Assessing the response of an urban stream ecosystem to salinization under different flow regimes

Urban streams are exposed to a variety of anthropogenic stressors. Freshwater salinization is a key stressor in these ecosystems that is predicted to be further exacerbated by climate change, which causes simultaneous changes in flow parameters, potentially resulting in non-additive effects on aquatic ecosystems. However, the effects of salinization and flow velocity on urban streams are still poorly understood as multiple-stressor experiments are often conducted at pristine rather than urban sites. Therefore, we conducted a mesocosm experiment at the Boye River, a recently restored stream located in a highly urbanized area in Western Germany, and applied recurrent pulses of salinity along a gradient (NaCl, 9 h daily of +0 to +2.5 mS/cm) in combination with normal and reduced current velocities (20 cm/s vs. 10 cm/s). Using a comprehensive assessment across multiple organism groups (macroinvertebrates, eukaryotic algae, fungi, parasites) and ecosystem functions (primary production, organic-matter decomposition), we show that flow velocity reduction has a pervasive impact, causing community shifts for almost all assessed organism groups (except fungi) and inhibiting organic-matter decomposition. Salinization affected only dynamic components of community assembly by enhancing invertebrate emigration via drift and reducing fungal reproduction. We caution that the comparatively small impact of salt in our study can be due to legacy effects from past salt pollution by coal mining activities >30 years ago. Nevertheless, our results suggest that urban stream management should prioritize the continuity of a minimum discharge to maintain ecosystem integrity. Our study exemplifies a holistic approach for the assessment of multiple-stressor impacts on streams, which is needed to inform the establishment of a salinity threshold above which mitigation actions must be taken.

Molecular epidemiology, antibiogram profile and risk factor analysis of pathogenic Escherichia coli associated with pre-weaning diarrhoea in piglets from Haryana, India

BACKGROUND

Piglet diarrhoea is a multifactorial disease with serious implications for the swine industry worldwide, including India. The Escherichia coli (E. coli) pathotypes, i.e., enterotoxigenic E. coli (ETEC) and Shiga toxin-producing E. coli (STEC) are among the major bacterial agents attributed as causative agent for piglet diarrhoea, but studies related to genetic diversity, antibiogram profile and their correlation with risk factors of these pathogens are sparse.

MATERIAL AND METHODS

A total of 104 faecal swab samples were collected from 32 different piggery units of Haryana, India and confirmed as E. coli by standard microbiological methods. The identified E. coli were characterized as ETEC and/or STEC using PCR assays and were studied for their genetic diversity by phylogenetic analysis of the sequences. All the isolates were subjected to antimicrobial susceptibility testing. Further, the correlation of variables with presence or absence of ETEC and/or STEC was also investigated by using Fisher's exact test.

RESULTS

Microbiological isolation led to identification of 208 E. coli isolates. A total of 17.3% (31/208) isolates were characterized as ETEC and 4.8% (10/208) isolates as STEC, whereas 2.4% (5/208) isolates exhibited both ETEC and STEC pathotype. Of the total studied piggery units (n = 32), ETEC were isolated from fourteen and both ETEC and STEC from eight farms. The phylogenetic analysis of Stx2 gene revealed 100% homology with Stx2eA variant from Germany, while analysis of STII gene revealed a distinct nucleotide and amino acid substitution when compared with standard strains. The antibiotic susceptibility testing revealed maximum resistance to moxifloxacin (71.9%) followed by tetracycline (58.1%) and amoxicillin with a total of 41.8% (87/208) E. coli isolates designated as multi-drug resistant (MDR). The multiple antibiotic resistance index varied from 0.05 to 0.75. The statistical analysis suggested three factors viz., number of farm worker(s), frequency of using disinfectant for floor cleaning and use of antibiotic in feed as risk factors significantly associated (p < 0.05) with ETEC associated diarrhoea at piggeries under study.

CONCLUSION

Current study warrants a need for systematic studies on the ETEC/STEC associated diarrhea and antibiotic resistance among these isolates to understand the mechanisms of origin and dissemination of drug resistant pathogens and to design suitable prevention and control measures to curb emergence of antibiotic resistance in the farm settings.

The Asymmetric Response Concept explains ecological consequences of multiple stressor exposure and release

Our capacity to predict trajectories of ecosystem degradation and recovery is limited, especially when impairments are caused by multiple stressors. Recovery may be fast or slow and either complete or partial, sometimes result in novel ecosystem states or even fail completely. Here, we introduce the Asymmetric Response Concept (ARC) that provides a basis for exploring and predicting the pace and magnitude of ecological responses to, and release from, multiple stressors. The ARC holds that three key mechanisms govern population, community and ecosystem trajectories. Stress tolerance is the main mechanism determining responses to increasing stressor intensity, whereas dispersal and biotic interactions predominantly govern responses to the release from stressors. The shifting importance of these mechanisms creates asymmetries between the ecological trajectories that follow increasing and decreasing stressor intensities. This recognition helps to understand multiple stressor impacts and to predict which measures will restore communities that are resistant to restoration.

Prevalence and Predictors of Depression, Anxiety and Stress among Elderly during COVID-19: A Cross-sectional Study from Central India

During the COVID-19 pandemic, elderly people have been more prone to depression, anxiety and stress. During these trying times, they require more attention and support for their mental health. This cross-sectional study was performed with the duration of 06 months from March 2021 to August 2021 in AIIMS, Bhopal in the state of Madhya Pradesh, in central India. And the participants recruited by systematic random sampling from a population aged more than 60 years, those who were able to read and write Hindi or English and having at least one family member; who reported to AIIMS, Bhopal during the second wave of COVID-19 in India. Those who were confirmed COVID-19 cases and undergoing treatment for the same, with diagnosed mental health disorders and who didn't give consent were excluded. A Google form based online semi-structured questionnaire along with DASS-21 scale was completed by participants. Elderly (>=60 years) will be selected. Of the 690 participants 7.25% reported mild to moderate depression, whereas 0.58 percent had severe or extremely severe depression. Mild to moderate anxiety were found in 9.56% of people, while 2.46% had severe or extremely severe anxiety. Mildly or moderately were stressed 4.78%, while 0.42% was severely or extremely anxious. Alcoholism and depression were found to have a statistically significant relationship (p=0.028). During the COVID-19 pandemic, elderly subjects who napped during the day were substantially less depressed (p=0.033). The older the respondents were, the more nervous they were during the pandemic (p=0.042). There is a link between alcohol consumption and stress (p=0.043) and it was seen that females were more stressed as compared to males (p=0.045). There was a strong correlation between participants' alcohol addiction and depressive symptoms. Psychological therapies for the elderly are thought to be necessary to enhance their psychological resilience and mental health. We need to tackle the stigma related to the COVID-19 and mental health issues.

