Alginate-Encapsulated Mesenchymal Stromal Cells Improve Hind Limb Ischemia in a Translational Swine Model

BACKGROUND

Cellular therapies have been investigated to improve blood flow and prevent amputation in peripheral artery disease with limited efficacy in clinical trials. Alginate-encapsulated mesenchymal stromal cells (eMSCs) demonstrated improved retention and survival and promoted vascular generation in murine hind limb ischemia through their secretome, but large animal evaluation is necessary for human applicability. We sought to determine the efficacy of eMSCs for peripheral artery disease-induced limb ischemia through assessment in our durable swine hind limb ischemia model.

METHODS AND RESULTS

Autologous bone marrow eMSCs or empty alginate capsules were intramuscularly injected 2 weeks post-hind limb ischemia establishment (N=4/group). Improvements were quantified for 4 weeks through walkway gait analysis, contrast angiography, blood pressures, fluorescent microsphere perfusion, and muscle morphology and histology. Capsules remained intact with mesenchymal stromal cells retained for 4 weeks. Adenosine-induced perfusion deficits and muscle atrophy in ischemic limbs were significantly improved by eMSCs versus empty capsules (mean±SD, 1.07±0.19 versus 0.41±0.16, P=0.002 for perfusion ratios and 2.79±0.12 versus 1.90±0.62 g/kg, P=0.029 for ischemic muscle mass). Force- and temporal-associated walkway parameters normalized (ratio, 0.63±0.35 at week 3 versus 1.02±0.19 preligation; P=0.17), and compensatory footfall patterning was diminished in eMSC-administered swine (12.58±8.46% versus 34.85±15.26%; P=0.043). Delivery of eMSCs was associated with trending benefits in collateralization, local neovascularization, and muscle fibrosis. Hypoxia-cultured porcine mesenchymal stromal cells secreted vascular endothelial growth factor and tissue inhibitor of metalloproteinase 2.

CONCLUSIONS

This study demonstrates the promise of the mesenchymal stromal cell secretome at improving peripheral artery disease outcomes and the potential for this novel swine model to serve as a component of the preclinical pipeline for advanced therapies.

Assessing limb apraxia after ischemic stroke: validation of the Chinese version of the diagnostic instrument for limb apraxia-short version (DILA-S) classic subtests

OBJECTIVE

This study aimed to translate and validate the Chinese version of the Diagnostic Instrument for Limb Apraxia-Short Version (DILA-S) classic subtests in Chinese patients after ischemic stroke.

METHODS

The DILA-S was translated and adapted for use in Mandarin-speaking Chinese patients. Internal consistency, test-retest reliability, dimensionality, convergent validity, divergent validity, and concurrent validity were tested.

RESULTS

A total of 112 ischemic stroke patients were included. The internal consistency (Cronbach's alpha 0.85 ~ 0.92) and test-retest reliability (ICC 0.88 ~ 0.93) were found satisfactory. Exploratory factor analysis obtained two factors for the imitation subtests and the execution scale of the pantomime of tool use. Convergent validity was supported by strong correlations (ρ > 0.7) between the scores of the DILA-S subtests and the LOTCA motor praxis subscale. Divergent validity was acceptable for weak to moderate correlations (ρ ranged from -0.25~ -0.41) between the scores of the DILA-S subtests and the NIHSS. Concurrent validity was supported by strong correlations (ρ > 0.7) between the scores of the DILA-S subtests and the MoCA, as well as strong correlations (ρ > 0.6 < 0.7) between the scores of the DILA-S subtests and the BI.

CONCLUSION

The Chinese version of the DILA-S classic subtests demonstrated satisfactory psychometric properties for assessing limb apraxia in Chinese patients after ischemic stroke.

Prospective pilot study utilizing changes in quantitative values obtained on serial fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET/CT) in dogs with appendicular osteosarcoma before and after stereotactic body radiation therapy (SBRT) and carboplatin chemotherapy to assess for prediction of survival and therapeutic effectiveness

Serial fluorine 18 fluorodeoxyglucose (18F-FDG) positron emission tomography-CT (PET/CT) is commonly used in human oncology to prognosticate and evaluate for therapeutic effectiveness. In this pilot study, dogs with naturally occurring appendicular osteosarcoma were evaluated with serial 18F-FDG PET/CT in an attempt to assess for response to therapy, prognostic factors, and appropriateness of imaging intervals. Fourteen dogs were enrolled in the trial. All dogs had the initial 18F-FDG PET/CT (PET1), with nine dogs having their end-of-therapy 18F-FDG PET/CT (EoT PET) 3 months after stereotactic body radiation therapy (SBRT) to the primary tumor. The median percent change from the PET1 to the EoT PET for the standard uptake value maximum (SUVmax%) was -58% (range: -17 to -88%), metabolic tumor volume (MTV%) was -99.8% (range: -65 to -100%), and total lesion glycolysis (TLG%) was -99.8% (range: -75 to -100%), all of which were significant (P < .05, <.05, and <.05, respectively). On evaluation, it was found that volumes of GTV and CTV were significant for survival (P < .05 and <.05), MTV1, TLG1, and SUVmax on the EoT PET (SUVmaxEoT) were predictive of metastasis (P < .05), and the SUVmax% was significantly correlated to the time to first event (P < .05). Based on this data, serial 18F-FDG PET/CT performed 3 months after SBRT can show a significant reduction in avidity, and the quantitative data collected may help predict metastatic disease in canine appendicular osteosarcoma.

Paired fins in vertebrate evolution and ontogeny

The origin of paired appendages became one of the most important adaptations of vertebrates, allowing them to lead active lifestyles and explore a wide range of ecological niches. The basic form of paired appendages in evolution is the fins of fishes. The problem of paired appendages has attracted the attention of researchers for more than 150 years. During this time, a number of theories have been proposed, mainly based on morphological data, two of which, the Balfour-Thacher-Mivart lateral fold theory and Gegenbaur's gill arch theory, have not lost their relevance. So far, however, none of the proposed ideas has been supported by decisive evidence. The study of the evolutionary history of the appearance and development of paired appendages lies at the intersection of several disciplines and involves the synthesis of paleontological, morphological, embryological, and genetic data. In this review, we attempt to summarize and discuss the results accumulated in these fields and to analyze the theories put forward regarding the prerequisites and mechanisms that gave rise to paired fins and limbs in vertebrates.

