Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology

AIM

To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported.

RESULTS

FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01).

CONCLUSION

Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

Immediate crossover fatigue after unilateral submaximal eccentric contractions of the knee flexors involves peripheral alterations and increased global perceived fatigue

After a unilateral muscle exercise, the performance of the non-exercised contralateral limb muscle can be also impaired. This crossover fatigue phenomenon is still debated in the literature and very few studies have investigated the influence of eccentric contractions. This study was designed to assess neuromuscular adaptations involved in the crossover fatigue of the non-exercised contralateral knee flexor muscles. Seventeen healthy young men performed a unilateral submaximal eccentric exercise of the right knee flexors until a 20% reduction in maximal voluntary isometric contraction torque was attained in the exercised limb. Before (PRE), immediately after exercise cessation (POST) and 24 hours later (POST24), neuromuscular function and perceived muscle soreness were measured in both the exercised limb and non-exercised limb. In addition, global perceived fatigue was assessed at each measurement time. At POST, significant reductions in maximal voluntary isometric contraction were observed in the exercised limb (-28.1%, p < 0.001) and in the non-exercised limb (-8.5%, p < 0.05), evidencing crossover fatigue. At POST, voluntary activation decreased in the exercised limb only (-6.0%, p < 0.001), while electrically evoked potentiated doublet torque was impaired in both the exercised limb and the non-exercised limb (-11.6%, p = 0.001). In addition, global perceived fatigue significantly increased at POST (p < 0.001). At POST24, all measured variables returned to PRE values, except for perceived muscle soreness scores exhibiting greater values than PRE (p < 0.05). A possible cumulative interaction between peripheral alterations and global perceived fatigue may account for the immediate crossover fatigue observed in the non-exercised limb.

The applicability of the "surprise question" as a prognostic tool in patients with severe chronic comorbidities in a university teaching outpatient setting

BACKGROUND

Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on quality of life and expectations about death and dying. The concept of advance directives (ADs) gives individuals the opportunity to make known their decisions about the treatments they would like to receive at the end of life. Despite the recognition of relevance in clinical practice, the applicability of the concept presents challenges, including establishing the appropriate prognosis for each patient and the ideal time to approach the patient. Some prognostic tools were developed, such as the surprise question (SQ): "Would you be surprised if your patient died in 12 months?", which is used in some clinical settings to predict patient deaths and to make decisions regarding ADs. The main objective of the present study was to evaluate the behavior of second-year resident physicians (PGY-2) when the SQ was applied.

METHOD

In our observational study, from July 1, 2016, to February 28, 2017, (PGY-2) in the Internal Medicine Residency Program (IMRP) applied SQ to all patients with multiple and varied chronic no communicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo- Brazil. The frequency of the outcome (death or non-death within 12 months) was analyzed by correlating it with the clinical data (impact of the studied variables).

RESULTS

Eight hundred forty patients entered the study. Fitfty-two of them (6.2%) died within one year. PGY-2 predicted that two hundred and fourteen patients (25.5% of total) would die within a year (answer No to SQ), of which, 32 (14.9%) did so. The correct residents' prognosis for the subgroup of 626 patients (answer "Yes" to SQ) was NPV = 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%). Answering "Yes" to SQ correlated negatively to addressing AD while the outcomes death and the answer No to SQ were positively correlated, according to the number of comorbidities.

CONCLUSION

The SQ, in addition to care, contributed to health education, communication and care planning shared by the doctor and patient.

Submaximal fatiguing eccentric contractions of knee flexors alter leg extrapersonal representation

This study assessed the immediate and prolonged effects of eccentric-induced fatigue on position sense, utilizing position-pointing tasks, which had not been previously implemented for this purpose. Fifteen healthy adults underwent a fatiguing eccentric protocol that entailed sets of unilateral submaximal contractions of knee flexor muscles until reaching a 20% decrease in maximal isometric torque production. Evaluations of knee flexor neuromuscular function as well as position-pointing tasks at 40° and 70° of knee flexion were conducted prior to the fatiguing eccentric protocol, immediately after (POST), and 24 h after (POST24) exercise termination. To assess neuromuscular fatigue etiology, electrical myostimulations were administered during and after maximal voluntary isometric contractions. At POST, the voluntary activation level and evoked potentiated doublet amplitude at 100 Hz were significantly reduced. In addition, position-pointing errors exhibited a significant increase at POST regardless of the tested angle, with participants positioning the pointer in a more extended position compared to their hidden exercised limb. At POST24, neuromuscular function and position sense parameters had reverted to their baseline levels. The findings of this experiment demonstrate that position-pointing accuracy was impaired immediately after the fatiguing eccentric protocol, manifesting in the presence of both central and peripheral fatigue. As position-pointing accuracy relies heavily on extrapersonal representation of the body at the brain level, acute changes in exercised limb's extrapersonal representation might have resulted from central fatigue-related mechanisms altering the cognitive processes responsible for converting kinesthetic signals into extrapersonal coordinates.