Changes in nasal symmetry after presurgical nasoalveolar molding in infants treated with complete unilateral cleft lip and palate: A follow-up study

Background

A significant improvement in the nasal symmetry after presurgical nasoalveolar molding (PNAM) is seen in complete unilateral cleft lip and palate (UCLP) infants. However, the follow-up changes in the nasal symmetry before and after PNAM and surgical repair have not been well documented.

Materials and Methods

The purpose of this retrospective study is to assess the progressive changes in the nasal symmetry after PNAM and primary cheiloplasty to 1 year in complete UCLP infants. Out of 28 complete UCLP patients who were given PNAM treatment during the period between January 2014 to March 2019, 19 UCLP infants could be included for the study. Submental oblique photographs at the initial visit (T1), immediately after cheiloplasty (T2), and 1 year (T3) after cheiloplasty were selected, and quantity of nasal asymmetry at each period (T1-T2; T1-T3; and T2-T3) was analyzed by paired t-test (P < 0.05).

Results

The quantity of asymmetry revealed that there was a highly significant improvement (P < 0.001) in nasal asymmetry at T1-T2 and T1-T3. Nonsignificant relapse was observed at T2-T3; however, a significant relapse in nasal dome height was observed during this period.

Conclusion

The improvement in the nasal symmetry after cheiloplasty in PNAM-treated patients is maintained till 1 year postsurgically though there is a nonsignificant relapse.

Post-COVID-19 manifestations: A study of analyzing symptoms, complications following hospitalization

Background

Post-COVID-19 symptoms and diseases appeared on recovered from COVID-19. Hence, the study aims to investigate and characterize the manifestations which appear after recovery from the corona virus infection.

Objectives

To investigate the post-COVID-19 Manifestation, to demonstrate different symptoms or signs that appeared during COVID and after recovery from the disease and to see association of independent factors (like age, sex, BMI, Comorbidities) with Post-COVID complication.

Methods

The study was conducted using cross-sectional study among COVID positive patients admitted and then recovered in Bangur Hospital, Pali, Rajasthan, including ICU and Isolation wards from March to December 2020. Sample size calculated was 423 with simple random sampling.

Findings

In our study of these 421 COVID-19 cases, median age was 36 year (Interquartile Range: 26-55 years). Post-COVID manifestation (at least one symptom) significantly associated with age of subjects (p = 0.001), subjects who were in ICU during COVID-19 positive (p = 0.003), symptomatic subjects (p = 0.009) during COVID positive and SPO₂ level at the time of admission during COVID positive (p = 0.01).

Conclusion

The recovered subjects should be highly vigilant in maintaining and monitoring their health status as there is a risk of future complications after recovery.

Slow Frequency Anuloma Viloma Pranayama Modulates Cardiac and Neural Oscillations in Yoga Practitioners

Anuloma viloma pranayama (AVP) also known as Alternate nostril breathing (ANB) is the most commonly used form of pranayama, the ancient breath control practice. It is known to modulate cardiovascular control and brain activity. This study analysed the simultaneous recording of Heart rate variability (HRV) and brain activity during and after AVP at a very slow frequency. We carried out an observational cohort study from October 2021 to December 2021 with purposive sample of 30 (Thirty) healthy volunteers involved in regular kriya yoga practice for the last 15 years were inducted into this study AVP involves slow and deep inhalation through one nostril at a time. The ECG for HRV analysis and spectrum of EEG waves were recorded throughout the pre-AVP, during-AVP and post-AVP (each of five-minute duration). The parameters were compared and analysed by repeated measures of analysis of variance with post-hoc analysis using Bonferroni and Holm's multiple comparisons. In time Domain parameters, SDNN and RMSSD were significantly higher during AVP as compared to the pre-AVP and post AVP. In frequency domain parameters total power, LF power, HF power, showed a significant increase during AVP, LF/HF ratio increased during AVP and remained higher post-AVP also. Similarly, Alpha, Beta and Gamma wave power increased significantly during AVP as compared to pre-AVP and post-AVP. The lungs-heart-brain act as coupled oscillators, the analysed data show an increased arousal, attentive and focused state with a negligible change in the heart rate. An overall increased variability in HRV was recorded.

Management of Root Perforation due to Internal Resorption: A 1-year Follow-up Study

Diagnosing tooth resorption is critical for effective management. Internal resorption is a rare phenomenon, presenting with a pathognomonic clinical sign of a “pink spot” in the crown. In case of infection-induced tooth resorption, endodontic therapy needs to be carried out to decrease bacterial load within the pulp space and facilitate repair of resorbed tooth structure. Following inflammation of the pulpal tissue, clastic cells infiltrate the pulp chamber along with physiological blood supply and thereby initiate the process of internal tooth resorption. Tooth resorption involves two phases: an initial injury phase and the subsequent stimulation phase. The injury phase pertains to the pulpal tissue getting injured by a noxious stimulus, whereas stimulation is caused by the infection present in the vicinity of the tooth. Additionally, in a case where the resorption is caused due to trauma, a multidisciplinary approach becomes imperative so that the long-term solution is achieved. This paper presents a case with internal resorption with a poor prognosis. However, surgical intervention was made to preserve the tooth until a definitive procedure can be instituted.