Fgf10 mutant newts regenerate normal hindlimbs despite severe developmental defects

In amniote limbs, Fibroblast Growth Factor 10 (FGF10) is essential for limb development, but whether this function is broadly conserved in tetrapods and/or involved in adult limb regeneration remains unknown. To tackle this question, we established Fgf10 mutant lines in the newt Pleurodeles waltl which has amazing regenerative ability. While Fgf10 mutant forelimbs develop normally, the hindlimbs fail to develop and downregulate FGF target genes. Despite these developmental defects, Fgf10 mutants were able to regenerate normal hindlimbs rather than recapitulating the embryonic phenotype. Together, our results demonstrate an important role for FGF10 in hindlimb formation, but little or no function in regeneration, suggesting that different mechanisms operate during limb regeneration versus development.

Comprehensive Assessment and Early Prediction of Gross Motor Performance in Toddlers With Graph Convolutional Networks-Based Deep Learning: Development and Validation Study

BACKGROUND

Accurate and timely assessment of children's developmental status is crucial for early diagnosis and intervention. More accurate and automated developmental assessments are essential due to the lack of trained health care providers and imprecise parental reporting. In various areas of development, gross motor development in toddlers is known to be predictive of subsequent childhood developments.

OBJECTIVE

The purpose of this study was to develop a model to assess gross motor behavior and integrate the results to determine the overall gross motor status of toddlers. This study also aimed to identify behaviors that are important in the assessment of overall gross motor skills and detect critical moments and important body parts for the assessment of each behavior.

METHODS

We used behavioral videos of toddlers aged 18-35 months. To assess gross motor development, we selected 4 behaviors (climb up the stairs, go down the stairs, throw the ball, and stand on 1 foot) that have been validated with the Korean Developmental Screening Test for Infants and Children. In the child behavior videos, we estimated each child's position as a bounding box and extracted human keypoints within the box. In the first stage, the videos with the extracted human keypoints of each behavior were evaluated separately using a graph convolutional networks (GCN)-based algorithm. The probability values obtained for each label in the first-stage model were used as input for the second-stage model, the extreme gradient boosting (XGBoost) algorithm, to predict the overall gross motor status. For interpretability, we used gradient-weighted class activation mapping (Grad-CAM) to identify important moments and relevant body parts during the movements. The Shapley additive explanations method was used for the assessment of variable importance, to determine the movements that contributed the most to the overall developmental assessment.

RESULTS

Behavioral videos of 4 gross motor skills were collected from 147 children, resulting in a total of 2395 videos. The stage-1 GCN model to evaluate each behavior had an area under the receiver operating characteristic curve (AUROC) of 0.79 to 0.90. Keypoint-mapping Grad-CAM visualization identified important moments in each behavior and differences in important body parts. The stage-2 XGBoost model to assess the overall gross motor status had an AUROC of 0.90. Among the 4 behaviors, "go down the stairs" contributed the most to the overall developmental assessment.

CONCLUSIONS

Using movement videos of toddlers aged 18-35 months, we developed objective and automated models to evaluate each behavior and assess each child's overall gross motor performance. We identified the important behaviors for assessing gross motor performance and developed methods to recognize important moments and body parts while evaluating gross motor performance.

Resolving the mechanisms underlying epithelial-to-mesenchymal transition of the lateral plate mesoderm

Formation of the vertebrate limb buds begins with a localized epithelial-to-mesenchymal transition (EMT) of the somatic lateral plate mesoderm (LPM). While the processes that drive proliferation and outgrowth of the limb mesenchyme are well established, the fundamental mechanisms that precede this process and initiate EMT are less understood. In this review, we outline putative drivers of EMT of the LPM, drawing from analyses across a range of vertebrates and developmental models. We detail the expression patterns of key EMT transcriptional regulators in the somatic LPM of the presumptive limb fields, and their potential role in producing a mesenchymal cell fate. These include a putative cooperative role between the EMT inducers PRRX1 and TWIST1, supported by evidence in zebrafish and chicken models but unconfirmed data from mice. As such, additional functional data are required to definitively determine the mechanisms that initiate and drive EMT of the somatic LPM, a critical transition preceding formation of the limb bud mesenchyme.

Theta oscillations within right dorsolateral prefrontal cortex contribute differently to speech versus limb inhibition

Evidence suggests that speech and limb movement inhibition are subserved by common neural mechanisms, particularly within the right prefrontal cortex. In a recent study, we found that cathodal stimulation of right dorsolateral prefrontal cortex (rDLPFC) differentially modulated P3 event-related potentials for speech versus limb inhibition. In the present study, we further analyzed these data to examine the effects of cathodal high-definition transcranial direct current stimulation (HD-tDCS) over rDLPFC on frontal theta - an oscillatory marker of cognitive control - in response to speech and limb inhibition, during a Go/No-Go task in 21 neurotypical adults. Electroencephalography data demonstrated that both speech and limb No-Go elicited prominent theta activity over right prefrontal electrodes, with stronger activity for speech compared to limb. Moreover, we found that cathodal stimulation significantly increased theta power over right prefrontal electrodes for speech versus limb No-Go. Source analysis revealed that cathodal, but not sham, stimulation increased theta activity within rDLPFC and bilateral premotor cortex for speech No-Go compared to limb movement inhibition. These findings complement our previous report and suggest (1) right prefrontal theta activity is an amodal oscillatory mechanism supporting speech and limb inhibition, (2) larger theta activity in prefrontal electrodes for speech versus limb following cathodal stimulation may reflect allocation of additional neural resources for a more complex motor task, such as speech compared to limb movement. These findings have translational implications for conditions such as Parkinson's disease, wherein both speech and limb movement are impaired.

Infection with multi‑drug resistant organisms in patients with limb fractures: Analysis of risk factors and pathogens

Infection with multi-drug resistant organisms (MDROs) has emerged as a global problem in medical institutions. Overuse of antibiotics is the main cause of drug resistance. Notably, the incidence of infection with MDROs increases in patients with limb fractures who have undergone invasive surgery. The present study aimed to analyze the risk factors for postoperative MDROs infection in a cohort of patients with limb fractures. A retrospective study was performed on the data of patients with fractures between January 2020 and August 2022. Postoperative surgical site infection occurred in 114 patients in total, of which 47 were infected with MDROs. Univariate logistic regression analysis and multivariate binary logistic regression were used to confirm the associations between independent risk factors and MDRO infection. A total of 155 bacteria were collected from patients with MDROs infection and patients with non-MDROs infection, of which 66.5% were gram-positive bacteria and 33.5% were gram-negative. Staphylococcus aureus accounted for 26.5% of the 155 pathogens. MDROs, such as methicillin-resistant S. aureus and extended-spectrum β-lactamases-positive gram-negative bacillus, were detected after antibiotic treatment. Univariate analysis indicated that the number of antibiotics administered, being bedridden, repeat infection, operative time and repeated operation were different in the two groups. In addition, univariate logistic analysis indicated that being bedridden (OR, 3.98; P=0.001), administration of >2 antibiotics (OR, 2.42; P=0.026), an operative time of >3 h (OR, 3.37; P=0.003), repeated infection (OR, 3.08; P=0.009) and repetition of procedures (OR, 2.25; P=0.039) were individual risk factors for MDRO infection. Multivariate analysis showed that being bedridden (OR, 2.66; P=0.037), repeated infection (OR, 4.00; P=0.005) and an operative time of >3 h (OR, 2.28; P=0.023) were risk factors of MDRO infection. In conclusion, constrained antibiotic use, shortened operative time and increased activity duration can effectively prevent surgical-site infection with MDROs in patients with fractures.

