Neuropathy in ARSACS is demyelinating but without typical nerve enlargement in nerve ultrasound

BACKGROUND

To specify peripheral nerve affection in autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) by correlating high-resolution nerve ultrasound and nerve conduction studies.

METHODS

We assessed a cohort of 11 ARSACS patients with standardized nerve conduction studies and high-resolution ultrasound of peripheral nerves and compared nerve ultrasound findings to a healthy control group matched for age, sex, size and weight.

RESULTS

Mean age of patients was 39.0 (± 14.1) years and disease duration at assessment 30.6 (± 12.5) years. All patients presented with a spasticity, ataxia and peripheral neuropathy. Neuropathy appeared to be primarily demyelinating in 9/11 cases and was not classifiable in 2/11 cases due to not evocable potentials. Nerve ultrasound revealed a normal ultrasound pattern sum score (UPSS) in each ARSACS patient and no significant nerve enlargement compared to the control group.

CONCLUSIONS

Peripheral neuropathy in ARSACS showed primarily demyelinating rather than axonal characteristics and presented without nerve enlargement. As demyelinating neuropathies do commonly present enlarged nerves we recommend further genetic testing of the SACS gene in patients who present with this combination of demyelinating neuropathy without nerve enlargement. ARSACS cases that initially presented only with neuropathy without spasticity or ataxia and therefore were misdiagnosed as Charcot-Marie-Tooth disease are supporting this suggestion.

The digital divide in rural and regional communities: a survey on the use of digital health technology and implications for supporting technology use

OBJECTIVE

A digital divide exists for people from rural and regional areas where they are less likely and confident to engage in digital health technologies. The aim of this study was to evaluate the digital health literacy and engagement of people from rural and regional communities, with a focus on identifying barriers and facilitators to using technology.

RESULTS

Forty adults living in rural/regional areas completed a survey consisting of the eHealth Literacy Scale (eHEALS) with additional items surveying participants' experience with a range of digital health technologies. All participants had used at least one digital health technology. Most (80%) participants had an eHEALS score of 26 or above indicating confidence in online health information. Commonly reported barriers to digital health technology use centred on product complexity and reliability, awareness of resources, lack of trust, and cost. Effective digital health technology use is becoming increasingly important, there may be a need to prioritise and support people with lower levels of digital health literacy. We present opportunities to support community members in using and accessing digital health technology.

iCare - a self-directed, interactive online program to improve health and wellbeing for people living with upper gastrointestinal or hepato-pancreato-biliary cancers, and their informal carers: the study protocol for a Phase II randomised controlled trial

BACKGROUND

Up to 70% of people diagnosed with upper gastrointestinal (GI) tract or hepato-pancreato-biliary (HPB) cancers experience substantial reductions in quality of life (QoL), including high distress levels, pain, fatigue, sleep disturbances, weight loss and difficulty swallowing. With few advocacy groups and support systems for adults with upper GI or HPB cancers (i.e. pancreas, liver, stomach, bile duct and oesophageal) and their carers, online supportive care programs may represent an alternate cost-effective mechanism to support this patient group and carers. iCare is a self-directed, interactive, online program that provides information, resources, and psychological packages to patients and their carers from the treatment phase of their condition. The inception and development of iCare has been driven by consumers, advocacy groups, government and health professionals. The aims of this study are to determine the feasibility and acceptability of iCare, examine preliminary efficacy on health-related QoL and carer burden at 3- and 6-months post enrolment, and the potential cost-effectiveness of iCare, from health and societal perspectives, for both patients and carers.

METHODS AND ANALYSIS

A Phase II randomised controlled trial. Overall, 162 people with newly diagnosed upper GI or HPB cancers and 162 carers will be recruited via the Upper GI Cancer Registry, online advertisements, or hospital clinics. Patients and carers will be randomly allocated (1:1) to the iCare program or usual care. Participant assessments will be at enrolment, 3- and 6-months later. The primary outcomes are i) feasibility, measured by eligibility, recruitment, response and attrition rates, and ii) acceptability, measured by engagement with iCare (frequency of logins, time spent using iCare, and use of features over the intervention period). Secondary outcomes are patient changes in QoL and unmet needs, and carer burden, unmet needs and QoL. Linear mixed models will be fitted to obtain preliminary estimates of efficacy and variability for secondary outcomes. The economic analysis will include a cost-consequences analysis where all outcomes will be compared with costs.

DISCUSSION

iCare provides a potential model of supportive care to improve QoL, unmet needs and burden of disease among people living with upper GI or HPB cancers and their carers.

AUSTRALIAN AND NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12623001185651. This protocol reflects Version #1 26 April 2023.

[Choosing the right imaging for the diagnostics and assessment of the course of peripheral nerve injuries]

BACKGROUND

Nerve injuries are a frequent problem in routine clinical practice and require intensive interdisciplinary care.

OBJECTIVE

The current status of imaging to confirm the diagnosis of nerve injuries is described. The role of high-resolution ultrasound and magnetic resonance imaging (MRI) in the diagnostics and follow-up of peripheral nerve injuries is elaborated.

MATERIAL AND METHODS

Review of the current state of imaging to confirm the diagnosis of nerve injuries.

RESULTS

Depending on the suspected site of damage, the primary domain of magnetic resonance (MR) imaging (MR neurography) is injuries in the region of the spine, nerve roots, brachial plexus and lumbar plexus, pelvis and proximal thigh. In contrast, in other peripheral nerve lesions of the extremities the advantages of high-resolution nerve ultrasound in a dynamic setting predominate. The MR neurography is indicated here, especially in the frequent bottleneck syndromes and only in very isolated and selected cases.

CONCLUSION

In addition to a correct anatomical assignment, the timely decision for a possible intervention and the appropriate concomitant treatment are an important basis for a favorable prognosis of nerve injuries. Imaging techniques should therefore be used early in the diagnostics and follow-up controls of peripheral nerve injuries.

[Diagnostics and surgical treatment of painful neuromas]

BACKGROUND

Painful neuromas that often develop after peripheral nerve injury require adequate diagnosis and treatment because of the suffering they cause. The scientific basis for the development of painful neuromas has not yet been sufficiently investigated. In addition to conservative procedures, a larger number of surgical techniques are available for treatment of painful neuromas.

OBJECTIVE

A review of the basic principles, diagnostic and treatment options for painful neuromas.

MATERIAL AND METHODS

Presentation of the scientific basis regarding the development of painful neuromas. Illustration and discussion of the most common diagnostic and treatment procedures.

RESULTS

The scientific basis regarding the development of painful neuromas after peripheral nerve injury has not yet been adequately developed. In order to be able to make a correct diagnosis, the use of standardized diagnostic criteria and adequate imaging techniques are recommended. In the sense of a paradigm shift, the use of the formerly neuroma-bearing nerve for reinnervation of target organs is to be preferred over mere burying in adjacent tissue.

CONCLUSION

In addition to standardized diagnostics the management of painful neuromas often requires a surgical intervention after all conservative therapeutic measures have been exhausted. As an alternative to restoring the continuity of the injured nerve, targeted reinnervation of electively denervated target organs by the formerly neuroma-bearing nerve is preferable over other techniques.

[Interdisciplinary networks in diseases of peripheral nerves-Exemplified by the Tübingen nerve team]

BACKGROUND

Nerve damage can be autoimmune inflammatory, metabolic or traumatic, among others, and can be difficult to differentiate.

OBJECTIVE

What are the advantages of interdisciplinary networks and how do they work?

