deserves further attention. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Histomorphometric changes of the fore-stomach of lambs fed with diets containing spineless cactus genotypes resistant to Dactylopius sp.

The histomorphometric parameters of the fore-stomach epithelium of lambs fed with spineless cactus genotypes resistant to Dactylopius sp. were evaluated. Thirty-two lambs (23.0 ± 2.06 kg body weight) were distributed in a completely randomized design with four treatments and eight replications. The treatments consisted of the base diet and diets in which part of the elephant grass hay and all ground corn was replaced by the Miúda, IPA-Sertânia, or Orelha de Elefante Mexicana (OEM) spineless cacti. The keratin layers of the ruminal epithelium of the animals consuming the spineless cacti Miúda and OEM presented greater thickening relative to the control diet: 47.31, 41.30, and 25.81 µm, respectively. The heights of the ruminal papillae were higher in the animals that were fed with the OEM spineless cactus. The Miúda spineless cactus caused an enlargement in the keratinized layer of the reticulum epithelium, as well as a decrease in the thickness of the non-keratinized layers. The diet containing OEM spineless cactus resulted in greater thickening of the keratin layer of the omasal epithelium and decreased thickness of the non-keratinized layers. The spineless cacti Miúda and OEM changed the morphology of the fore-stomach epithelium and increased the dry matter intake and weight gain of lambs.

Can elderly individuals perform partial weight bearing on their lower limbs? A prospective cohort study using ambulatory real-time biofeedback.

BACKGROUND: Partial weight bearing in an orthosis and with forearm crutches is a widespread and well-accepted therapeutic principle after an injury of the lower extremity during early rehabilitation. Complying may be challenging to do under these circumstances, especially for elderly people. This study compares the spatiotemporal parameters and peak loads performed by a group of older participants before and after activating real-time biofeedback (BF) to determine whether they benefit from a biofeedback. METHODS: Twenty-four healthy subjects between 61 and 80 years learned how to walk using forearm crutches in a lower leg orthosis while performing a weight of 20 kg using a bathroom scale with the aim of loading in a zone between 15 and 30 kg. After that, they completed a course that was on level ground (50 m) and another course on stairs (11 steps). They did a walk without BF first, and then with BF. Each step was given a maximum load, which was determined and statistically checked. In addition, spatiotemporal parameters were collected. RESULTS: The classical teaching method with a bathroom scale was ineffective. Only 32.3% of the loads could be adequately carried by a person on level ground in the 15-30 kg target zone. On the stairs, it was 48.2% and 34.3%, respectively. Thus, on level ground, 52.7% of loads exceeded 30 kg. Downstairs it was 46.4%, and upstairs it was 41.6%. Subjects clearly benefit from activated biofeedback. Biofeedback significantly reduced missteps > 30 kg in every course. The loads decreased significantly to 25.0% on level ground, to 23.0% upstairs, and to 24.4% downstairs. At the same time, speed and stride length decreased per course while total time increased. CONCLUSION: Partial weight bearing is more complex and difficult for the elderly. These study results may help better understand 3-point gait in older adults in an outpatient setting. When partial weight bearing is recommended, special follow-up attention must be given for this group. Age-based therapy strategies can be developed and monitored with the assistance of ambulatory biofeedback devices. Trial registration Retrospectively registered, https://www.drks.de/DRKS00031136 .

Biomechanical testing of osteosynthetic locking plates for proximal humeral shaft fractures - a systematic literature review.