How to cite this article: Deep A, Thakur S, Singhal P, et al. Management of Root Perforation due to Internal Resorption: A 1-year follow-up Study. Int J Clin Pediatr Dent 2021;14(4):593–595.

Temperature-regulated gold nanoparticle sensors for immune chromatographic rapid test kits with reproducible sensitivity: a study

Immune‐chromatographic kits are being used since several years in the rapid detection of infectious diseases. It is also called the lateral flow technique, and is used for antigen or antibody detection. There are a series of steps involved in the development of these immune‐chromatographic test kits. Still, the preparation of gold nanoparticles (AuNPs) is an important quality variable for the immune‐chromatographic test kit sensitivity. The immune chromatographic test must be specific in detection for specific antigen and antibody; this implies that the test kit should not show a false result. Secondly, the test kit should be sensitive enough to give a readable result, and the intensity of the test line should increase or decrease with the concentration of an analytic sample. Various factors can influence the performance of a test. Temperature differences in AuNPs preparation can alter the assay kinetics and contribute to assay variability. Other factors such as assay components, manufacturing processes and reagent variation also contribute to assay precision and accuracy. It is important to note that assay reproducibility is the combined effect of individual sources of variability. The authors have synthesized AuNPs by immediately controlling the reaction temperature. Different batches of Malaria rapid test kit were developed and the test kit sensitivity was analysed. It was found that test kits designed with temperature‐controlled AuNPs sensor had reproducible uniformity in terms of batch to batch sensitivity than AuNPs synthesized by conventional Turkevich and Fern process.

A randomized control trial comparing the efficacy of 3Mixtatin and Modified 3Mix-MP paste using lesion sterilization and tissue repair technique to conventional root canal treatment in primary molars of children aged 4–8 years: An in vivo study

Background:

The aim of this study was to evaluate clinical and radiographic success rates of 3Mixtatin and Modified 3Mix-MP paste and compare it with conventional root canal treatment procedure in primary molars requiring pulpectomy.

Materials and Methods:

In this in vivo study, 66 primary molars in 52 children aged between 4 and 8 years with primary molars having chronic periapical abscess were treated randomly with 3Mixtatin, Modified 3Mix-MP paste, and Metapex. The subjects were reviewed at 6 and 12 months both clinically and radiographically after pulpal therapy to evaluate and compare the healing process. The data obtained were subjected to statistical analysis at a significance level of 0.05.

Results:

By the end of 12-month follow-up among the three groups, Group I seemed to be performing consistently better as compared to the other two groups when evaluated clinically and radiographically. However, Group III resulted in the greatest number of failures, with success rate being mere 42.9% at the end of follow-up period.

Conclusion:

Radiographic and clinical healing occurred in all the three groups; however, based on our results, Group I seemed to be performing consistently better among the three groups at 12-month follow-up. Hence, it can be inferred that 3Mixtatin used as a localized agent is effective and comparable to both Modified 3Mix-MP paste and conventional pulpectomy procedure involving calcium hydroxide and iodoform paste in primary teeth.

Bone disease in chronic pancreatitis

Bone disease (osteopenia or osteoporosis) is a highly prevalent condition in society and presents a tremendous, preventable public health burden. Screening procedures, such as, dual-energy X-ray absorptiometry scans, have allowed early identification and intervention to improve bone health, and reduce the risk of osteoporotic fractures, which carry significant morbidity and mortality. The association of bone disease has been recognized in several diseases of the gastrointestinal tract, resulting in established guidelines for screening in patients with malabsorptive disorders such as inflammatory bowel disease and celiac disease. Increasingly, the risk of bone disease has been recognized in patients with chronic pancreatitis (CP), who share similar risk factors as patients with other high gastrointestinal disorders. As a result, there have been a number of studies examining the prevalence and risks of bone disease and fractures in patients with CP. This review aims to summarize the recent literature and current recommendations related to bone disease in CP.

International round-robin experiment for angle-resolved light scattering measurement

An international round-robin experiment has been conducted to test procedures and methods for the measurement of angle-resolved light scattering. ASTM E2387-05 has been used as the main guide, while the experience gained should also contribute to the new ISO standard of angle-resolved scattering currently under development (ISO/WD 19986:2016). Seven laboratories from Europe and the United States measured the angle-resolved scattering from Al/SiO₂-coated substrates, transparent substrates, volume diffusors, quasi-volume diffusors, white calibration standards, and grating samples at laser wavelengths in the UV, VIS, and NIR spectra. Results were sent to Fraunhofer IOF, which coordinated the experiments and analyzed the data, while ESA-ESTEC, as the project donor, defined conditions and parameters. Depending mainly on the sample type, overall good to reasonable agreements were observed, with largest deviations at scattering angles very close to the specular beam. Volume diffusor characterization unexpectedly turned out to be challenging. Not all participants provided measurement uncertainty ranges according to the Guide to the Expression of Uncertainty in Measurement; often, a single general scatterometer-related measurement uncertainty value was stated. Although relative instrument measurement uncertainties close to 1% are sometimes claimed, the comparison results did not support these claims for specular scattering samples as mirrors, substrates, or gratings.

Falls When Standing, Falls When Walking: Different Mechanisms, Different Outcomes in Parkinson Disease

Our retrospective study of falls and resultant trauma in consecutive Parkinson disease (PD) patients seen in one year at the Muhammad Ali Parkinson Clinic found that multiple-fallers could be divided into patients who fell mainly when walking or those who fell mainly when standing. Patients who fell when walking were more likely to visit an emergency room or be admitted to a hospital. Of 455 consecutive patients who were evaluated over a one-year period, 51 were excluded because they had atypical Parkinson disorders, had multiple risk factors for falling, or were demented. Unified Parkinson Disease Rating Scales and Zeno Walkway results were compared among non-fallers, single-fallers, and multiple-fallers. Among multiple-fallers, comparisons were made between patients who fell mainly when standing and those who fell mainly when walking. Most patients (197, 49%) did not fall, 142 (35%) fell once, and 65 (16%) fell more than once. Multiple-fallers differed significantly from single-fallers and non-fallers: they had PD significantly longer (p<0.001), were more severely affected (p<0.001), and took shorter steps (p<0.001). Of 65 multiple-fallers, 26 (40%) fell mainly when standing, 28 (43%) fell mainly when walking, and 11 (17%) fell equally often when standing or walking. Falls when walking resulted in more severe injuries. Patients who fell mainly when standing did not realize they could fall when standing; engaged in inappropriate weight shifting, bending, reaching, and multitasking; and failed to use their assistive devices. Such patients would benefit from being counseled about falling when standing. Patients who fell mainly when walking were aware they could fall, despite using an assisted device, and were more likely to have freezing of gait (FOG). They were more likely to sustain a severe injury, and were more likely to be admitted to an emergency room or hospital. Such patients would benefit from reducing, if possible, FOG.