MATERIAL AND METHOD

Field report with case presentation from the University Hospital Tübingen in cooperation with the BG Accident Clinic Tübingen.

CONCLUSION

Interdisciplinary networks improve the care of our patients and also serve as regular multidisciplinary continuing education.

The experience of bereaved cancer carers in rural and regional areas: The impact of the COVID-19 pandemic and the potential of peer support

BACKGROUND

Caring for someone with cancer during end of life care can be a challenging and complex experience. Those living in rural and regional areas are less likely to have local healthcare services and may be physically isolated. Even where support services such as respite do exist, they may be less likely to be accessed due to the time burden in travelling to services. This was compounded by the COVID-19 pandemic.

AIM

To understand the potential benefits of peer support for bereaved carers of people with cancer from rural and regional locations during the COVID-19 period.

METHODS

Phone interviews were conducted with bereaved cancer carers living in rural and regional areas in Victoria. Semi-structured interviews were used, and participants were asked about their experience as a carer, bereavement and the potential for peer support. Interviews were audio recorded and transcribed verbatim; transcripts were coded and a thematic analysis was conducted.

FINDINGS

12 interviews were conducted. Carers were mostly female (85%) and were on average 58 years of age (range 42-71). Interviews lasted an average of 58 minutes (range 53-91 minutes). Three themes were derived from the data; 1) Supportive care needs while caring and the impact of COVID-19; 2) Isolation during bereavement compounded by the COVID-19 pandemic; and 3) Peer support requires flexibility to meet diverse needs.

CONCLUSION

Peer support has potential to assist bereaved carers of people with cancer. A co-design approach may be beneficial for developing a flexible model for supporting and linking carers together.

Evaluation of a teleaudiology service in regional Australia

OBJECTIVE

Evaluate accessibility, effectiveness, acceptability and efficiency of a student- assisted teleaudiology model of care in a regional hospital in Queensland, Australia.

DESIGN

Prospective mixed method service evaluation study.

STUDY SAMPLE

Demographic, service and satisfaction data were collected from 233 patients (children aged ≥5 and adults) who received teleaudiology assessment. Satisfaction data was collected from 27 hospital clinic staff (medical, nursing and clinic assistants) and 28 university audiology clinical educator participants. Experience and satisfaction data were collected from 16 teleaudiology clinic university students. Quantitative data was analysed using SPSS software. Qualitative data were analysed using inductive content analysis.

RESULTS

Following introduction of the teleaudiology service in 2017 and evaluation during the first 6 months, 95% of patients were able to access audiology assessments on the same day as their Ear, Nose and Throat appointments. New referrals to the service were seen within a month. The audiology assessment battery was completed 95% of the time within an average of 33 minutes by the end of the study period. Patients, hospital and university staff and students reported high satisfaction with their experiences of teleaudiology, including its convenience and efficiency.

CONCLUSIONS

A student-assisted teleaudiology model of care can deliver accessible, effective, and efficient services with high levels of satisfaction by participants.

Supportive interventions for carers of men with prostate cancer: systematic review and narrative synthesis

PURPOSE

The objective of this study was to summarise the literature on current interventions available for carers of men with prostate cancer and analyse the outcomes of these interventions in supporting carers' needs.

METHODS

A systematic review was conducted, searching databases MEDLINE, PsycINFO, CINAHL, Scopus and Cochrane, using terms related to prostate cancer, carers and interventions. Randomised controlled trials and non-randomised controlled trials of interventions for informal carers with or without patients were included. Data were analysed using descriptive and frequency statistics; interventions and their impact on carers' outcomes were reported on narratively. The SwiM guidelines were applied to guide data synthesis.

RESULTS

Overall, 24 articles were included in the review. On average, participants were spouses (92%) and women (97%). Interventions largely rwere delivered face-to-face (42%) or used a combination of face to face and online modalities (38%). Two-thirds (63%) showed a significant improvement in carer's outcomes including psychological, sexual, physical and relationship/marital. The majority of studies (79%) tailored contents to carers' circumstances, most within a couples counselling format. Over one-third (42%) of studies focused on a range of supportive care needs, most commonly were psychological (58%), sexual (42%) and informational (25%).

CONCLUSIONS

Interventions for carers of men with prostate cancer were largely face to face, patient-spouse focused and two-thirds had some measurable impact on carer's outcomes. Research continues to underserve other patient-carer roles, including non-spousal carers. Interventions delivered solely for carers are required to meet gaps in care, and determine the impact on carer outcomes. Further research and more targeted interventions are needed.

PROSPERO REGISTRATION NUMBER

CRD42021249870.

Nerve Ultrasound of Peripheral Nerves in Patients Treated with Immune Checkpoint Inhibitors

Background and Objectives: Immune checkpoint inhibitors (ICIs) have enriched tumor therapy, improving overall survival. Immunotherapy adverse events (irAEs) occur in up to 50% of patients and also affect the peripheral nervous system. The exact pathomechanism is unclear; however, an autoimmune process is implicated. Thus, the clinical evaluation of irAEs in the peripheral nervous system is still demanding. We retrospectively analyzed nerve ultrasound (NU) data of polyneuropathies (PNPs) secondary to checkpoint inhibitors. Materials and Methods: NU data of patients with PNP symptoms secondary to ICI therapy were retrospectively analyzed using the Ultrasound Pattern Sum Score (UPSS) as a quantitative marker. Our findings were compared with a propensity score match analysis (1:1 ratio) to NU findings in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and chemotherapy-associated PNP patients. Results: In total, 10 patients were included (4 female, mean age 66 ± 10.5, IQR 60-77), where NU was performed in 80%. The UPSS obtained ranged from 0 to 5 (mean 2 ± 1.6, IQR 1-2.5). The morphological changes seen in the NUs resembled sonographic changes seen in chemotherapy-associated PNP (n = 10, mean UPSS 1 ± 1, IQR 0-2) with little to no nerve swelling. In contrast, CIDP patients had a significantly higher UPSS (n = 10, mean UPSS 11 ± 4, IQR 8-13, p < 0.0001). Conclusions: Although an autoimmune process is hypothesized to cause peripheral neurological irAEs, NU showed no increased swelling as seen in CIDP. The nerve swelling observed was mild and comparable to ultrasound findings seen in chemotherapy-associated PNP.

The prodromal phase of hereditary spastic paraplegia type 4: the preSPG4 cohort study

This cohort study aimed to characterize the prodromal phase of hereditary spastic paraplegia type 4 (SPG4) using biomarkers and clinical signs and symptoms that develop before manifest gait abnormalities. Fifty-six first-degree relatives at risk of developing SPG4 underwent blinded genotyping and standardized phenotyping, including the Spastic Paraplegia Rating Scale (SPRS), complicating symptoms, non-motor affection, Three-Minute Walk, and neurophysiological assessment. Automated MR image analysis was used to compare volumetric properties. CSF of 33 probands was analysed for neurofilament light chain (NfL), tau, and amyloid-β (Aβ). Thirty participants turned out to be SPAST mutation carriers, whereas 26 did not inherit a SPAST mutation. Increased reflexes, ankle clonus, and hip abduction weakness were more frequent in prodromal mutation carriers but were also observed in non-mutation carriers. Only Babinski's sign differentiated reliably between the two groups. Timed walk and non-motor symptoms did not differ between groups. Whereas most mutation carriers had total SPRS scores of 2 points or more, only two non-mutation carriers reached more than 1 point. Motor evoked potentials revealed no differences between mutation and non-mutation carriers. We found NfL but not tau or Aβ to rise in CSF of mutation carriers when approaching the time point of predicted disease manifestation. Serum NfL did not differ between groups. Volumetric MRI analyses did not reveal group differences apart from a smaller cingulate gyrus in mutation carriers. This study depicts subtle clinical signs which develop before gait abnormalities in SPG4. Long-term follow-up is needed to study the evolution of SPG4 in the prodromal stage and conversion into manifest disease. NfL in CSF is a promising fluid biomarker that may indicate disease activity in prodromal SPG4 but needs further evaluation in longitudinal studies.