Making a new limb out of old cells: exploring endogenous cell reprogramming and its role during limb regeneration

Cellular reprogramming is characterized by the induced dedifferentiation of mature cells into a more plastic and potent state. This process can occur through artificial reprogramming manipulations in the laboratory such as nuclear reprogramming and induced pluripotent stem cell (iPSC) generation, and endogenously in vivo during amphibian limb regeneration. In amphibians such as the Mexican axolotl, a regeneration permissive environment is formed by nerve-dependent signaling in the wounded limb tissue. When exposed to these signals, limb connective tissue cells dedifferentiate into a limb progenitor-like state. This state allows the cells to acquire new pattern information, a property called positional plasticity. Here, we review our current understanding of endogenous reprogramming and why it is important for successful regeneration. We will also explore how naturally induced dedifferentiation and plasticity were leveraged to study how the missing pattern is established in the regenerating limb tissue.

DNA-guided transcription factor cooperativity shapes face and limb mesenchyme

Transcription factors (TFs) can define distinct cellular identities despite nearly identical DNA-binding specificities. One mechanism for achieving regulatory specificity is DNA-guided TF cooperativity. Although in vitro studies suggest that it may be common, examples of such cooperativity remain scarce in cellular contexts. Here, we demonstrate how "Coordinator," a long DNA motif composed of common motifs bound by many basic helix-loop-helix (bHLH) and homeodomain (HD) TFs, uniquely defines the regulatory regions of embryonic face and limb mesenchyme. Coordinator guides cooperative and selective binding between the bHLH family mesenchymal regulator TWIST1 and a collective of HD factors associated with regional identities in the face and limb. TWIST1 is required for HD binding and open chromatin at Coordinator sites, whereas HD factors stabilize TWIST1 occupancy at Coordinator and titrate it away from HD-independent sites. This cooperativity results in the shared regulation of genes involved in cell-type and positional identities and ultimately shapes facial morphology and evolution.

Effects of a Virtual Reality Cycling Platform on Lower Limb Rehabilitation in Patients With Ataxia and Hemiparesis: Pilot Randomized Controlled Trial

Background

New interventions based on motor learning principles and neural plasticity have been tested among patients with ataxia and hemiparesis. Therapies of pedaling exercises have also shown their potential to induce improvements in muscle activity, strength, and balance. Virtual reality (VR) has been demonstrated as an effective tool for improving the adherence to physical therapy, but it is still undetermined if it promotes greater improvements than conventional therapy.

Objective

Our objective was to compare the effect on lower limb range of motion (ROM) when using VR technology for cycling exercise versus not using VR technology.

Methods

A randomized controlled trial with 20 patients with ataxia and hemiparesis was carried out. The participants were divided into 2 groups: the experimental group (n=10, 50%) performed pedaling exercises using the VR system and the control group (n=10, 50%) performed pedaling exercises without using VR. Measurements of the active and passive ROM of the hip and knee joint were taken before and after a cycling intervention, which consisted of 3 sessions of the same duration but with progressively increasing speeds (4, 5, and 6 km/h). Repeated measures ANOVAs were conducted to compare the preintervention (Ti) and postintervention (Te) assessments within each group. Additionally, the improvement effect of using the VR system was analyzed by comparing the variation coefficient (Δ = 1 - [Te / Ti]) between the preintervention and postintervention assessments for each group. Group comparisons were made using independent 1-tailed t tests.

Results

Significant improvements were shown in active left hip flexion (P=.03) over time, but there was no group-time interaction effect (P=.67). Passive left hip flexion (P=.93) did not show significant improvements, and similar results were observed for active and passive right hip flexion (P=.39 and P=.83, respectively). Neither assessments of knee flexion (active left: P=.06; passive left: P=.76; active right: P=.34; passive right: P=.06) nor knee extension showed significant changes (active left: P=.66; passive left: P=.92; active right: P=.12; passive right: P=.38). However, passive right knee extension (P=.04) showed a significant improvement over time. Overall, although active and passive ROM of the knee and hip joints showed a general improvement, no statistically significant differences were found between the groups.

Conclusions

In this study, participants who underwent the cycling intervention using the VR system showed similar improvement in lower limb ROM to the participants who underwent conventional training. Ultimately, the VR system can be used to engage participants in physical activity.

Movement Component Analysis of Reaching Strategies in Individuals With Stroke: Preliminary Study

BACKGROUND

Upper limb motor paresis is a major symptom of stroke, which limits activities of daily living and compromises the quality of life. Kinematic analysis offers an in-depth and objective means to evaluate poststroke upper limb paresis, with anticipation for its effective application in clinical settings.

OBJECTIVE

This study aims to compare the movement strategies of patients with hemiparesis due to stroke and healthy individuals in forward reach and hand-to-mouth reach, using a simple methodology designed to quantify the contribution of various movement components to the reaching action.

METHODS

A 3D motion analysis was conducted, using a simplified marker set (placed at the mandible, the seventh cervical vertebra, acromion, lateral epicondyle of the humerus, metacarpophalangeal [MP] joint of the index finger, and greater trochanter of the femur). For the forward reach task, we measured the distance the index finger's MP joint traveled from its starting position to the forward target location on the anterior-posterior axis. For the hand-to-mouth reach task, the shortening of the vertical distance between the index finger MP joint and the position of the chin at the start of the measurement was measured. For both measurements, the contributions of relevant upper limb and trunk movements were calculated.

RESULTS

A total of 20 healthy individuals and 10 patients with stroke participated in this study. In the forward reach task, the contribution of shoulder or elbow flexion was significantly smaller in participants with stroke than in healthy participants (mean 52.5%, SD 24.5% vs mean 85.2%, SD 4.5%; P<.001), whereas the contribution of trunk flexion was significantly larger in stroke participants than in healthy participants (mean 34.0%, SD 28.5% vs mean 3.0%, SD 2.8%; P<.001). In the hand-to-mouth reach task, the contribution of shoulder or elbow flexion was significantly smaller in participants with stroke than in healthy participants (mean 71.8%, SD 23.7% vs mean 90.7%, SD 11.8%; P=.009), whereas shoulder girdle elevation and shoulder abduction were significantly larger in participants with stroke than in healthy participants (mean 10.5%, SD 5.7% vs mean 6.5%, SD 3.0%; P=.02 and mean 16.5%, SD 18.7% vs mean 3.0%, SD 10.4%; P=.02, respectively).