Gastrointestinal, pancreatic, and hepatic toxicity profile of CTLA-4 immune checkpoint inhibitors alone and in combination with PD-1/PD-L1 inhibitors: A meta-analysis of clinical trials

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Background: Cytotoxic T-lymphocyte activator-4 immune checkpoint inhibitors (CTLA-4-ICPI) is believed to cause more toxicity than programmed cell death/Ligand-1 (PD-1/PD-L1) ICPIs. We conducted a meta-analysis to outline the gastrointestinal (GI), pancreatic, and hepatic toxicity of CTLA-4 ICPIs when used alone and in combination with PD-1/PD-L1 ICPIs (C-ICPI). Methods: Ovid MEDLINE, EMBASE, Cochrane Library, SCOPUS, Web of Science, ClinicalTrials.gov, and WHO ICTRP were queried from January 2007-October 2018. Clinical trials reporting ICPI associated adverse events (AEs) were included. Colitis was defined as the development of diarrhea or documented colitis of any grade. Pancreatitis was defined as an elevation of amylase or lipase. Hepatitis was defined as elevation of ALT, AST, or transaminitis of any grade. A meta-analysis of proportions was conducted to report pooled AEs rate with 95% confidence intervals (CI) using a random effects model. Results: Overall, 30 study arms (20 CTLA-4, 10 C-ICPI) enrolling 3721 patients were included. There were a total of 3944 and 3317 AEs with CTLA-4 and C-ICPI use, respectively, with a pooled incidence of high grade AEs (grade 3-5; HAEs) of 23% (95% CI 16-33%) with CTLA-4 use and 52% (95% CI 37-67%) with C-ICPI use ( Table). The incidence of high-grade colitis was higher among patients treated with CTLA-4 ICPI. The proportion of high-grade pancreatitis was higher among patient who received C-ICPI. Two GI perforations were reported with CTLA-4 use. Pooled incidence of treatment related mortality was 1% in both groups. Conclusions: Though the overall GI, hepatic and pancreatic safety profile of CTLA-4 is comparable to C-ICPI, a higher incidence of high-grade colitis was found with CTLA-4. Two GI perforations were reported with CTLA-4 and warrant further investigation. No difference in treatment related mortality was found among the two groups. [Table: see text]

Abstract WP113: Racial Disparities in Patient Selection for Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke

Introduction: There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center.

Methods: AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.

Results: Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p < 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p<0.001) on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, door-to-needle time, baseline stroke severity, serum glucose, BP parameters and ASPECTS. Among DNS patients, the rates of sICH, three-month favorable functional outcome (mRS-scores of 0-1) and mortality did not differ between AA and CS. Using geospatial software, the observed treatment disparity could not be explained by racial zipcode. distribution.

Conclusions: Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.

A Novel Approach of Drug Localization through Development of Polymeric Micellar System Containing Azelastine HCl for Ocular Delivery

BACKGROUND

Development of polymeric micelles for the management of allergic conjunctivitis to overcome the limitations of topical installation, such as poor patient compliance, poor stromal permeability, and significant adverse effects, increase precorneal residence time and efficacy, and also control the release of drug at the target site.

OBJECTIVE

The investigation was aimed at developing a polymeric micellar system of Azelastine HCl for Ocular Delivery.

METHODS

Drug loaded micelles of tri-block copolymers Pf 127 were prepared by Thin Film hydration method. The polymeric micelles formulations (F1 to F9) were assessed for entrapment efficiency, micelle size, in vitro permeation, ex vivo transcorneal permeation, in vivo Ocular Irritation, and Histology.

RESULTS

Optimized micelles formulation (F3), with the lowest micelle size of 92 nm, least polydispersity value of 0.135, highest entrapment efficiency of 95.30 ± 0.17%, and a cumulative drug permeation of 84.12 ± 1.26% in 8h, was selected to develop pH-sensitive micelles loaded carbopol in situ gel. The optimized in situ gel (G4) proved to be superior in its ex vivo transcorneal permeation when compared with Market Preparation and pure drug suspension, exhibiting 43.35 ± 1.48% Permeation with zero-order kinetics (r2 = 0.9944) across goat cornea. Transmission Electron microscopy revealed spherical polymeric micelles trapped in the gel matrix. A series of experiments showed hydration capability, non-irritancy, and histologically safe gel formulation that had appropriate handling characteristics.

CONCLUSION

A controlled release pH-sensitive ocular formulation capable of carrying the drug to the anterior section of the eye via topical delivery was successfully developed for the treatment of allergic conjunctivitis.

Therapeutic Benefit of Cilostazol in Patients with Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized and Nonrandomized Studies

OBJECTIVE

To assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase type III, in preventing cerebral ischemia related to cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A total of six clinical studies met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. The primary endpoint was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the final follow-up.

RESULTS

A total of 136 (22%) of 618 subjects (38 and 98 assigned to cilostazol and control treatments, respectively) with SAH developed cerebral ischemia related to vasospasm. The risk of cerebral ischemia related to vasospasm was significantly lower in subjects assigned to cilostazol treatment (RR 0.43; 95% CI 0.31-0.60; p< 0.001). The risks of angiographic vasospasm (RR 0.67, 95% CI 0.54-0.84, p< 0.001 ) and new cerebral infarct (RR 0.37, 95% CI 0.24-0.57, p< 0.001) were significantly lower in subjects assigned to cilostazol treatment. There was a significantly lower rate of death or disability in subjects assigned to cilostazol treatment at follow-up (PR 0.55, 95% 0.39-0.78, p = 0.001).