Insomnia-A Systematic Review and Comparison of Medical Resident's Average Off-Call Sleep Times

Sleep deprivation is known to have serious consequences, including a decrease in performance, attention and neurocognitive function. It seems common knowledge that medical residents are routinely sleep deprived, yet there is little objective research recording their average sleep times. To discern whether residents may be suffering from the abovementioned side effects, this review aimed to analyze their average sleep times. Thirty papers recording the average sleep time of medical residents were found via a literature search using the key words "resident" and "sleep". An analysis of the mean sleep times cited therein revealed a range of sleep from 4.2 to 8.6 h per night, the median being 6.2 h. A sub-analysis of papers from the USA showed barely any significant differences in sleep time between the specialties, but the mean sleep times were below 7 h. The only significant difference (p = 0.039) was between the mean sleep times of pediatric and urology residents, with the former achieving less sleep. The comparison of methods for data collection showed no significant difference in the sleep times collected. The results of this analysis imply that residents are regularly sleep deprived and may therefore suffer from the abovementioned consequences.

[Hereditary transthyretin amyloidosis: A multifaceted disease]

Hereditary transthyretin amyloidosis (ATTRv, amyloidosis transthyretin variant) encompasses a broad spectrum of clinical manifestations, with polyneuropathy and cardiomyopathy being the most common organ manifestations. In addition, other organ systems such as kidneys, gastrointestinal tract, eyes and brain may be affected. If left untreated, the disease progresses rapidly, leading to significantly reduced quality of life and increased mortality. Early diagnosis is of particular importance, as drug treatment options have been available for a few years.

Versorgungssituation von CIDP-Patienten in neun deutschen Zentren des Neuritis Netzes

Hintergrund

Die Diagnose und Behandlung von Patienten mit immunvermittelten Polyneuropathien ist aufgrund der Heterogenität der Erkrankungen herausfordernd.

Ziel der Arbeit

Ein aktueller epidemiologischer Überblick über die Versorgungssituation von Patienten mit immunvermittelten Polyneuropathien innerhalb des deutschen Neuritis-Netzwerks „Neuritis Netz“.

Material und Methoden

Es erfolgte eine Umfrage in neun deutschen neurologischen Zentren, die auf die Betreuung von Patienten mit Immunneuropathie spezialisiert sind. Wir erfassten Diagnose, Vorgehen in der Diagnostik und Nachsorge, typische Symptome bei Manifestation und im Krankheitsverlauf sowie Therapiedaten.

Ergebnisse

Die Erhebung umfasst Daten von 1529 jährlich behandelten Patienten mit Immunneuropathien, 1320 davon mit chronisch inflammatorisch demyelinisierender Polyneuropathie (CIDP). Die Diagnostik umfasste fast immer Lumbalpunktionen sowie Elektroneuro- und -myografien entsprechend den aktuellen Leitlinien. Der Einsatz von Ultraschall, Biopsie und MRT war unterschiedlich. Wichtigster klinischer Parameter zum Therapiemonitoring in allen Zentren war die motorische Funktion in den klinischen Nachuntersuchungen. Zur Erhaltungstherapie wurde bei rund 15 % der Patienten ein breites Spektrum unterschiedlicher Immunsuppressiva eingesetzt.

Diskussion

Die Studie liefert wichtige epidemiologische Daten zur aktuellen Versorgungsituation von Patienten mit Immunneuropathien in Deutschland. Die Weiterentwicklung spezifischer Empfehlungen zur Therapie und Nachverfolgung von CIDP-Patienten ist notwendig, um einen einheitlichen Standard der Patientenversorgung zu gewährleisten. Dieses wird durch die strukturierte Zusammenarbeit von Exzellenzzentren wie dem deutschen Neuritis Netz erheblich unterstützt.

Experiences of female partners of prostate cancer survivors: A systematic review and thematic synthesis

The purpose of this systematic review and synthesis of studies reporting qualitative data was to understand the gendered experiences of female partners of prostate cancer survivors to inform psychosocial support for women. We searched Medline, PsycINFO, EMBASE, AMED, CINAHL, Cochrane Database of Systematic Reviews, and Sociological Abstracts for articles on 15 and 16 April 2019, and again on 30 November 2020. English language articles published in peer-reviewed journals were included if they reported solely on findings describing the perspectives of the female partners. Extracted data were analysed using line-by-line coding, organisation of codes into descriptive themes, and development of analytical themes. A theoretical framework was then selected to organise the relationships between issues that were found to be central to the experiences of female partners. Of 4839 articles screened, 14 met inclusion criteria, reporting 13 studies with a total sample of 359 female partners. Ussher and Sandoval's theory to describe the gendered positionings of cancer caregivers accommodated the thematic findings. The overarching theme reflected the substantive psychosocial impact of prostate cancer on female partners. Women's experiences were influenced by self-positioning (as part of a couple; provider of support to their male partner; resilient; and guided by faith and spirituality), being positioned by their partners' response (manager of male partner's psychological distress or strengthened by male partner's positive response) and by their broader contexts (family members and social networks; clinicians and the health system; and cultural values and customs). Findings highlight the need to avoid reductionist approaches to gender. Greater consideration of 'contextualised femininities', or conceptualising the influence of gender roles, relations, and identities within the wider life course contexts of female partners is required in the design and delivery of psychosocial support services.

Designing Supportive e-Interventions for Partners of Men With Prostate Cancer Using Female Partners’ Experiences: Qualitative Exploration Study

Background

Partners of men living with prostate cancer (PCa) can experience a variety of unmet needs that are largely unaddressed by health care professionals. There is limited evidence to suggest which approach may be most effective in supporting partners’ unmet needs and further research is required to determine how to provide support to caregivers and how technology solutions can be designed.

Objective

This study aims to explore the experience of partners of men living with PCa and their perceptions of the potential role of information technology in supporting their needs.

Methods

A qualitative descriptive methodology using focus groups and phone interviews was used. Purposive sampling was used to recruit people attending a national conference supported by a national PCa organization. Interview guides were adapted from an existing evidence-based smartphone app for caregivers of people with colorectal cancer. Sessions were audio recorded and transcribed verbatim. A coding framework was developed, and transcripts were coded line by line into the framework. Codes within the framework were grouped into descriptive categories that were then developed into analytical themes.

Results

A total of 17 female partners participated in the study, with an average age of 64 (SD 8.5) years. The following two main themes emerged: In the first theme, that is, How technology can be shaped to support female partners of prostate cancer survivors, the content and design of the smartphone app was discussed in addressing female partners’ needs. The following four subthemes were developed: getting support from social networks and resources, the lack of relevant information, demystifying future care expectations during and following a PCa diagnosis, and delivering the smartphone app—to whom and from whom. In the second theme, that is, The benefits and barriers of technology, the suitability of smartphone apps as a supportive modality for female partners was described. This included three subthemes: the smartphone app as an appropriate modality for supporting female partners, the future anticipated benefits of using the smartphone app, and concerns for storing and accessing information on the internet.