Proximal humeral shaft fractures can be treated with helically deformed bone plates to reduce the risk of iatrogenic nerve lesion. Controversially to this common surgical technique that was first established in 1999, no biomechanical investigation on humeral helical plating is recorded by other reviews, which focus on proximal fractures exclusively. Does an additional scope for shaft fractures reveal findings of helical testing? The present systematic literature review was performed based on guidelines by Kitchenham et al. to systematically search and synthesize literature regarding biomechanical testing of osteosynthetic systems for proximal humeral shaft fractures. Therefore, a systematic approach to search and screen literature was defined beforehand and applied on the findings of the database PubMed®. Synthesized information of the included literature was categorized, summarized and analyzed via descriptive statistics. Out of 192 findings, 22 publications were included for qualitative synthesis. A wide range of different test methods was identified, leading to a suboptimal comparability of specific results between studies. Overall, 54 biomechanical test scenarios were identified and compared. Physiological based boundary conditions (PB-BC) were referenced in 7 publications only. One study of testing straight and helical dynamic compression plates without PB-BCs was identified, showing significant differences under compressional loading. The absence of test standards of specific fields like humeral fractures lead to a high variance in biomechanical testing of osteosynthetic locking plates for proximal humeral shaft fractures. Physiological approaches offer realistic test scenarios but need to be uniformed for enhanced comparability between studies. The impact of helically deformed locking plates under PB-BC was not identified in literature.

Protective and Risk Factors for Humerus Head Necrosis After Proximal Humerus Fracture Treated with Internal Locking Plate.

BACKGROUND: Proximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3-35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel's criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis. METHODS: In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN. RESULTS: HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer's classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN. CONCLUSION: We conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Primary angiitis of the central nervous system as a mimic of multiple sclerosis: A case report.

BACKGROUND: Primary angiitis of the central nervous system is a rare inflammatory vasculopathy and it is a difficult diagnosis to make because of its kaleidoscopic presentation and its multiple mimics, including multiple sclerosis. CASE PRESENTATION: A 21-year-old men presented a four-year history of progressive gait deterioration. Magnetic resonance imaging of the brain and spine showed hyperintense round-shaped lesions on T2 images, many with contrast enhancement, in supra/infratentorial and spinal segments. He received treatment for multiple sclerosis but presented clinical worsening, and follow-up neuroimaging showed persistent contrast enhancement lesions and a cerebellar hematoma. Brain biopsy was performed and demonstrated inflammatory infiltrations in blood vessels. The patient received 6 monthly schedules of 5 g methylprednisolone and 1 g cyclophosphamide with clinical stabilization. DISCUSSION: Our patient presented a primary angiitis central nervous system according to the Birnbaum and Hellmann proposed criteria. This case reinforces the importance of advancing the differential diagnosis of patients that present red flags in brain neuroimaging. CONCLUSION: The presence of the micro/macrobleeds and persistent contrast enhancing lesions should raise the suspicion of vasculitis in the differential diagnosis of multiple sclerosis.

Neurological consultations and diagnoses in a large, dedicated COVID-19 university hospital.

BACKGROUND: More than one-third of COVID-19 patients present neurological symptoms ranging from anosmia to stroke and encephalopathy. Furthermore, pre-existing neurological conditions may require special treatment and may be associated with worse outcomes. Notwithstanding, the role of neurologists in COVID-19 is probably underrecognized. OBJECTIVE: The aim of this study was to report the reasons for requesting neurological consultations by internists and intensivists in a COVID-19-dedicated hospital. METHODS: This retrospective study was carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, a 900-bed COVID-19 dedicated center (including 300 intensive care unit beds). COVID-19 diagnosis was confirmed by SARS-CoV-2-RT-PCR in nasal swabs. All inpatient neurology consultations between March 23rd and May 23rd, 2020 were analyzed. Neurologists performed the neurological exam, assessed all available data to diagnose the neurological condition, and requested additional tests deemed necessary. Difficult diagnoses were established in consensus meetings. After diagnosis, neurologists were involved in the treatment. RESULTS: Neurological consultations were requested for 89 out of 1,208 (7.4%) inpatient COVID admissions during that period. Main neurological diagnoses included: encephalopathy (44.4%), stroke (16.7%), previous neurological diseases (9.0%), seizures (9.0%), neuromuscular disorders (5.6%), other acute brain lesions (3.4%), and other mild nonspecific symptoms (11.2%). CONCLUSIONS: Most neurological consultations in a COVID-19-dedicated hospital were requested for severe conditions that could have an impact on the outcome. First-line doctors should be able to recognize neurological symptoms; neurologists are important members of the medical team in COVID-19 hospital care.