CONCLUSIONS

Compared with healthy participants, participants with stroke achieved a significantly greater distance via trunk flexion in the forward reach task and shoulder abduction and shoulder girdle elevation in the hand-to-mouth reach task, both of these differences are regarded as compensatory movements. Understanding the characteristics of individual motor strategies, such as dependence on compensatory movements, may contribute to tailored goal setting in stroke rehabilitation.

Characteristics and mechanism of lower limb injury induced by landmine blast: A research in a rabbit model

BACKGROUND

Limb injuries caused by landmine explosions are tricky to treat and difficult to protect. It is necessary to establish an animal model for studying lower limb injury and to investigate the characteristics and mechanisms of lower limb injury induced by landmine blasts.

METHODS

Twenty-six mature white rabbits were randomly divided into sham group (n=10) and injury group (n=16). Landmine blast was simulated by electric detonators under the right lower limb in upright state by a special modified fixation frame. High-speed photography was used to observe the body movements. Vital signs, vascular injury (determining by digital subtraction angiography), pathological characteristics, and ATP concentration of the tibialis anterior muscle and triceps surae of shank were recorded for com-parison.

RESULTS

Generally, middle and lower segment of the injured legs of the rabbits was seriously damaged. The limb stump presents a distribution of three areas, tissue free zone, contusion hematoma, and edema contusion. Sneak wound track, myofascial destruction, and periosteum stripping were typical characteristics of landmine blast injury. ATP concentration and pathological analysis showed that the tibialis anterior muscle was the most seriously injured, followed by the gastrocnemius and soleus. ATP concentration of affected muscle of both the contusion and commotio area declined remarkably over time, but the muscle in the avulsion area stayed at a low activity level with no change over the time. Small vascular injury in the contusion area was evident. The site of the sciatic nerve lesion was higher than the muscle. Injured site of sciatic nerve injury was higher than serious contusion muscle. High-speed photography demonstrated that the joints of the injured limb extremely flexed followed by a rapid stretch under the blast shock wave.

CONCLUSION

The established experimental model presents typical effect of lower limbs wounded by the mine blast in war field. Landmine blast can cause typical damage on lower limbs including nerve lesion, knee injury, and microcirculation damage that is pro-gressive over time. The limb stump is divided into three zones based on gross pathology and micropathology, which can provide an important reference for clinical treatments and prognosis.

[Anatomic study and clinical application of iliac crest chimeric tissue flap]

Objective

To conduct anatomical study on the iliac crest chimeric tissue flap and summarize its effectiveness of clinical application in repairing limb wounds.

Methods

Latex perfusion and anatomical study were performed on 6 fresh adult cadaver specimens with 12 sides, to observe the initial location, distribution, quantity, and direction of the common circumflexa iliac artery, the deep circumflexa iliac artery, and the superficial circumflexa iliac artery, and to measure their initial external diameter. Between December 2020 and September 2022, the iliac crest chimeric tissue flap repair was performed on 5 patients with soft tissue of limbs and bone defects. There were 3 males and 2 females, with an average age of 46 years (range, 23-60 years). Among them, there were 3 cases of radii and skin soft tissue defects and 2 cases of tibia and skin soft tissue defects. The length of bone defects was 4-8 cm and the area of skin soft tissue defects ranged from 9 cm×5 cm to 15 cm×6 cm. The length of the iliac flap was 4-8 cm and the area of skin flap ranged from 12.0 cm×5.5 cm to 16.0 cm×8.0 cm. The donor sites were directly sutured.

Results

Anatomical studies showed that there were 10 common circumflex iliac arteries in 5 specimens, which originated from the lateral or posterolateral side of the transition between the external iliac artery and the femoral artery, with a length of 1.2-1.6 cm and an initial external diameter of 0.8-1.4 mm. In 1 specimen without common circumflexa iliac artery, the superficial and deep circumflex iliac arteries originated from the external iliac artery and the femoral artery, respectively, while the rest originated from the common circumflex iliac artery. The length of superficial circumflex iliac artery was 4.6-6.7 cm, and the initial external diameter was 0.4-0.8 mm. There were 3-6 perforator vessels along the way. The length of deep circumflex iliac artery was 7.8-9.2 cm, and the initial external diameter was 0.5-0.7 mm. There were 3-5 muscular branches, 4-6 periosteal branches, and 2-3 musculocutaneous branches along the way. Based on the anatomical observation results, all iliac crest chimeric tissue flaps were successfully resected and survived after operation. The wounds at recipient and donor sites healed by first intention. All patients were followed up 8-24 months, with an average of 12 months. The tissue flap has good appearance and soft texture. X-ray film reexamination showed that all the osteotomy healed, and no obvious bone resorption was observed during follow-up.

Conclusion

The common circumflex iliac artery, deep circumflex iliac artery, and superficial circumflex iliac artery were anatomically constant, and it was safe and reliable to use iliac crest chimeric tissue flap in repairing the soft tissue and bone defects of limbs.

The Relationship Between Knee Osteoarthritis-Related Pain Severity and Daily Activities Involving the Upper and Lower Limbs in Saudi Adults: A Cross-Sectional Study

Introduction Earlier research has shown an association between pain intensity and everyday activities in adults. However, it is vital to examine the relationship within the context of Saudi people who have knee osteoarthritis. Therefore, this study aimed to explore the connection between pain intensity and daily activities involving the lower and upper limbs among patients with knee osteoarthritis in Saudi Arabia. Methods This study enrolled 209 individuals aged 55 years and above who were diagnosed with radiographic knee osteoarthritis by physicians from five hospitals in Riyadh, Saudi Arabia, between March 2016 and March 2017. Participants were divided into two groups based on their pain intensity, measured using the visual analog scale. The first group included 141 individuals with mild or moderate pain, while the second group comprised 68 individuals with severe pain. The study assessed the physical functioning of these individuals by evaluating their ability to perform daily activities involving the lower and upper limbs, using the Physical Functioning Subscale of the 36-item Short Form Health Survey, which includes 10 items. Results Adjusted logistic regression analysis revealed that individuals experiencing severe pain related to knee osteoarthritis were more likely to encounter difficulties in climbing several flights of stairs (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.09-1.29), and one flight of stairs (OR = 1.19, 95% CI = 1.06-1.34), with challenges in bending, kneeling, or stooping (OR = 1.14, 95% CI = 1.05-1.23), walking more than one mile (OR = 1.15, 95% CI = 1.06-1.25), walking several blocks (OR = 1.17, 95% CI = 1.08-1.27), and walking one block (OR = 1.19, 95% CI = 1.06-1.34) than those with mild or moderate pain. Conclusion Our study results highlight the significant impact of severe pain on activities like climbing stairs, bending, kneeling, stooping, and walking longer distances among people with knee osteoarthritis in Saudi Arabia.

Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study

BACKGROUND

Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential.

OBJECTIVE

We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption.

METHODS

A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption).

RESULTS

The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007).

CONCLUSIONS

This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

The salamander blastema within the broader context of metazoan regeneration

Throughout the animal kingdom regenerative ability varies greatly from species to species, and even tissue to tissue within the same organism. The sheer diversity of structures and mechanisms renders a thorough comparison of molecular processes truly daunting. Are "blastemas" found in organisms as distantly related as planarians and axolotls derived from the same ancestral process, or did they arise convergently and independently? Is a mouse digit tip blastema orthologous to a salamander limb blastema? In other fields, the thorough characterization of a reference model has greatly facilitated these comparisons. For example, the amphibian Spemann-Mangold organizer has served as an amazingly useful comparative template within the field of developmental biology, allowing researchers to draw analogies between distantly related species, and developmental processes which are superficially quite different. The salamander limb blastema may serve as the best starting point for a comparative analysis of regeneration, as it has been characterized by over 200 years of research and is supported by a growing arsenal of molecular tools. The anatomical and evolutionary closeness of the salamander and human limb also add value from a translational and therapeutic standpoint. Tracing the evolutionary origins of the salamander blastema, and its relatedness to other regenerative processes throughout the animal kingdom, will both enhance our basic biological understanding of regeneration and inform our selection of regenerative model systems.

Comment on 'A conserved strategy for inducing appendage regeneration in moon jellyfish, Drosophila, and mice'

Abrams et al. report that a simple dietary supplement is sufficient to induce appendage regeneration in jellyfish, fruit flies, and mice (Abrams et al., 2021). This conclusion is surprising because it was previously thought that flies and mice lack the capacity for regeneration after injury. We replicated the Drosophila experiments of Abrams et al. but did not observe any instances of leg regeneration. We also conclude that the "white blob" observed at the amputation site by Abrams et al. consists of bacteria and is not regenerated tissue.

DNA-guided transcription factor cooperativity shapes face and limb mesenchyme

Transcription factors (TFs) can define distinct cellular identities despite nearly identical DNA-binding specificities. One mechanism for achieving regulatory specificity is DNA-guided TF cooperativity. Although in vitro studies suggest it may be common, examples of such cooperativity remain scarce in cellular contexts. Here, we demonstrate how 'Coordinator', a long DNA motif comprised of common motifs bound by many basic helix-loop-helix (bHLH) and homeodomain (HD) TFs, uniquely defines regulatory regions of embryonic face and limb mesenchyme. Coordinator guides cooperative and selective binding between the bHLH family mesenchymal regulator TWIST1 and a collective of HD factors associated with regional identities in the face and limb. TWIST1 is required for HD binding and open chromatin at Coordinator sites, while HD factors stabilize TWIST1 occupancy at Coordinator and titrate it away from HD-independent sites. This cooperativity results in shared regulation of genes involved in cell-type and positional identities, and ultimately shapes facial morphology and evolution.

Efficacy of Naprapathy in Brachial Plexus Injury: Protocol for a Randomized Clinical Trial

BACKGROUND

Clinical rehabilitation for brachial plexus injury is difficult in terms of chronic pain and dysfunction. Physiotherapy is considered a routine intervention for rehabilitation. Common physical therapy may require a variety of instruments. One approach that does not need instruments, but belongs to the field of complementary and alternative medicine, is naprapathy. Naprapathy, also called Tuina in China, has been applied in rehabilitation after brachial plexus injury for a long time. Naprapathy can relieve chronic neuropathic pain, promote local blood circulation, and improve body edema. Naprapathy can passively help improve motor functions in patients with peripheral nerve injury. However, the efficacy of naprapathy in improving rehabilitation after brachial plexus injury is unclear.

OBJECTIVE

This study aims to evaluate the additional value of naprapathy when combined with conventional physical therapy for the treatment of brachial plexus injury.

METHODS

This will be a single-center randomized controlled trial. A total of 116 eligible patients with brachial plexus injury will be randomly divided into an experimental group (naprapathy plus physical therapy group) or a control group (physical therapy group). The participants will be followed up for 4 weeks of treatment. Observation outcomes will include the visual analog scale score, upper limb index, electromyography findings, and adverse reactions, among others. The measuring points for outcomes will be the baseline and the completion of treatment. In addition, a quality control group independent from the research team will be set up to control the quality of the trial. Finally, the data will be analyzed using SPSS software (version 21.0; IBM Corp).

RESULTS

The study is recruiting participants. The first participant was enrolled in September 2021. As of January 2023, a total of 100 participants have been enrolled. The trial is expected to be completed by September 2023. The study protocol was approved by the Ethics Review Committee of Yue Yang Hospital affiliated with the Shanghai University of Traditional Chinese Medicine (2021-012).

CONCLUSIONS

One limitation of this trial is that we will be unable to achieve strict double-blinding because of the features of naprapathy. The trial aims to contribute reliable evidence for decision-making in naprapathy for treating brachial plexus injury.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100043515; http://www.chictr.org.cn/showproj.aspx?proj=122154.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46054.

Manufacture and Vibration-Damping Effect of Composites for Archery Carbon Fiber-Reinforced Polymer Limb with Glass Fiber-Reinforced Polymer Stabilizer

Typically, archers prepare two sets of bows for competitions in case of bow breakage, but if the limbs of the bow break during a match, archers can become psychologically disadvantaged, leading to potentially fatal consequences. Archers are very sensitive to the durability and vibration of their bows. While the vibration-damping properties of Bakelite^® stabilizer are excellent, its low density and somewhat lower strength and durability are disadvantages. As a solution, we used carbon fiber-reinforced plastic (CFRP) and glass fiber-reinforced plastic (GFRP) for the archery limb with stabilizer, commonly used for the limbs of the bow, to manufacture the limb. The stabilizer was reverse-engineered from the Bakelite^® product and manufactured using glass fiber-reinforced plastic in the same shape as the existing product. Analyzing the vibration-damping effect and researching ways to reduce the vibration that occurs during shooting through 3D modeling and simulation, it was possible to evaluate the characteristics and the effect of reducing the limb's vibration by manufacturing archery bows and limbs using carbon fiber- and glass fiber-reinforced composites. The objective of this study was to manufacture archery bows using CFRP and GFRP, and to assess their characteristics as well as their effectiveness at reducing limb vibration. Through testing, the limb and stabilizer that were produced were determined to not fall behind the abilities of the bows currently used by athletes, and they also exhibited a noticeable reduction in vibrations.