Conclusions

A smartphone app may be a suitable modality for providing information and peer support to female partners of men living with PCa. There is a need to provide peer support for female partners in future interventions to ensure that female partners’ intimacy and daily practical needs are met.

Heterozygous POLG variant Ser1181Asn co-segregating in a family with autosomal dominant axonal neuropathy, proximal muscle fatigability, ptosis, and ragged red fibers

By whole-exome sequencing, we found the heterozygous POLG variant c.3542G>A; p.Ser1181Asn in a family of four affected individuals, presenting with a mixed neuro-myopathic phenotype. The variant is located within the active site of polymerase gamma, in a cluster region associated with an autosomal dominant inheritance. In adolescence, the index developed distal atrophies and weakness, sensory loss, afferent ataxia, double vision, and bilateral ptosis. One older sister presented with Charcot-Marie-Tooth-like symptoms, while the youngest sister and father reported exercise-induced muscle pain and proximal weakness. In none of the individuals, we observed any involvement of the central nervous system. Muscle biopsies obtained from the father and the older sister showed ragged-red fibers, and electron microscopy confirmed mitochondrial damage. We conclude that this novel POLG variant explains this family’s phenotype.

Engagement Strategies to Improve Adherence and Retention in Web-Based Mindfulness Programs: Systematic Review

Background

Web-based mindfulness programs may be beneficial in improving the well-being outcomes of those living with chronic illnesses. Adherence to programs is a key indicator in improving outcomes; however, with the digitization of programs, it is necessary to enhance engagement and encourage people to return to digital health platforms. More information is needed on how engagement strategies have been used in web-based mindfulness programs to encourage adherence.

Objective

The aim of this study is to develop a list of engagement strategies for web-based mindfulness programs and evaluate the impact of engagement strategies on adherence.

Methods

A narrative systematic review was conducted across the MEDLINE Complete, CINAHL Complete, APA PsycINFO, and Embase databases and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Articles were screened using the population, intervention, comparator, and outcome framework. Adults aged >18 years with chronic health conditions were included in the study. Mindfulness interventions, including those in combination with mindfulness-based cognitive therapy, delivered on the web through the internet or smartphone technology were included. Interventions lasted at least 2 weeks. Studies with a randomized controlled trial design or a pilot randomized controlled trial design were included. Engagement strategies, including web-based program features and facilitator-led strategies, adherence, and retention, were included.

Results

A total of 1265 articles were screened, of which 19 were relevant and were included in the review. On average, 70.98% (2258/3181) of the study participants were women with a mean age of 46 (SD 13) years. Most commonly, mindfulness programs were delivered to people living with mental health conditions (8/19, 42%). Of the 19 studies, 8 (42%) used only program features to encourage adherence, 5 (26%) used facilitator-led strategies, and 6 (32%) used a combination of the two. Encouraging program adherence was the most common engagement strategy used, which was used in 77% (10/13) of the facilitator-led studies and 57% (8/14) of the program feature studies. Nearly two-thirds (63%) of the studies provided a definition of adherence, which varied between 50% and 100% completion across studies. The overall mean participant compliance to the mindfulness programs was 56% (SD 15%). Most studies (10/19, 53%) had a long-term follow-up, with the most common follow-up period being 12 weeks after intervention (3/10, 30%). After the intervention, the mean retention was 78% (SD 15%).

Conclusions

Engagement strategies in web-based mindfulness programs comprise reminders to use the program. Other features may be suitable for encouraging adherence to interventions, and a facilitator-led component may result in higher retention. There is variance in the way adherence is measured, and intervention lengths and follow-up periods are inconsistent. More thorough reporting and a standardized framework for measuring adherence are needed to more accurately assess adherence and engagement strategies.

Efficacy and cost-effectiveness of an online mindfulness program (MindOnLine) to reduce fear of recurrence among people with cancer: study protocol for a randomised controlled trial

INTRODUCTION

Fear of cancer recurrence (FCR) is a common condition among cancer survivors that can lead to significant levels of distress, anxiety and depression. Online mindfulness programmes may provide the mechanism to support cancer survivors manage FCR and distress, and improve people's well-being over the short, medium and long term. The primary aim of this study is to determine the potential efficacy of MindOnLine, a 9 session mindfulness-based programme for survivors of breast, prostate and colorectal cancer. A formal economic programme will also be conducted.

METHODS AND ANALYSIS

A single-blind randomised controlled trial to determine the efficacy and cost-efficacy of a MindOnLine programme for cancer survivors. A total of 400 people living with cancer will be recruited via online advertisements on social media platforms, peak consumer advocacy groups or through outpatient services at healthcare providers across Victoria, Australia. People will be randomly allocated to either the MindOnLine programme (n=200) or waitlist control (n=200). Participant assessments will occur at baseline, at 9 weeks and 9-month follow-up. The primary outcome is change in Fear of Recurrence Index Score total score between baseline and 9 weeks; secondary outcomes are changes in depression and anxiety, quality of life and mindfulness. The economic analysis comprises a cost-consequences analysis where all outcomes will be compared with costs.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Peter MacCallum Cancer Centre (20-53) and Deakin University (2020-284). All participants will be required to provide written informed consent. Findings will be disseminated in peer reviewed journals and among key stakeholder organisations including hospitals, cancer and community organisations and Government. If successful the project will be rolled out nationally with a formal implementation plan.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (12620000645954); Pre-results. Registered 6 June 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379520&isReview=true.

Beyond the Knife-Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions

Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker's compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation.

Establishing Clinical Swallowing Assessment Services via Telepractice: A Multisite Implementation Evaluation

Purpose While research has confirmed the feasibility and validity of delivering clinical swallowing evaluations (CSEs) via telepractice, challenges exist for clinical implementation. Using an implementation framework, strategies that supported implementation of CSE services via telepractice within 18 regional/rural sites across five health services were examined. Method A coordinated implementation strategy involving remote training and support was provided to 18 sites across five health services (five hub and spoke services) that had identified a need to implement CSEs via telepractice. Experiences of all 10 speech-language pathologists involved at the hub sites were examined via interviews 1 year post implementation. Interview content was coded using the Consolidated Framework for Implementation Research (CFIR) and constructs were rated for strength and direction of influence, using published CFIR coding conventions. Results Services were established and are ongoing at all sites. Although there were site-specific differences, 10 CFIR constructs were positive influencing factors at all five sites. The telepractice model was perceived to provide clear advantages for the service, and clinicians were motivated by positive patient response. Strategies used to support implementation, including having a well-organized implementation resource and an external facilitator who worked closely with the local champions, were highly valued. Two CFIR constructs, Structural Characteristics and Available Resources, were challenges for all sites. Conclusions A complex interplay of factors influenced service implementation at each site. A strong local commitment to improving patient care, and the assistance of targeted strategies to support local implementation were viewed as central to enabling implementation.