CONCLUSION

The reduction in rates of cerebral ischemia related to vasospasm and death or disability at follow-up support further evaluation of oral cilostazol in patients with aneurysmal SAH in a large randomized clinical trial.

Dual antiplatelet therapy pretreatment in IV thrombolysis for acute ischemic stroke

OBJECTIVE

We sought to determine the safety and efficacy of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients with a history of dual antiplatelet therapy pretreatment (DAPP) in a prospective multicenter study.

METHODS

We compared the following outcomes between DAPP+ and DAPP- IVT-treated patients before and after propensity score matching (PSM): symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial hemorrhage, favorable functional outcome (modified Rankin Scale score 0-1), and 3-month mortality.

RESULTS

Among 790 IVT patients, 58 (7%) were on DAPP before stroke (mean age 68 ± 13 years; 57% men; median NIH Stroke Scale score 8). DAPP+ patients were older with more risk factors compared to DAPP- patients. The rates of sICH were similar between groups (3.4% vs 3.2%). In multivariable analyses adjusting for potential confounders, DAPP was associated with higher odds of asymptomatic intracranial hemorrhage (odds ratio = 3.53, 95% confidence interval: 1.47-8.47; p = 0.005) but also with a higher likelihood of 3-month favorable functional outcome (odds ratio = 2.41, 95% confidence interval: 1.06-5.46; p = 0.035). After propensity score matching, 41 DAPP+ patients were matched to 82 DAPP- patients. The 2 groups did not differ in any of the baseline characteristics or safety and efficacy outcomes.

CONCLUSIONS

DAPP is not associated with higher rates of sICH and 3-month mortality following IVT. DAPP should not be used as a reason to withhold IVT in otherwise eligible AIS candidates.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for IVT-treated patients with AIS, DAPP is not associated with a significantly higher risk of sICH. The study lacked the precision to exclude a potentially meaningful increase in sICH bleeding risk.

Abstract TP68: Shorter Door-to-Needle Time is the Only Independent Predictor for Initiation of Intravenous Thrombolysis (IVT) Within the Golden Hour

Introduction: Administration of tPA in the first 60 min post-onset, the golden hour (GH), is associated with improved functional outcomes but remains unachievable in the vast majority of patients. We sought to identify independent predictors of IVT in the GH in a prospective, multi-center study.

Methods: AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Demographics, vascular risk factors, onset to treatment time, door-to-needle time (DTN) admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. The etiopathogenic mechanism of AIS was documented using TOAST criteria. Subjects with in-hospital stroke or treated in the mobile stroke unit were excluded.

Results: Out of total 658 IVT-treated AIS patients (mean age 64±15 years; 50% men; median NIHSS-score 6, IQR: 4-12) we identified 26 (4%) subjects treated in the GH (mean age 62±15 years; 46% men; median NIHSS-score 8, IQR: 4-12). GH patients had shorter median DTN (23 min, IQR: 18-44 vs. 38 min, IQR: 26-49). DTN 2 30 min was more prevalent in the GH group (62% vs. 20%; p<0.001). DTN emerged as the only independent predictor of IVT in the GH in multivariable logistic regression models adjusting for demographics, risk factors, admission blood pressure and serum glucose levels, TOAST subtype, baseline NIHSS and ASPECTS. A 10-min delay in DTN approximately halved the odds of IVT in the GH (OR: 0.54; 95%CI: 0.41-0.71; p<0.001). Alternatively, DTN equal or less than 30min increased exponentially the likelihood of tPA initiation in the GH (OR: 6.29; 95%CI: 2.78-14.25; p<0.001).

Conclusions: Shorter DTN is the only independent predictor of IVT initiation within the GH. Continued improvements in systems of acute stroke care should aim to further reduce DTN in order to increase the availability of tPA delivery in the GH.

Abstract 37: The Efficacy and Safety of Cilostazol in Subarachnoid Hemorrhage. A Meta-analysis of Randomized and Non Randomized Studies

Objective: Extensive research has long been focused on improving morbidity and mortality related to cerebral vasospasm which is well known as a major complication in subarachnoid hemorrhage (SAH) patients. The aim of this meta-analysis is to assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase Type III, on cerebral vasospasm after SAH.

Methods: Randomized and non randomized studies that compared effectiveness of cilostazol in SAH were included. A total of 6 trials met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% CIs (confidence intervals) using random-effects models. Primary end point was symptomatic vasospasm. Secondary end points were angiographic vasospasm, new cerebral infarct, mortality, and functional outcome i.e Modified Rankin scale ≤ 2.

Results: Of the 618 total subjects, total of 136 (22%) symptomatic vasospasm events occurred during the follow-up period. The RR of symptomatic vasospasm was lower in patients treated with Cilostazol (RR = 0.43; 95% CI, 0.31-0.60; P < 0.001). Angiographic vasospasm was also significantly lower among those who received cilostazol as compared to control group (RR 0.67, 95% CI 0.51-0.84, p = .001). Cilostazol was associated with lower likelihood of new cerebral infarct in comparison to best medical therapy (RR 0.33 CI 95% 0.20-0.54, p<0.001). There was no difference between the risk of mortality between subjects who received airway cilostazol compared with those who were in control group (RR 0.64 CI 95% 0.15-2.76, p=0.55). There was improvement of mRS noted in patients who received cilostazol therapy (RR 1.21 CI 95% 1.05-1.39, p=0.008).

Conclusion: Cilostazol administration may improve the outcome of patients with SAH. Further studies are needed to confirm this efficacy of cilostazol

Abstract TMP22: Safety of Pretreatment With Dual Antiplatelet Therapy in Intravenous Thrombolysis for Acute Ischemic Stroke

Introduction: There are preliminary data indicating that pretreatment with dual antiplatelet therapy (DAPT) may increase the risk of symptomatic intracranial hemorrhage (sICH) following intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to identify the safety and efficacy of pretreatment with DAPT in IVT for AIS in a prospective, multi-center study.