Ex vivo expansion of primary cells from limb tissue of Pleurodeles waltl

Pleurodeles waltl comes to light as an animal model, especially in regeneration study, but in deep study on molecular mechanisms has been limited due to the absence of primary tissue cells for widely usage. Thus, we aimed to grow primary cells from limb tissue of P. waltl for in vitro experiments. Limb tissues were cut into small pieces and seeded as "explant" on culture dish coated with fibronectin and gelatin. Compared to the control without coating, both fibronectin and gelatin coating supports quicker outgrowth of cells from explant and faster cell adhesion, although fibronectin shows significant better performance than gelatin. Interestingly, doubling time of cells on fibronectin- and gelatin-coated surface is almost same (42.39 ± 2.79 h vs. 42.91 ± 3.69 h) and was not significantly differed from the non-coated condition (49.64 ± 3.63 h). The cryopreserved cells were successfully recovered and showed similar multiplying capacity like fresh cells. Senescent cells were barely detected even through long-term sub-culture (>15 passages). Moreover, enhanced fluorescence of MitoSOX™ Red in cells under H₂ O₂ exposure confirmed the respondence to chemical stimuli. Collectively, we are able to grow enough number of good quality cells from P. waltl limb tissue for in vitro experiments, and fibronectin coating provides the best biocompatible environment for cell outgrow and attachment. This article is protected by copyright. All rights reserved.

In vivo pressure-flow relation of human cutaneous vessels following prolonged iterative exposures to hypergravity

The study examined intra- and inter-limb variations in cutaneous vessel responsiveness to acute and repeated transmural pressure elevations. In eleven healthy men, red blood cell flux was assessed via laser-Doppler flowmetry on both glabrous and nonglabrous skin regions of an arm (finger and forearm) and leg (toe and lower leg), across a wide range of stepwise increasing distending pressures imposed in the vessels of each limb separately. The pressure-flux cutaneous responses were evaluated before and after 5 weeks of intermittent (40 min, 3 sessions･week^-1) exposures to hypergravity (~2.6 - 3.3 G; G-training). Before and after G-training, forearm and lower-leg blood flux were relatively stable up to ~210 mmHg and ~240 mmHg distending pressures, respectively; and then they increased two- to three-fold (P < 0.001). Finger blood flux dropped promptly (P < 0.001), regardless of the G-training (P = 0.64). At ≤120 mmHg distending pressures, toe blood flux enhanced by ~40% (P ≤ 0.05); the increase was augmented after the G-training (P = 0.01). At high distending pressures, toe blood flux dropped by ~70% in both trials (P < 0.001). The present results demonstrate that circulatory autoregulation is more pronounced in glabrous than in nonglabrous skin, and in nonglabrous sites of the leg than in those of the arm. Repetitive high-sustained gravitoinertial stress does not modify the pressure-flow relationship in the dependent skin vessels of the arm nor in the nonglabrous sites of the lower leg. Yet it may partly inhibit the myogenic responsiveness of the toe's glabrous skin.

Bmp-signaling and the finfold size in zebrafish: implications for the fin-to-limb transition

In tetrapods, BMP signalling coordinates limb outgrowth, skeleton patterning, and apoptosis during the formation of their typical autopod structures, the digits. In addition, inhibition of BMP signalling during mouse limb development leads to the persistence and enlargement of an important signalling center, the apical ectodermal ridge (AER), and consequent digit defects. Interestingly, during fish fin development there is a natural elongation of the AER, rapidly converted into an apical finfold (FF), in which osteoblasts differentiate into dermal fin rays used in aquatic locomotion. Previous reports have led us to suggest that upregulation of Hox13 genes in the distal fin mesenchyme, caused by the origin of novel enhancer modules, may have caused an increment of the BMP signalling potentially leading to the apoptosis of these osteoblasts precursors of the fin-rays. To explore this hypothesis, we characterized the expression of several components of the BMP signalling in zebrafish lines with distinct finfold sizes (bmp2b, smad1, smoc1, smoc2, grem1a, msx1b, msx2b, Psamd1/5/9). Our data suggest that the BMP signalling is enhanced in shorter finfolds and inhibited in longer finfolds, as implied by the differential expression of several components of this network. In addition, we detected an earlier expression of several of these BMP-signalling components associated with the development of short finfolds and the opposite tendency during the development of longer finfolds. Thus, our results suggest that a heterochronic shift, involving enhanced Hox13 expression and BMP-signalling may have caused the reduction of the finfold size during the evolutionary transition from fish fins to tetrapod limbs.

Predictor of Burn Wound Conversion as a Reference for Conservative and Operative Management: Review of Imagej, Flir One® And Development Of A Risk Actor Score Model

Burn wound conversion describes the process by which superficial-partial thickness burns convert into deeper burns within 3-7 days after burn. Autophagy, inflammation, ischemia, infection and reactive oxygen species are thought to have a role in pathogenesis of burn wound conversion. This study aims to assess risk factors for burn conversion and develop a scoring system to predict it. The study was conducted using nested case control method, in burn patients treated in Dr. Cipto Mangunkusumo Hospital and Jakarta Islamic Hospital Cempaka Putih. Subjects were recruited by consecutive sampling in February 2019-August 2020. The role of clinical characteristics, local and systemic examination as predictors of burn wound conversion were assessed. Risk factors were analysed using bivariate and multivariate analysis. There were 40 subjects in the case group and 20 subjects in the control group. Involvement of trunk, limbs, burn extent measured using ImageJ, ≥ 9.49%TBSA, wound surface temperature measured using Flir one® thermography ≤ -1.55°C, procalcitonin level ≥ 0.075 ng/mL, and blood lactate level ≥ 1.75 mmol/L had a significant relationship with burn wound conversion. Three scoring models were developed: model 1 to be applied in tertiary health facilities, and model 2 and 3 to be applied in primary and secondary health facilities with sensitivity and specificity of 92.5% and 85%, 95% and 70% and 92.5% and 85%, respectively. The scoring models can be used in daily practice, especially as a reference for conservative and operative management.