New Keys to Early Diagnosis: Muscle Echogenicity, Nerve Ultrasound Patterns, Electrodiagnostic, and Clinical Parameters in 150 Patients with Hereditary Polyneuropathies

Hereditary neuropathies are of variable genotype and phenotype. With upcoming therapies, there is urgent need for early disease recognition and outcome measures. High-resolution nerve and muscle ultrasound is a dynamic, non-invasive, well-established tool in the field of inflammatory and traumatic neuropathies. In this study, we defined nerve and muscle ultrasound parameters as recognition and progression markers in 150 patients with genetically confirmed hereditary neuropathies, including Charcot-Marie-Tooth (CMT) disease (CMT1A, n = 55; other CMT1/4, n = 28; axonal CMT, n = 15; CMTX, n = 15), hereditary neuropathy with liability to pressure palsies (HNPP, n = 16), hereditary transthyretin-amyloidosis (ATTRv, n = 14), and Fabry's disease (n = 7). The CMT1A, followed by the CMT1/4 group, had the most homogeneous enlargement of the nerve cross-sectional areas (CSA) in the ultrasound pattern sum (UPSS) and homogeneity score. Entrapment scores were highest in HNPP, ATTRv amyloidosis, and Fabry's disease patients. In demyelinating neuropathies, the CSA correlated inversely with nerve conduction studies. The muscle echo intensity was significantly highest in the clinically most affected muscles, which was independent from the underlying disease cause and correlated with muscle strength and disease duration. Further correlations were seen with combined clinical (CMTES-2) and electrophysiological (CMTNS-2) scores of disease severity. We conclude that nerve ultrasound is a helpful tool to distinguish different types of hereditary neuropathies by pattern recognition, whereas muscle ultrasound is an objective parameter for disease severity. The implementation of neuromuscular ultrasound might enrich diagnostic procedures both in clinical routines and research.

Virtual neuromuscular ultrasound courses during COVID-19 pandemic: Leveraging technology to enhance learning opportunities

INTRODUCTION/AIMS

Hands-on supervised training is essential for learning diagnostic ultrasound. Unfortunately, the coronavirus disease 2019 (COVID-19) pandemic led to suspension of in-person training courses. As a result, many hands-on training courses were converted into virtual courses during the pandemic. Several reports regarding virtual ultrasound courses exist, but none has addressed virtual neuromuscular ultrasound courses, their design, or participants' views of this form of training. Therefore, the aims of this study were: (1) to determine the feasibility of conducting virtual neuromuscular ultrasound courses during the COVID-19 pandemic; and (2) to report the positive and negative aspects of the courses through the analyses of the responses of post-course surveys.

METHODS

Two virtual neuromuscular ultrasound courses, basic and intermediate level, were conducted by the Egyptian Neuromuscular Ultrasound society during August 2020. Post-course, the attendees were directed to an electronic survey that consisted of eight questions. Ninety-three responses (23.8%) were obtained from the survey of the basic course and 156 responses (44.4%) were obtained from the survey of the intermediate course.

RESULTS

Ninety-eight percent of the respondents to basic course surveys, and 100% of the respondents to the intermediate course survey found the courses useful or very useful.

DISCUSSION

This report demonstrates the utility of virtual neuromuscular ultrasound courses for those participants willing to respond to a survey and describes a proposed design for such courses. Although hands-on supervised ultrasound training is ideal, virtual courses can be useful alternatives to in-person training when in-person interaction is restricted.

Therapeutic Potential of Sodium Channel Blockers as a Targeted Therapy Approach in KCNA1-Associated Episodic Ataxia and a Comprehensive Review of the Literature

Introduction: Among genetic paroxysmal movement disorders, variants in ion channel coding genes constitute a major subgroup. Loss-of-function (LOF) variants in KCNA1, the gene coding for KV1.1 channels, are associated with episodic ataxia type 1 (EA1), characterized by seconds to minutes-lasting attacks including gait incoordination, limb ataxia, truncal instability, dysarthria, nystagmus, tremor, and occasionally seizures, but also persistent neuromuscular symptoms like myokymia or neuromyotonia. Standard treatment has not yet been developed, and different treatment efforts need to be systematically evaluated. Objective and Methods: Personalized therapeutic regimens tailored to disease-causing pathophysiological mechanisms may offer the specificity required to overcome limitations in therapy. Toward this aim, we (i) reviewed all available clinical reports on treatment response and functional consequences of KCNA1 variants causing EA1, (ii) examined the potential effects on neuronal excitability of all variants using a single compartment conductance-based model and set out to assess the potential of two sodium channel blockers (SCBs: carbamazepine and riluzole) to restore the identified underlying pathophysiological effects of KV1.1 channels, and (iii) provide a comprehensive review of the literature considering all types of episodic ataxia. Results: Reviewing the treatment efforts of EA1 patients revealed moderate response to acetazolamide and exhibited the strength of SCBs, especially carbamazepine, in the treatment of EA1 patients. Biophysical dysfunction of KV1.1 channels is typically based on depolarizing shifts of steady-state activation, leading to an LOF of KCNA1 variant channels. Our model predicts a lowered rheobase and an increase of the firing rate on a neuronal level. The estimated concentration dependent effects of carbamazepine and riluzole could partially restore the altered gating properties of dysfunctional variant channels. Conclusion: These data strengthen the potential of SCBs to contribute to functional compensation of dysfunctional KV1.1 channels. We propose riluzole as a new drug repurposing candidate and highlight the role of personalized approaches to develop standard care for EA1 patients. These results could have implications for clinical practice in future and highlight the need for the development of individualized and targeted therapies for episodic ataxia and genetic paroxysmal disorders in general.

Effective integration of caregivers and families as part of the care team for people with cancer

BACKGROUND

Informal caregivers (family or friends of people with cancer) are a group of highly important people who support those diagnosed with cancer to remain at home and out of hospital, but this comes at a significant personal cost. Understanding strategies to support cancer caregivers is critical.

OBJECTIVE

This article will present an overview of cancer caregiving and how the caregivers involved can be assisted by general practitioners (GPs). Two key approaches to general practice teams supporting caregivers will be explored: acknowledging and integrating caregivers as part of the care team and providing referrals into services and supports.

DISCUSSION

The general practice team is ideally positioned to assist in the support of cancer caregivers. GPs can assist caregivers by acknowledging them as valid and important members of the care team and referring them into existing support programs. These strategies are central to supporting this important, but often forgotten, group of people affected by cancer.

Stellenwert klinischer, funktioneller und bildgebender Diagnostik zur Früherkennung, Differenzialdiagnose und Verlaufskontrolle diabetischer Neuropathien

Von weltweit mehr als 400 Mio. Menschen mit Diabetes mellitus entwickeln bis zu 50% im Laufe ihrer Erkrankung eine Neuropathie. Trotz oder gerade wegen dieser Häufigkeit darf jedoch nicht jede Neuropathie, die in Koinzidenz mit einem Diabetes mellitus auftritt, unkritisch als diabetische Neuropathie diagnostiziert werden. Eine präzise Ausschluss- und Ausmaßdiagnostik ist entscheidend, um andere behandelbare Erkrankungen wie z. B. die Chronisch Inflammatorische Demyelinisierende Polyradikuloneuropathie oder die hereditäre Transthyretin-Amyloidose nicht zu übersehen. Einfache, nicht-invasive, preiswerte und allzeit verfügbare Screeningmethoden stellen Anamnese und klinische Untersuchung dar. Ergänzend ist in frühen Erkrankungsstadien die Quantitativ Sensorische Testung hilfreich zur Eingrenzung einer Small Fiber-Dysfunktion. Sind, typischerweise im Verlauf, große Nervenfasern geschädigt, so ist das charakteristische elektrophysiologische Bild das einer längenabhängigen, axonalen, sensibel betonten oder sensomotorischen Neuropathie. Die Nervensonografie kann zur Unterscheidung von autoimmun-demyelinisierenden Neuropathien hilfreich sein. Moderne Untersuchungsverfahren wie die MR-Neurografie können auch proximale Nervenabschnitte bis auf Faszikelebene darstellen, sind allerdings nur an wenigen Zentren verfügbar. Haut- und Nervenbiopsien sind v. a. bei untypischen Verläufen zur Abgrenzung von Differenzialdiagnosen hilfreich. Diabetische Neuropathien können zu einer erheblichen Reduktion von Lebensqualität und Lebensdauer führen. Zur frühest- und bestmöglichen ursächlichen und symptomatischen Therapieeinleitung ist eine präzise Diagnostik essentiell.