Methods: AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Three-month functional status was assessed using modified Rankin Scale (mRS). We compared the following outcomes between DAPT (+) and DAPT (-) patients before and after propensity score matching (PSM): 1.sICH, 2. asymptomatic intracranial hemorrhage (aICH) 3. favourable functional outcome (FFO; mRS scores of 0-1), 4. 3-month mortality.

Results: Out of total 790 IVT-treated AIS patients, we identified 58 (7%) pretreated with DAPT (mean age 68±13 years; 57% men; median NIHSS-score 8, IQR: 4-14). The two groups did not differ (p>0.05) in terms of sICH [DAPT(+): 3% vs. DAPT(-): 3%], FFO (64% vs. 50%) and 3-month mortality (9% vs. 9%) in unmatched analyses. DAPT pretreatment was associated with higher odds of aICH before (17% vs. 6%) and after adjustment (OR: 2.4; 95%CI: 1.1-5.5) for potential confounders. After PSM, patients with (n=41) and without (n=82) DAPT pretreatment did not differ in any of the baseline characteristics. The differences in rates of all outcome events were non-significant in the two groups including sICH (2% vs. 1%, p=0.63), aICH (17% vs. 7%, p=0.06) and 3-month mRS (p=0.60; Figure).

Conclusions: Pretreatment with DAPT is not associated with higher rates of sICH or three-month mortality and does not reduce the odds of FFO following IVT for AIS. IVT should not be withheld in otherwise eligible candidates due to pretreatment with DAPT.

Downward finger displacement distinguishes Parkinson disease dementia from Alzheimer disease

Purpose/Aim of the study: To study finger displacement in patients with Parkinson disease dementia (PDD) and in patients with Alzheimer disease (AD).

METHODS

We examined 56 patients with PDD and 35 with AD. Patients were examined during their regular outpatient clinic visit. Finger displacement was measured by observers not actively involved in the study using a creative grid ruler for all PDD and AD patients. Finger displacement was examined by asking patients to point their index fingers toward the grid ruler with the nails facing upward. Patients were asked to maintain the pointing position for 15 s. After 15 s, patients were asked to close their eyes for another 15 s while maintaining the same position. A positive result was downward index finger displacement of ≥5 cm within the 15-second time window with eyes closed.

RESULTS

Of the 56 PDD patients, 53 had bilateral finger displacement of >5 cm. In comparison, of the 35 AD patients, only 1 patient had minimal displacement.

CONCLUSIONS

Results of the non-invasive finger displacement test may provide insight, on an outpatient basis, of the integrity of subcortical-cortical circuits. Downward finger displacement, especially bilateral downward displacement, may signal the extensive disruption of subcortical-cortical circuits that occurs in PDD patients.

ABBREVIATIONS

AChE: acetylcholinesterase; AD: Alzheimer disease; DLB: dementia with Lewy bodies; ET: essential tremor; MDS-UPDRS: Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale; MMSE: Mini-Mental State Examination; PD: Parkinson disease; PDD: Parkinson disease dementia.

Minimum light intensity threshold to prevent negative effects on broiler production and welfare

1. Research focused on lower light intensity levels is required to set minimum standards appropriate for production and welfare of intensively housed broilers. The objective of this research was to study light intensity (0.1 to 10 lx) effects on Ross × Ross 308 and 708 genotypes. 2. Three experiments (35 d each) using 18 720 broilers were conducted with the initial experiment using two replicates of 0.1, 1, 5 and 10 lx. The second and third experiments examined 0.5, 1, 5 and 10 lx with treatments replicated twice in each experiment in a randomised complete block design with experiment acting as a block. In each experiment, mixed sex broilers from each genotype were housed in 6 equally sized pens per room. 3. In Experiment 1, the introduction of 0.1 lx at d 7 caused high levels of mortality and poor growth rate from d 7 to 14 and was discontinued. 4. In Experiments 2 and 3, increasing light intensity increased body weight gain (0-35 d) and feed intake (0-35 d) in a quadratic and linear fashion, respectively. Similarly, mortality corrected gain to feed ratio (FCR, 0-35 d) demonstrated a quadratic response with a maximum at 5 lx. Carcass, breast meat and skin, abdominal fat and drum skin, as a percentage of live weight, increased while drum bone and wing yield decreased in a linear fashion with increasing light intensity. Total carcass composition was unaffected by light intensity. 5. Genotype effects were numerous. No interactions were found between genotype and light intensity. 6. Ocular dimensions and the incidence of foot pad lesions decreased in a quadratic and linear fashion, respectively, with increasing light intensity. In contrast, welfare-associated gait score and mortality levels were not affected by light intensity. 7. It was concluded that performance, breast meat yield and bird welfare improved with increasing light intensity. The data support 5 lx as a minimum light intensity in broiler production.

Treatment of spinal cord injury: a review of engineering using neural and mesenchymal stem cells

Over time, various treatment modalities for spinal cord injury have been trialed, including pharmacological and nonpharmacological methods. Among these, replacement of the injured neural and paraneural tissues via cellular transplantation of neural and mesenchymal stem cells has been the most attractive. Extensive experimental studies have been done to identify the safety and effectiveness of this transplantation in animal and human models. Herein, we review the literature for studies conducted, with a focus on the human-related studies, recruitment, isolation, and transplantation, of these multipotent stem cells, and associated outcomes.

Synthesis, antimicrobial and anticancer evaluation of N'-(substituted benzylidene)-2-(benzo[d]oxazol-3(2H)-yl)acetohydrazide derivatives

A series of N'-(substituted benzylidene)-2-(benzo[d]oxazol-3(2H)-yl)acetohydrazide derivatives was synthesized and evaluated for its in vitro antimicrobial and anticancer activities. Antimicrobial activity results revealed that compound 12 was found to be the most potent antimicrobial agent. Results of anticancer study indicated that the synthesized compounds exhibited average anticancer potential. Compound 7 (IC 50 =3.12 µM) and compound 16 (IC 50 =2.88 µM) were found to be most potent against breast cancer (MCF7) cell lines. In conclusion, compound 12 and 16 have the potential to be selected as lead compound for the developing of novel antimicrobial and anticancer agents respectively.