Neurological consultations and diagnoses in a large, dedicated COVID-19 university hospital / Consultas neurológicas e diagnósticos em um grande hospital universitário dedicado a COVID-19

ABSTRACT Background: More than one-third of COVID-19 patients present neurological symptoms ranging from anosmia to stroke and encephalopathy. Furthermore, pre-existing neurological conditions may require special treatment and may be associated with worse outcomes. Notwithstanding, the role of neurologists in COVID-19 is probably underrecognized. Objective: The aim of this study was to report the reasons for requesting neurological consultations by internists and intensivists in a COVID-19-dedicated hospital. Methods: This retrospective study was carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, a 900-bed COVID-19 dedicated center (including 300 intensive care unit beds). COVID-19 diagnosis was confirmed by SARS-CoV-2-RT-PCR in nasal swabs. All inpatient neurology consultations between March 23rd and May 23rd, 2020 were analyzed. Neurologists performed the neurological exam, assessed all available data to diagnose the neurological condition, and requested additional tests deemed necessary. Difficult diagnoses were established in consensus meetings. After diagnosis, neurologists were involved in the treatment. Results: Neurological consultations were requested for 89 out of 1,208 (7.4%) inpatient COVID admissions during that period. Main neurological diagnoses included: encephalopathy (44.4%), stroke (16.7%), previous neurological diseases (9.0%), seizures (9.0%), neuromuscular disorders (5.6%), other acute brain lesions (3.4%), and other mild nonspecific symptoms (11.2%). Conclusions: Most neurological consultations in a COVID-19-dedicated hospital were requested for severe conditions that could have an impact on the outcome. First-line doctors should be able to recognize neurological symptoms; neurologists are important members of the medical team in COVID-19 hospital care.

RESUMO Introdução: Mais de um terço dos pacientes com COVID-19 apresentam sintomas neurológicos que variam de anosmia a AVC e encefalopatia. Além disso, doenças neurológicas prévias podem exigir tratamento especial e estar associadas a piores desfechos. Não obstante, o papel dos neurologistas na COVID-19 é provavelmente pouco reconhecido. Objetivo: O objetivo deste estudo foi relatar os motivos para solicitar consultas neurológicas por clínicos e intensivistas em um hospital dedicado à COVID-19. Métodos: Estudo retrospectivo realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brasil, um centro dedicado à COVID-19 com 900 leitos (incluindo 300 leitos para unidades de terapia intensiva). O diagnóstico de COVID-19 foi confirmado por SARS-CoV-2-RT-PCR em swabs nasais. Todas as interconsultas de neurologia hospitalar entre 23 de março e 23 de maio de 2020 foram analisadas. Os neurologistas realizaram o exame neurológico, avaliaram todos os dados disponíveis para diagnosticar a patologia neurológica e solicitaram exames adicionais conforme necessidade. Diagnósticos difíceis foram estabelecidos em reuniões de consenso. Após o diagnóstico, os neurologistas participaram da condução dos casos. Resultados: Foram solicitadas consultas neurológicas para 89 de 1.208 (7,4%) em pacientes internados por COVID-19 durante o período. Os principais diagnósticos neurológicos incluíram: encefalopatia (44,4%), acidente vascular cerebral (16,7%), doenças neurológicas prévias (9,0%), crises epilépticas (9,0%), transtornos neuromusculares (5,6%), outras lesões encefálicas agudas (3,4%) e outros sintomas leves inespecíficos (11,2%). Conclusões: A maioria das consultas neurológicas em um hospital dedicado à COVID-19 foi solicitada para condições graves que poderiam afetar o desfecho clínico. Os médicos na linha de frente devem ser capazes de reconhecer sintomas neurológicos. Os neurologistas são membros importantes da equipe médica no atendimento hospitalar à COVID-19.