Muscle Ultrasound Shear Wave Elastography as a Non-Invasive Biomarker in Myotonia

Myotonia, i.e., delayed muscle relaxation in certain hereditary muscle disorders, can be assessed quantitatively using different techniques ranging from force measurements to electrodiagnostics. Ultrasound shear wave elastography (SWE) has been proposed as a novel tool in biomechanics and neuromuscular medicine for the non-invasive estimation of muscle elasticity and, indirectly, muscle force. The aim of this study is to provide ‘proof-of-principle’ that SWE allows a quantitative measurement of the duration of delayed muscle relaxation in myotonia in a simple clinical setting. In six myotonic muscle disorder patients and six healthy volunteers, shear wave velocities (SWV) parallel to the fiber orientation in the flexor digitorum superficialis muscle in the forearm were recorded with a temporal resolution of one per second during fist-clenching and subsequent relaxation; the relaxation time to 10% of normalized shear wave velocity (RT_0.1) was calculated. Forty-six SWE imaging sequences were acquired, yielding a mean RT_0.1 of 7.38 s in myotonic muscle disorder patients, significantly higher than in healthy volunteers (1.36 s), which is comparable to data obtained by mechanical dynamometry. SWV measurements during the baseline relaxation and voluntary contraction phases did not differ significantly between groups. We conclude that SWE is a promising, non-invasive, widely available tool for the quantitative assessment of myotonia to aid in diagnosis and therapeutic monitoring.

[The interdisciplinary diagnostics and treatment of peripheral nerve lesions]

Nerve lesions are a frequent and often neglected problem in the daily routine of hospitals and clinical work and necessitate an intensive interdisciplinary treatment. In addition to correct anatomical allocation, the correct timing of the appropriate diagnostics, the timely decision for a possible intervention and the appropriate accompanying treatment are important prerequisites for a favorable prognosis. The basic diagnostics are, above all, neurography and electromyography after a sound clinical examination and documentation. In recent years both high-resolution ultrasound imaging and magnetic resonance imaging (MRI) of nerves have increasingly become established as indispensable diagnostic tools. In addition to describing the electrophysiological and sonographic principles, this article provides insights into surgical procedures, interdisciplinary cooperation and practical approaches.

Peripheral Nerve Imaging Aids in the Diagnosis of Immune-Mediated Neuropathies-A Case Series

Background: Diagnosis of immune-mediated neuropathies and their differentiation from amyotrophic lateral sclerosis (ALS) can be challenging, especially at early disease stages. Accurate diagnosis is, however, important due to the different prognosis and available treatment options. We present one patient with a left-sided dorsal flexor paresis and initial suspicion of ALS and another with multifocal sensory deficits. In both, peripheral nerve imaging was the key for diagnosis. Methods: We performed high-resolution nerve ultrasound (HRUS) and 7T or 3T magnetic resonance neurography (MRN). Results: In both patients, HRUS revealed mild to severe, segmental or inhomogeneous, nerve enlargement at multiple sites, as well as an area increase of isolated fascicles. MRN depicted T2 hyperintense nerves with additional contrast-enhancement. Discussion: Peripheral nerve imaging was compatible with the respective diagnosis of an immune-mediated neuropathy, i.e., multifocal motor neuropathy (MMN) in patient 1 and multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) in patient 2. Peripheral nerve imaging, especially HRUS, should play an important role in the diagnostic work-up for immune-mediated neuropathies and their differentiation from ALS.

Normative Observational Nerve Ultrasound Values in School-Age Children and Adolescents and Their Application to Hereditary Neuropathies

Backgrounds: We have aimed to establish nerve ultrasound reference data in 8 to 17-year-old children and adolescents and to compare those data to younger children, adults, and age-matched children with polyneuropathies.

Methods: High-resolution ultrasounds of the nerves were performed in 117 healthy children and adolescents at 20 predefined landmarks in the neck and the extremities of both sides. Mean values, side-to-side differences and intraneural ratios, as well as upper limits have been calculated. In a second step, a comparison between 25 children and adolescents of the same age range with proven hereditary and acquired neuropathies and lysosomal storage diseases has been carried out.

Results: Nerve growth correlates significantly with age and reaches adult values at the age of around 15 years. The influence of body mass index and gender is negligible at most segments. By the use of age-specific upper limits, nerve enlargement could be seen in distinct types of neuropathies, particularly in demyelinating hereditary and inflammatory types, which is comparable to findings in adults, but also in rare lysosomal storage diseases.

Conclusion: Nerve size correlates with age during childhood and reaches a climax in younger adults. Age-matched reference data are inevitable to differ between hypertrophic and non-hypertrophic nerve damage, e.g., in neuropathies.

Role of high-resolution ultrasound in detection and monitoring of peripheral nerve tumor burden in neurofibromatosis in children

PURPOSE

Peripheral nerve sheath tumors are hallmark findings in neurofibromatosis types 1 and 2. With increasing size, they typically lead to neurological symptoms, and NF1 patients have a lifetime risk of 8-13% for developing malignant peripheral nerve sheath tumors. Medical imaging is therefore highly needed for early detection and exact localization of symptomatic or potentially malignant tumors. This review will give an overview of the ultrasound characteristics of peripheral nerve sheath tumors and findings in patients with neurofibromatosis types 1 and 2.

METHODS

A systematic search of electronic databases, reference lists, and unpublished literature was conducted including the keywords "schwannoma," "neurofibroma," "neurofibromatosis," "benign and malignant peripheral nerve sheath tumor."

RESULTS

The high-resolution allows a clear analysis of tumor echotexture, definition of margins, and the relation to the parent nerve. The use of color duplex/Doppler and contrast agent adds valuable information for the differentiation of benign and malignant tumors.

CONCLUSION

High-resolution ultrasound is a well-established, non-invasive, and easily repeatable first-line tool in diagnostic procedures of soft tissue tumors.

Implementation of speech pathology telepractice services for clinical swallowing assessment: An evaluation of service outcomes, costs and consumer satisfaction

Introduction

Timely assessment of swallowing disorders (dysphagia) by speech pathologists helps minimise patient risk, optimise quality of life, and limit healthcare costs. This study involved a multi-site implementation of a validated model for conducting adult clinical swallowing assessments via telepractice and examined its service outcomes, costs and consumer satisfaction.

Methods

Five hub-spoke telepractice services, encompassing 18 facilities were established across a public health service. Service implementation support, including training of the telepractice speech pathologists (T-SP) and healthcare support workers in each site, was facilitated by an experienced project officer. New referrals from spoke sites were managed by the hub T-SP as per published protocols for dysphagia assessments via telepractice. Data was collected on existing service models prior to implementation, and then patient demographics, referral information, session outcomes, costs and patient and T-SP satisfaction when using telepractice.

Results

The first 50 sessions were analysed. Referrals were predominantly for inpatients at spoke sites. Telepractice assessments were completed successfully, with only minor technical issues. Changes to patient management (i.e. food/fluid changes post assessment) to optimise safety or progress oral intake, was required for 64% of patients. Service and cost efficiencies were achieved with an average 2-day reduction in waiting time and an average cost benefit of $218 per session when using the telepractice service over standard care. High clinician and patient satisfaction was reported.