Failure of digit tip regeneration in the absence of Lmx1b suggests Lmx1b functions disparate from dorsoventral polarity

Mammalian digit tip regeneration is linked to the presence of nail tissue, but a nail-explicit model is missing. Here, we report that nail-less double-ventral digits of ΔLARM1/2 mutants that lack limb-specific Lmx1b enhancers fail to regenerate. To separate the nail's effect from the lack of dorsoventral (DV) polarity, we also interrogate double-dorsal double-nail digits and show that they regenerate. Thus, DV polarity is not a prerequisite for regeneration, and the nail requirement is supported. Transcriptomic comparison between wild-type and non-regenerative ΔLARM1/2 mutant blastemas reveals differential upregulation of vascularization and connective tissue functional signatures in wild type versus upregulation of inflammation in the mutant. These results, together with the finding of Lmx1b expression in the postnatal dorsal dermis underneath the nail and uniformly in the regenerative blastema, open the possibility of additional Lmx1b roles in digit tip regeneration, in addition to the indirect effect of mediating the formation of the nail.

Fetoscopic surgery for amniotic band syndrome: Case series

We aimed to evaluate the fetoscopic procedure indications, procedure-related complications, and neonatal outcomes in cases diagnosed with amniotic band syndrome (ABS). Stage II and III cases according to Hüsler classification were included for fetoscopic surgery. Scissors were used to release the amniotic band in six cases, and a diode laser was used in one case. A single entry was made in all cases. The majority of the children acquired a functional limb (71.4%). Fetal morbidity was mainly linked to the consequences of preterm premature rupture of the membranes (57.1%) and preterm birth (28.5%). Excluding complicated cases, fetoscopic band release is encouraging in cases of ABS in the limbs.

Multiple nerve cords connect the arms of octopuses, providing alternative paths for inter-arm signaling

Octopuses are remarkable in their ability to use many arms together during behavior (e.g., see Levy et al., ¹ Mather,² Byrne et al.,³ and Hanlon et al.⁴). Arm responses and multi-arm coordination can occur without engagement of major brain regions,⁵ which indicates the importance of local proprioceptive responses and peripheral connections. Here, we examine the intramuscular nerve cords (INCs),^6,7,8,9 the key proprioceptive anatomy in the arms. INCs are understood to include proprioceptive neurons, multipolar neurons, and motoneurons (reviewed by Graziadei¹⁰) and are thought to contribute to structuring whole-arm movement.¹¹ There are four INCs running the full length of each arm (e.g., see Guérin-Ganivet,⁶ Martoja and May,⁸ and Graziadei⁹); we focused on the pair closest to the suckers, called the oral INCs. In tracking the oral INCs, we found that they extend proximally and continue beyond the arm, through the arm's base. Each oral INC bypasses two adjacent arms and is continuous with the nearer oral INC of the third arm over. As a result, an arm connects through oral INC pathways to arms that are two arms away to the right and left of it. In addition to connecting distant arms, nerve fibers project from the central region of the INCs, suggesting function in local tissues. The other two INCs, paired aboral INCs, also extend proximally beyond the arm's base with trajectories suggestive of the oral INC pattern. These data identify previously unknown regions of the INCs that link distant arms, creating anatomical connections. They suggest potential INC proprioceptive function in extra-arm tissues and contribute to an understanding of embodied organization for octopus behavioral control.^12,13,14,15.

Playfully Assessing Lower Extremity Selective Voluntary Motor Control in Children With Cerebral Palsy: Psychometric Study

BACKGROUND

Objective measures specifically assessing selective voluntary motor control are scarce. Therefore, we have developed an interval-scaled assessment based on accelerometers.

OBJECTIVE

This study provided a preliminary evaluation of the validity and reliability of this novel gamelike assessment measuring lower limb selective voluntary motor control in children with cerebral palsy (CP).

METHODS

Children with CP and their neurologically intact peers were recruited for this psychometric evaluation of the assessgame. The participants played the assessgame and steered an avatar by selective hip, knee, or ankle joint movements captured with accelerometers. The assessgame's scores provide information about the accuracy of the selective movement of the target joint and the amplitude and frequency of involuntary movements occurring in uninvolved joints. We established discriminative validity by comparing the assessgame scores of the children with CP with those of the neurologically intact children, concurrent validity by correlations with clinical scores and therapists' opinions, and relative and absolute test-retest reliability.

RESULTS

We included 20 children with CP (mean age 12 years and 5 months, SD 3 years and 4 months; Gross Motor Function Classification System levels I to IV) and 31 neurologically intact children (mean age 11 years and 1 month, SD 3 years and 6 months). The assessgame could distinguish between the children with CP and neurologically intact children. The correlations between the assessgame's involuntary movement score and the therapist's rating of the occurrence of involuntary movements during the game were moderate (Spearman ρ=0.56; P=.01), whereas the correlations of the assessgame outcomes with the Selective Control Assessment of the Lower Extremity and Gross Motor Function Classification System were low and not significant (|ρ|≤0.39). The intraclass correlation coefficients were >0.85 and indicated good relative test-retest reliability. Minimal detectable changes amounted to 25% (accuracy) and 44% (involuntary movement score) of the mean total scores. The percentage of children able to improve by the minimal detectable change without reaching the maximum score was 100% (17/17) for the accuracy score and 94% (16/17) for the involuntary movement score.

CONCLUSIONS

The assessgame proved reliable and showed discriminative validity in this preliminary evaluation. Concurrent validity was moderate with the therapist's opinion but relatively poor with the Selective Control Assessment of the Lower Extremity. We assume that the assessment's gamelike character demanded various other motor control aspects that are less considered in current clinical assessments.

Evi5 is required for Xenopus limb and tail regeneration

Amphibians such as salamanders and the African clawed frog Xenopus are great models for regeneration studies because they can fully regenerate their lost organs. While axolotl can regenerate damaged organs throughout its lifetime, Xenopus has a limited regeneration capacity after metamorphosis. The ecotropic viral integrative factor 5 (Evi5) is of great interest because its expression is highly upregulated in the limb blastema of axolotls, but remains unchanged in the fibroblastema of post-metamorphic frogs. Yet, its role in regeneration-competent contexts in Xenopus has not been fully analyzed. Here we show that Evi5 is upregulated in Xenopus tadpoles after limb and tail amputation, as in axolotls. Down-regulation of Evi5 with morpholino antisense oligos (Mo) impairs limb development and limb blastema formation in Xenopus tadpoles. Mechanistically, we show that Evi5 knockdown significantly reduces proliferation of limb blastema cells and causes apoptosis, blocking the formation of regeneration blastema. RNA-sequencing analysis reveals that in addition to reduced PDGFα and TGFβ signaling pathways that are required for regeneration, evi5 Mo downregulates lysine demethylases Kdm6b and Kdm7a. And knockdown of Kdm6b or Kdm7a causes defective limb regeneration. Evi5 knockdown also impedes tail regeneration in Xenopus tadpoles and axolotl larvae, suggesting a conserved function of Evi5 in appendage regeneration. Thus, our results demonstrate that Evi5 plays a critical role in appendage regeneration in amphibians.