Whole Body Vibration Training Improves Maximal Strength of the Knee Extensors, Time-to-Exhaustion and Attenuates Neuromuscular Fatigue

Whole-body vibration (WBV) training programs were reported to improve knee extensor muscle (KE) strength in healthy participants. Unfortunately, the underlying mechanisms of these strength gains remain unresolved. In addition, WBV training was shown to increase the time-to-exhaustion of a static submaximal endurance task. However, the effects of WBV training on neuromuscular fatigue (i.e., a decrease of the maximal voluntary isometric contraction; MVIC) induced by an endurance task is unknown. We, therefore, investigated the influence of WBV training on (i) KE MVIC and neuromuscular function, (ii) the time-to-exhaustion of the KE associated with a submaximal isometric fatiguing exercise, and (iii) KE neuromuscular fatigue and its etiology. Eighteen physically active males were assigned to a WBV group (n = 10) or a sham training group (SHAM; n = 8). The MVIC of the KE, voluntary activation, and electrically evoked responses of the KE were assessed (i) before and after a fatiguing exercise (i.e., submaximal isometric contraction) performed until failure, and (ii) before (PRE) and after a 6-week training (POST) period. At POST, the WBV training increased the KE MVIC (+12%, p = 0.001) and voluntary activation (+6%, p < 0.05) regardless of the fatiguing exercise. The time-to-exhaustion was also lengthened at POST in the WBV group (+34%, p < 0.001). Finally, the relative percentage of MVIC decrease after fatiguing exercises diminished in the WBV group between PRE and POST (-14% vs. -6%, respectively, p < 0.001). Significant neural adaptation enhancements account for the trend in KE strength improvements observed after the WBV training program. In addition, the WBV training was effective at increasing the time-to-exhaustion and attenuating neuromuscular fatigue.

Knee position sense and knee flexor neuromuscular function are similarly altered after two submaximal eccentric bouts

PURPOSE

This study examined eccentric-induced fatigue effects on knee flexor (KF) neuromuscular function and on knee position sense. This design was repeated across two experimental sessions performed 1 week apart to investigate potential repeated bout effects.

METHODS

Sixteen participants performed two submaximal bouts of KF unilateral eccentric contractions until reaching a 20% decrease in maximal voluntary isometric contraction force. Knee position sense was evaluated with position-matching tasks in seated and prone positions at 40° and 70° of knee flexion so that KF were either antagonistic or agonistic during the positioning movement. The twitch interpolation technique was used to assess KF neuromuscular fatigue. Perceived muscle soreness was also assessed. Measurements were performed before, immediately (POST) and 24 h after (POST24) each eccentric bout.

RESULTS

No repeated bout effect on neuromuscular function and proprioceptive parameters was observed. At POST, central and peripheral factors contributed to the force decrement as shown by significant decreases in voluntary activation level (- 3.8 ± 4.8%, p < 0.01) and potentiated doublet torque at 100 Hz (- 10 ± 15.8%, p < 0.01). At this time point, position-matching errors significantly increased by 1.7 ± 1.9° in seated position at 40° (p < 0.01). At POST24, in presence of muscle soreness (p < 0.05), although KF neuromuscular function had recovered, position-matching errors increased by 0.6 ± 2.6° in prone position at 40° (p < 0.01).

CONCLUSION

These results provide evidence that eccentric-induced position sense alterations may arise from central and/or peripheral mechanisms depending on the testing position.

Antimicrobial activity in the tick Rhipicephalus (Boophilus) microplus eggs: Cellular localization and temporal expression of microplusin during oogenesis and embryogenesis

Arthropods display different mechanisms to protect themselves against infections, among which antimicrobial peptides (AMPs) play an important role, acting directly against invader pathogens. We have detected several factors with inhibitory activity against Candida albicans and Micrococcus luteus on the surface and in homogenate of eggs of the tick Rhipicephalus (Boophilus) microplus. One of the anti-M. luteus factors of the egg homogenate was isolated to homogeneity. Analysis by electrospray mass spectrometry (ESI-MS) revealed that it corresponds to microplusin, an AMP previously isolated from the cell-free hemolymph of R. (B.) microplus. Reverse transcription (RT) quantitative polymerase chain reactions (qPCR) showed that the levels of microplusin mRNA gradually increase along ovary development, reaching an impressive highest value three days after the adult females have dropped from the calf and start oviposition. Interestingly, the level of microplusin mRNA is very low in recently laid eggs. An enhance of microplusin gene expression in eggs is observed only nine days after the onset of oviposition, achieving the highest level just before the larva hatching, when the level of expression decreases once again. Fluorescence microscopy analysis using an anti-microplusin serum revealed that microplusin is present among yolk granules of oocytes as well as in the connecting tube of ovaries. These results, together to our previous data, suggest that microplusin may be involved not only in protection of adult female hemocele, but also in protection of the female reproductive tract and embryos, what points this AMP as a considerable target for development of new methods to control R. (B.) microplus as well as the vector-borne pathogens.