Conclusion

Telepractice services were successfully introduced across multiple sites, and achieved service and cost benefits with high consumer satisfaction.

Nerve Ultrasonography as an Additive Tool to Clinical Examination and Electrodiagnostics in Sporadic Mononeuritis - Imaging is the Key

PURPOSE

 Sporadic mononeuropathies without trauma or compression are challenging to diagnose. Nerve ultrasound has recently proven its usefulness in the diagnosis of traumatic neuropathies, tumors and polyneuropathies. However, its role in mononeuropathies currently remains unclear. We describe ultrasonography follow-up results in 12 patients with suggested spontaneous, monophasic mononeuritis without signs of generalization.

MATERIALS AND METHODS

 Nerve conduction studies (NCS), ultrasonography of the affected nerves and the contralateral side, laboratory analysis, and if possible magnetic resonance imaging (MRI) of the affected nerves were established in all patients at onset. In one patient, additive nerve biopsy was performed. In all patients, ultrasonography was repeated after immunotherapy.

RESULTS

 An infectious pathogen of neuritis was not found in any patient. All but one patient showed predominant axonal nerve damage in NCS, whereas ultrasonography and MRI revealed fascicular and/or overall cross-sectional area (CSA) enlargement or T2 hyperintensity of the affected nerve segments, suggesting an inflammatory background of the neuropathy. Most patients showed significant clinical amelioration of symptoms under treatment (75.0 %) and consequently a decrease in CSA/fascicle enlargement over time (77.8 %).

CONCLUSION

 Ultrasonography and MRI of the nerves revealed enlargement in patients with mononeuropathy of axonal NCS pattern of unknown origin. Ultrasonography can facilitate the therapeutic decision for immunotherapy. Next to nerve trauma, nerve tumors and nerve entrapments, ultrasonography reliably shows nerve enlargement in the case of inflammation and therefore could further enrich neurophysiology. Nerve imaging might serve as a follow-up tool by observing a decrease in nerve enlargement and improved function.

Differentiation Between Guillain-Barré Syndrome and Acute-Onset Chronic Inflammatory Demyelinating Polyradiculoneuritis-a Prospective Follow-up Study Using Ultrasound and Neurophysiological Measurements

Differentiation of Guillain-Barré syndrome (GBS) and acute-onset chronic inflammatory demyelinating polyradiculoneuritis (CIDP) might be intricate in early stages. We compared electrodiagnostics (EDx) and nerve ultrasound (NUS) as tools for early distinction and follow-up. NUS and EDx have been performed at first visitation and after 6 months. The nerve conduction study score (NCSS), the ultrasound pattern sum score (UPSS), and clinical scores were used for comparison. Compared with the 33 GBS patients, the 34 CIDP patients (50% with symptoms < 4 weeks) revealed significant nerve enlargement in ultrasound (p < 0.001) except for the roots and vagus, which exhibited increased values in both groups. EDx has no significant differences between both groups except for the A-wave frequency and the sural sparing pattern, which is more frequent in GBS (Fisher's exact p < 0.05). In the latter, particularly, pure sensory nerves were not enlarged in contrast to CIDP, in which those were mostly enlarged (p < 0.001). This ultrasonic sensory sparing pattern (uSSP) in combination with enlarged roots/vagus is the hallmark finding in GBS with sensitivity, specificity, and positive predictive value > 85%, whereas in CIDP, enlarged sensory und multifocally enlarged sensorimotor nerves are key differentiation features to GBS. Increased echointensity of the nerves further arises only in CIDP. After 6 months, in CIDP, the significant nerve enlargement persisted, whereas in GBS, all segments almost normalized. Clinical, ultrasonic, and NCS scores correlated significantly over the time. Enlarged roots/vagus in combination with uSSP might facilitate differentiation of GBS and CIDP in the early stage, and ultrasonic 6-month normalization underlines the diagnosis of GBS in cases of uncertainty. Trial Registration: DRKS-ID 00005253.

Nerve ultrasound characterizes AMN polyneuropathy as inhomogeneous and focal hypertrophic

Objective

High-resolution nerve ultrasound (HRUS) is a painless tool to quickly evaluate peripheral nerve morphology in vivo. This study set out to characterize peripheral nerve involvement in X-linked adrenomyeloneuropathy (AMN) by HRUS.

Methods

Thirteen adults with genetically proven AMN were examined using the Ultrasound pattern sum score (UPSS) to evaluate morphological abnormalities of peripheral nerves, vagal nerves, as well as cervical nerve roots. Ultrasound results were correlated with clinical findings and nerve conduction studies.

Results

UPSS was increased in six out of 13 patients. Nerve enlargement was mostly inhomogeneous and regional. The median, ulnar, and vagal nerves presented with more prominent alterations than nerves of the lower limbs. The proximal-to-distal ratio was significantly enlarged for the median nerve. HRUS findings matched nerve conduction studies, but identified one patient with enlarged nerves and yet normal conduction velocities. Sonographic findings did not correlate with disease duration or disease severity as assessed by the spastic paraplegia rating scale.

Conclusion

HRUS reveals significant multifocal regional nerve swellings with reduced echo intensity as the morphological equivalent of electrophysiological peripheral nerve affection in AMN patients. Ultrasound and NCS characteristics in AMN seem to differ from other demyelinating neuropathies like CIDP or CMT1a.

Trial registration

German clinical-trial-register (DRKS) (DRKS-ID 00005253) Registered 15 October 2013.

Electronic supplementary material

The online version of this article (10.1186/s13023-018-0939-7) contains supplementary material, which is available to authorized users.

Nerve Ultrasound Predicts Treatment Response in Chronic Inflammatory Demyelinating Polyradiculoneuropathy-a Prospective Follow-Up

As reliable biomarkers of disease activity are lacking, monitoring of therapeutic response in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) remains a challenge. We sought to determine whether nerve ultrasound and electrophysiology scoring could close this gap. In CIDP patients (fulfilling EFNS/PNS criteria), we performed high-resolution nerve ultrasound to determine ultrasound pattern sum scores (UPSS) and predominant echotexture nerve conduction study scores (NCSS) as well as Medical Research Council sum scores (MRCSS) and inflammatory neuropathy cause and treatment disability scores (INCAT) at baseline and after 12 months of standard treatment. We retrospectively correlated ultrasound morphology with nerve histology when available. 72/80 CIDP patients featured multifocal nerve enlargement, and 35/80 were therapy-naïve. At baseline, clinical scores correlated with NCSS (r2 = 0.397 and r2 = 0.443, p < 0.01), but not or hardly with UPSS (Medical Research Council sum scores MRCSS r2 = 0.013, p = 0.332; inflammatory neuropathy cause and treatment disability scores INCAT r2 = 0.053, p = 0.048). Longitudinal changes in clinical scores, however, correlated significantly with changes in both UPSS and NCSS (r2 = 0.272-0.414, p < 0.0001). Combining nerve/fascicle size with echointensity and histology at baseline, we noted 3 distinct classes: 1) hypoechoic enlargement, reflecting active inflammation and onion bulbs; 2) nerve enlargement with additional hyperechogenic fascicles/perifascicular tissue in > 50% of measured segments, possibly reflecting axonal degeneration; and 3) almost no enlargement, reflecting "burned-out" or "cured" disease without active inflammation. Clinical improvement after 12 months was best in patients with pattern 1 (up to 75% vs up to 43% in pattern 2/3, Fisher's exact test p < 0.05). Nerve ultrasound has additional value not only for diagnosis, but also for classification of disease state and may predict treatment response.