Characteristics of falls in the epilepsy monitoring unit: a retrospective study

Falls are an important adverse event in an epilepsy monitoring unit (EMU). We identified patterns of falls in an EMU and compared them with risk factors for inpatient falls. Twenty-six patients with 26 falls (2.3% of admissions) in the EMU were compared with 50 general neurology inpatients with 56 falls over a 4-year period. In the EMU, the majority (62%) of falls happened during the first 3 days of admission, mostly in the bathroom (74%), in patients with a normal mental status (77%). Most general inpatients fell after the third day (64%), inside their rooms (68%), and had an altered mental status before the fall (68%). All 26 EMU patients were identified as high risk at admission, in spite of which falls were not prevented. We outline these differences between EMU patients and general inpatients and highlight the practice gap in preventing falls in an EMU.

Use of a post-production fractionation process improves the nutritional value of wheat distillers grains with solubles for young broiler chicks

Background

Post-production fractionation of wheat distillers grains with solubles (DDGS) increases their crude protein content and reduces their fiber content. This experiment was conducted to determine the effects of fractionation of wheat DDGS on apparent total tract digestibility (ATTD) and performance when fed to broiler chicks (0–21 d).

Methods

A total of 150, day-old, male broiler chicks (Ross-308 line; Lilydale Hatchery, Wynyard, Saskatchewan) weighing an average of 49.6 ± 0.8 g were assigned to one of five dietary treatments in a completely randomized design. The control diet was based on wheat and soybean meal and contained 20% regular wheat DDGS. The experimental diets contained 5, 10, 15 or 20% fractionated wheat DDGS added at the expense of regular wheat DDGS.

Results

The ATTD of dry matter and gross energy were linearly increased (P < 0.01) as the level of fractionated wheat DDGS in the diet increased. Nitrogen retention was unaffected by level of fractionated wheat DDGS (P > 0.05). Weight gain increased linearly (P = 0.05) as the level of fractionated wheat DDGS in the diet increased. Feed intake, feed conversion and mortality were unaffected by level of fractionated wheat DDGS in the diet (P > 0.05).

Conclusions

Post-production fractionation of wheat DDGS improves their nutritional value by lowering their fiber content and increasing their content of crude protein and energy. These changes in chemical composition supported increased weight gain of broilers fed wheat DDGS.

Nutritional evaluation of low-phytate peas (Pisum sativum L.) for young broiler chicks

This experiment determined the effects of including normal and low-phytate peas in diets fed to young broiler chickens on performance, phosphorus availability and bone strength. A total of 180, day-old, male broilers (Ross-308 line) were assigned to six treatments. The control was based on corn and soybean meal while two additional corn-based diets were formulated containing 30% of either normal or low-phytate pea providing 0.45% available phosphorus. For each of these three diets, a similar diet was formulated by reducing the amount of dicalcium phosphate to produce a diet with 0.3% available phosphorus. The total tract apparent availability (TTAA) of phosphorus was higher (p = 0.02) for broilers fed the low-phytate pea than for birds fed the normal pea diets. Birds fed diets containing the lower level of phosphorus had a higher TTAA of phosphorus (50.64 vs. 46.68%) than broilers fed diets adequate in phosphorus. Protein source had no effect on weight gain, feed intake or feed conversion. Broilers fed the low phosphorus diets had lower weight gain (p = 0.04) and feed intake (p < 0.01) than broilers fed the higher phosphorus level. Bone strength was higher (p < 0.01) for broilers fed diets based on low-phytate pea than for those fed diets based on normal pea or soybean meal. Increasing the availability of the phosphorus in peas could mean that less inorganic phosphorus would be required in order to meet the nutritional requirements of broilers. Since inorganic phosphorus sources tend to be expensive, a reduction in their use would lower ration costs. In addition, increased availability of phosphorus would reduce the amount of phosphorus excreted thus reducing the amount of phosphorus that can potentially pollute the environment.

Progressive limb ataxia following inferior olive lesions

Cerebellar climbing fibres originate in the inferior olive (IO). Temporary IO inactivation produces movement deficits. Does permanent inactivation produce similar deficits and, if so, do they recover? The excitotoxin, kainic acid, was injected into the rostral IO of three cats. Behaviour was measured during reaching and locomotion. Two cats were injected during the reaching task. Within minutes, grasping became difficult and the trajectories of the reaches showed higher arcing than normally seen. During locomotion, both cats showed head and trunk deviation to the injected side, walking paths curved to the injected side, and the paws were lifted higher than normal. Limbs contralateral to the injections became rigid. Within 1 day, posture had normalized, locomotion was unsteady and high lifting of the paws had reversed to a tendency to drag the dorsum of the paws. Passive body movement produced vestibular signs. Over a few days, locomotion normalized and vestibular signs disappeared. Reach trajectories were normal but grasping deficits persisted. Over the first week, the amplitude of limb lift during reaching and locomotion began to increase. The increase continued over time and, after several months, limb movements became severely ataxic. The effects followed the somatotopy of the rostral IO: a loss of cells in medial rostral IO only affected the forelimb, whereas a loss of cells in medial and lateral IO affected both forelimb and hindlimb. Deficits produced by IO lesions involve multiple mechanisms; some recover rapidly, some appear stable, and some worsen over time. The nature of the progressive deficit suggests a gradual loss of Purkinje cell inhibition on cerebellar nuclear cells.