A look inside the nerve - Morphology of nerve fascicles in healthy controls and patients with polyneuropathy

OBJECTIVE

Polyneuropathies are increasingly analyzed by ultrasound. Summarizing, diffuse enlargement is typical in Charcot-Marie Tooth type 1 (CMT1a), regional enlargement occurs in inflammatory neuropathies. However, a distinction of subtypes is still challenging. Therefore, this study focused on fascicle size and pattern in controls and distinct neuropathies.

METHODS

Cross-sectional area (CSA) of the median, ulnar and peroneal nerve (MN, UN, PN) was measured at predefined landmarks in 50 healthy controls, 15 CMT1a and 13 MMN patients. Additionally, largest fascicle size and number of visible fascicles was obtained at the mid-upper arm cross-section of the MN and UN and in the popliteal fossa cross-section of the PN.

RESULTS

Cut-off normal values for fascicle size in the MN, UN and PN were defined (<4.8mm², <2.8mm² and <3.5mm²). In CMT1a CSA and fascicle values are significantly enlarged in all nerves, while in MMN CSA and fascicles are regionally enlarged with predominance in the upper arm nerves. The ratio of enlarged fascicles and all fascicles was significantly increased in CMT1a (>50%) in all nerves (p<0.0001), representing diffuse fascicle enlargement, and moderately increased in MMN (>20%), representing differential fascicle enlargement (enlarged and normal fascicles at the same location) sparing the peroneal nerve (regional fascicle enlargement). Based on these findings distinct fascicle patterns were defined.

CONCLUSION

Normal values for fascicle size could be evaluated; while CMT1a features diffuse fascicle enlargement, MMN shows regional and differential predominance with enlarged fascicles as single pathology.

SIGNIFICANCE

Pattern analysis of fascicles might facilitate distinction of several otherwise similar neuropathies.

Nerve ultrasound as follow-up tool in treated multifocal motor neuropathy

BACKGROUND AND PURPOSE

High-resolution ultrasound is a valuable tool in supporting the diagnosis of multifocal motor neuropathy (MMN) but longitudinal data under therapy are lacking.

METHODS

The change in peripheral nerve ultrasound pattern in patients with MMN was assessed over time. Patients with MMN received a thorough initial examination and follow-up over a period of 6-12 months using high-resolution ultrasound of the cervical roots and the nerves of the arms and legs, nerve conduction studies, Medical Research Council Sum Score (MRCSS) and Rotterdam Inflammatory Neuropathy Cause and Treatment Group (INCAT) score to evaluate changes under treatment. The Ultrasound Pattern Sum Score (UPSS) was used as standardized peripheral nerve ultrasound protocol.

RESULTS

Seventeen patients with MMN received initial examinations of whom 12 were successfully followed up. All patients with MMN showed at least localized but often multifocal peripheral nerve enlargement. An enlarged overall cross-sectional area as well as enlarged single fascicles (>3 mm²) in clinically and electrophysiologically affected (>90%) and unaffected (>70%) nerves were found. The UPSS did not correlate with clinical disability at both visits. However, the change in clinical disability (evaluated as difference in MRCSS) and the change in UPSS correlated significantly inversely (P = 0.004).

CONCLUSIONS

High-resolution sonography of peripheral nerves revealed multifocal nerve enlargement in MMN. Distinct enlargement patterns may support the diagnosis. Ultrasound findings did not correlate well with clinical severity or electrophysiological findings at initial presentation. As changes in UPSS correlated significantly with the clinical course in terms of muscle strength (MRCSS), sonographic assessment may represent a useful tool for therapeutic monitoring.

Ultrasound assessment of peripheral nerve pathology in neurofibromatosis type 1 and 2

OBJECTIVE

The neurofibromatoses (NF) type 1 and 2 are hereditary tumor predisposition syndromes caused by germline mutations in the NF1 and NF2 tumor suppressor genes. In NF1 and 2, peripheral nerve tumors occur regularly. For further characterizing nerve ultrasound was performed in patients with NF1 and 2.

METHODS

Patients with established diagnosis of NF1 (n=27) and NF2 (n=10) were included. Ultrasound of peripheral nerves and cervical roots was performed during routine follow-up visits. Healthy volunteers were studied for comparison.

RESULTS

In patients with NF1, median cross-sectional area (CSA) of most nerves was significantly increased compared to controls and to NF2 due to generalized plexiform tumors, which arose out of multiple fascicles in 23 of 27 patients (85%). These were often accompanied by cutaneous or subcutaneous neurofibromas. In NF2, the overall aspect of peripheral nerves consisted of localized schwannomas (80%) and, apart from that, normal nerve segments.

CONCLUSION

Nerve ultrasound is able to visualize different nerve pathologies in NF1 and NF2. It is a precise and inexpensive screening method for peripheral nerve manifestation in neurofibromatosis and should be considered as the first choice screening imaging modality for all peripheral nerves within reach of non-invasive ultrasound techniques.

SIGNIFICANCE

Ultrasound patterns of peripheral nerve pathologies are described for the first time in a large cohort of patients with NF1 and NF2. It is a suitable screening tool and enables targeted MRI analysis.

Peripheral nerve ultrasound scoring systems: benchmarking and comparative analysis

Ultrasound of the nerves is an additive diagnostic tool to evaluate polyneuropathy. Recently, the need for standardized scoring systems has widely been discussed; different scores are described so far. Therefore, 327 patients with polyneuropathy were analyzed by ultrasound in our laboratory. Consequently, several ultrasound scoring tools were applied, i.e., the nerve pattern classification according to Padua et al. in all patients with CIDP and variants, the Bochum ultrasound score (BUS) and the neuritis ultrasound protocol in immune-mediated neuritis, the ultrasound pattern sum score, the homogeneity score, and the nerve enlargement distribution score in all neuropathies if possible. For all scores good accuracy was found. Most patients with CIDP revealed hypoechoic enlarged nerves (Class 1), the BUS/NUP was useful to identify GBS (sensitivity >85%), MMN (100%) and CIDP (>70%), while the UPSS showed high sensitivity and positive/negative predictive values (N/PPV) in the diagnosis of GBS (>70%), CIDP (>85%) and axonal non-inflammatory neuropathies (>90%). Homogeneous nerves were found in most CMT1 patients (66.7%), while immune-mediated neuropathies mostly show regional nerve enlargement. The HS was suitable to identify CMT patients with an HS ≥5 points. All scores were easily applicable with high accuracy. The former-reported results could be similarly confirmed. However, all sores have some incompleteness concerning unselected polyneuropathy population, particularly rare and focal types. Scoring systems are useful and easily applicable. They show high accuracy in certain neuropathies, but also offer some gaps and can, therefore, only be used in addition to standard diagnostic routines such as electrophysiology.

Universal Three-Body Physics in Ultracold KRb Mixtures

Ultracold atomic gases have recently become a driving force in few-body physics due to the observation of the Efimov effect. While initially observed in equal mass systems, one expects even richer few-body physics in the heteronuclear case. In previous experiments with ultracold mixtures of potassium and rubidium, an unexpected nonuniversal behavior of Efimov resonances was observed. In contrast, we measure the scattering length dependent three-body recombination coefficient in ultracold heteronuclear mixtures of ^{39}K-^{87}Rb and ^{41}K-^{87}Rb and do not observe any signatures of Efimov resonances for accessible scattering lengths in either mixture. Our results show good agreement with our theoretical model for the scattering dependent three-body recombination coefficient and reestablish universality across isotopic mixtures.