Josef Klingler's models of white matter tracts: influences on neuroanatomy, neurosurgery, and neuroimaging

During the 1930s, white matter tracts began to assume relevance for neurosurgery, especially after Cajal's work. In many reviews of white matter neurobiology, the seminal contributions of Josef Klingler (1888-1963) and their neurological applications have been overlooked. In 1934 at the University of Basel under Eugen Ludwig, Klingler developed a new method of dissection based on a freezing technique for brain tissue that eloquently revealed the white matter tracts. Klingler worked with anatomists, surgeons, and other scientists, and his models and dissections of white matter tracts remain arguably the most elegant ever created. He stressed 3-dimensional anatomic relationships and laid the foundation for defining mesial temporal, limbic, insular, and thalamic fiber and functional relationships and contributed to the potential of stereotactic neurosurgery. Around 1947, Klingler was part of a Swiss-German group that independently performed the first stereotactic thalamotomies, basing their targeting and logic on Klingler's white matter studies, describing various applications of stereotaxy and showing Klingler's work integrated into a craniocerebral topographic system for targeting with external localization of eloquent brain structures and stimulation of deep thalamic nuclei. Klingler's work has received renewed interest because it is applicable for correlating the results of the fiber-mapping paradigms from diffusion tensor imaging to actual anatomic evidence. Although others have described white matter tracts, none have had as much practical impact on neuroscience as Klinger's work. More importantly, Josef Klingler was an encouraging mentor, influencing neurosurgeons, neuroscientists, and brain imaging for more than three quarters of a century.

Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis

Object

Currently, mannitol is the recommended first choice for a hyperosmolar agent for use in patients with elevated intracranial pressure (ICP). Some authors have argued that hypertonic saline (HTS) might be a more effective agent; however, there is no consensus as to appropriate indications for use, the best concentration, and the best method of delivery. To answer these questions better, the authors performed a review of the literature regarding the use of HTS for ICP reduction.

Methods

A PubMed search was performed to locate all papers pertaining to HTS use. This search was then narrowed to locate only those clinical studies relating to the use of HTS for ICP reduction.

Results

A total of 36 articles were selected for review. Ten were prospective randomized controlled trials (RCTs), 1 was prospective and nonrandomized, 15 were prospective observational trials, and 10 were retrospective trials. The authors did not distinguish between retrospective observational studies and retrospective comparison trials. Prospective studies were considered observational if the effects of a treatment were evaluated over time but not compared with another treatment.

Conclusions

The available data are limited by low patient numbers, limited RCTs, and inconsistent methods between studies. However, a greater part of the data suggest that HTS given as either a bolus or continuous infusion can be more effective than mannitol in reducing episodes of elevated ICP. A meta-analysis of 8 prospective RCTs showed a higher rate of treatment failure or insufficiency with mannitol or normal saline versus HTS.

The arcade of Struthers: An anatomical study with potential neurosurgical significance

BACKGROUND

Significant controversy exists regarding the existence of the so-called arcade of Struthers and whether this structure is involved in some cases of proximal ulnar nerve entrapment. Therefore, the aim of the present study was to further elucidate this anatomy.

METHODS

Fifteen cadavers (30 sides) underwent dissection of the medial arm with special attention to the course of the ulnar nerve and its relationships to the soft tissues of this region.

RESULTS

We identified a thickening in the inferior medial arm that crosses the ulnar nerve and is consistent with the so-called arcade of Struthers in 86.7% of sides. On 57.7% of the sides, the arcade was found to be due to a thickening of the brachial fascia and was classified as a type I arcade. On 19.2% of the sides, the arcade was due to the internal brachial ligament and these were classified as type II arcades. On 23.1% of the sides, the arcade was due to a thickened medial intermuscular septum and these were classified as type III arcades. The mean length of the arcade was 4.3 cm and the distal end of the arcade was, on average, 6.8 cm above the medial epicondyle. Although the presence of an arcade of Struthers was slightly more common in female specimens, this did not reach statistical significance. However, arcades were found more often on right side (P < 0.001).

CONCLUSIONS

Based on our findings, the arcade of Struthers is an anatomical band of connective tissue in the medial distal arm that crosses the ulnar nerve. This structure was found in the majority of our specimens and may need to be evaluated in proximal ulnar neuropathies. We believe that past studies that have not observed the arcade and past studies with varied findings are due to the various definitions used for this anatomical structure. Using the classification system as demonstrated in the present study may make future communications regarding the arcade of Struthers more exact.

Kenneth Grant Jamieson (1925-1976): his life and contributions to neurosurgery

Manuscript submitted May 23, 2011. Accepted September 25, 2011. Kenneth Grant Jamieson is celebrated as one of Australia's top neurosurgeons. His most notable contributions to neurosurgery included novel treatments of aneurysms and pineal tumors and studies of head injury. Jamieson was also an innovator for the development of new neurosurgical instruments and renowned for his teaching abilities, prolificacy, and mentorship. This preeminent neurosurgeon's life was cut short at the age of 51. Our current understanding and knowledge of treatments of various neurosurgical diseases is based on pioneers such as Kenneth Grant Jamieson.

Chemical priming for spinal cord injury: a review of the literature part II-potential therapeutics

INTRODUCTION

Spinal cord injury is a complex cascade of reactions secondary to the initial mechanical trauma that puts into action the innate properties of the injured cells, the circulatory, inflammatory, and chemical status around them, into a non-permissive and destructive environment for neuronal function and regeneration. Priming means putting a cell, in a state of "arousal" towards better function. Priming can be mechanical as trauma is known to enhance activity in cells.

MATERIALS AND METHODS

A comprehensive review of the literature was performed to better understand the possible chemical primers used for spinal cord injuries.

CONCLUSIONS

Taken together, many studies have shown various promising results using the substances outlined herein for treating SCI.

Chemical priming for spinal cord injury: a review of the literature. Part I-factors involved

INTRODUCTION

There are significant differences between the propensity of neural regeneration between the central and peripheral nervous systems.

MATERIALS AND METHODS

Following a review of the literature, we describe the role of growth factors, guiding factors, and neurite outgrowth inhibitors in the physiology and development of the nervous system as well as the pathophysiology of the spinal cord. We also detail their therapeutic role as well as those of other chemical substances that have recently been found to modify regrowth following cord injury.

CONCLUSIONS

Multiple factors appear to have promising futures for the possibility of improving spinal cord injury following injury.