Unusual Findings in Down's Syndrome: Hand Agenesis and Hypospadias

A baby with Down syndrome presented initial findings at the first-trimester ultrasound of increased nuchal thickness and unilateral hand agenesis. During follow-up, other elements were found mainly hypospadias. This report emphasizes through prenatal and postnatal imaging the phenotypic variability of Down syndrome babies.

Clinical characteristics and survival analysis of patients with limb epithelioid sarcoma

Limb epithelioid sarcoma (LES) is a rare and aggressive soft tissue sarcoma, which is scarcely reported. Therefore, the current study was performed to analyze the clinicopathologic features and risk factors of survival among patients with LES. By using the Surveillance, Epidemiology, and End Results database, data were obtained regarding patients who were diagnosed with LES for the period between 2010 and 2016. We first analyzed overall survival (OS) and cancer-specific survival (CSS) by applying univariate Cox regression analysis. Then we performed multivariate analysis to confirm independent predictors of survival. In total, we identified 475 patients with LES for survival analysis, of which 291 were males (61.3%) and 184 females (38.7%). The mean and median age at diagnosis were 38 and 36 years, respectively. The 5-year OS and CSS rates among Patients with LES were 65.4% and 69.5%, respectively. Gender, age, tumor stage, tumor size, and treatment type were significant predictors of OS on both univariate and multivariate analyses (P < .05). As for CSS, multivariable analysis revealed that age <60 years, localized stage, and tumor size <5 cm were significantly associated with increased survival (P < .05). Predictors of improved survival for LES patients include gender, age, tumor stage, tumor size, and treatment type. Surgery only was recommended for treating LES patients. Future studies are warranted to determine effective treatment types for LES patients.

Unusual subcutaneous emphysema extending to the limbs following blunt chest injury

Subcutaneous emphysema can be traumatic, infectious, iatrogenic, or spontaneous. Traumatic subcutaneous emphysema of the upper limb is not infrequent following trauma to that limb. However, the subcutaneous emphysema of the limbs following trauma to a site other than the limb is seldom reported. A 45-year-old male was referred from a private hospital to a tertiary care hospital with right-sided multiple rib fractures and pneumothorax following chest injury. The patient was having acidotic breathing on examination, and crepitus was present over the bilateral chest and bilateral upper and lower limbs, suggesting subcutaneous emphysema. Right and left intercostal drainage tubes were inserted at our hospital. The patient died in the emergency after a few hours of treatment. The X-ray performed at the autopsy revealed extensive bilateral upper and lower limb subcutaneous emphysema. The deceased had multiple rib fractures over the right side with fractured ends of the two ribs piercing the pleural cavity, causing tears in the lung parenchyma. The cause of death was attributed to the chest injury and its sequelae. Such rapidly expanding subcutaneous emphysema can be a sign of underlying severe chest injury. Prompt insertion of the intercostal drainage tube could be the lifesaving procedure in such cases.

10: Efficacy of premixed versus sequential administration of fentanyl and bupivacaine in subarachnoid block for lower limb tibial surgeries: A randomised double blind clinical Study

Background and Aims:

Opioids are most commonly used as adjuvants in subarachnoid block. The drug and its mode of administration affects the various block characteristics. Intrathecal administration of bupivacaine and fentanyl as premixed is compared to sequential administration in two separate syringes.

Methods:

Total eighty patients were randomly allocated into two groups of 40 each: Group M (Mixed) received premixed 0.5% heavy bupivacaine 2.5 ml (12.5 mg) and 0.5 ml (25µg ) of fentanyl in a single 5.0 ml syringe, Group S (Sequential) received 0.5 ml (25 microgram) of fentanyl in a 2.0 ml syringe followed by 0.5% heavy bupivacaine 2.5 ml (12.5 mg) in a 5.0 ml syringe. Double blinding was ensured in all the cases performed. The onset and duration of sensory and motor blockade and haemodynamic parameters were observed. Data analysis was done using MedCalc software.

Results:

The mean time for onset of sensory and motor block was less in group S (P<0.0001). The duration of sensory and motor block was prolonged in group S (P<0.0001). Patients in group M experienced more hypotension as compared to group S (P<0.05). Need for rescue analgesia was less in Group S in 24 hours (P<0.05).

Conclusion:

Administering fentanyl first followed by hyperbaric bupivacaine leads to an early onset and prolonged duration of sensory and motor block and better haemodynamic stability and less need of rescue analgesia in 24 hours.

Bidirectional bionic limbs: a perspective bridging technology and physiology

Precise control of bionic limbs relies on robust decoding of motor commands from nerves or muscles signals and sensory feedback from artificial limbs to the nervous system by interfacing the afferent nerve pathways. Implantable devices for bidirectional communication with bionic limbs have been developed in parallel with research on physiological alterations caused by an amputation. In this perspective article, we question whether increasing our effort on bridging these technologies with a deeper understanding of amputation pathophysiology and human motor control may help to overcome pressing stalls in the next generation of bionic limbs.

[Repair of complex wounds of limbs with free lobed perforator flaps]

OBJECTIVE

To explore the effectiveness of free lobed perforator flaps in repairing of complex wounds of limbs.

METHODS

Between January 2018 and January 2021, 10 patients with complex wounds of limbs were admitted. There were 7 males and 3 females, aged from 32 to 64 years, with an average age of 45 years. There were 4 cases of traffic accident injuries, 3 cases of machine strangulation injuries, 1 case of machine crush injury, and 2 cases of heavy object crush injuries. There were 5 cases of upper limb wounds and 5 cases of lower limb wounds. The size of wounds ranged from 11 cm×10 cm to 25 cm×18 cm. The wounds were repaired with tri-lobed flaps of the descending branch of the lateral femoral circumflex artery in 7 cases, four-lobed flaps in 2 cases, and with tri-lobed flaps of the descending branch of the lateral femoral circumflex artery combined with oblique branch in 1 case. The size of flaps ranged from 12.0 cm×10.5 cm to 28.0 cm×12.0 cm. The donor sites were sutured directly in 9 cases and repaired with superficial iliac circumflex artery perforator flap in 1 case.

RESULTS

Sinus formed at the edge of the flap in 1 patient, which healed after dressing change and drainage; other flaps survived well, and the wounds healed by first intention. The skin flap at donor site survived, and the incisions healed by first intention. All patients were followed up 6-24 months (mean, 11 months). All flaps had good appearance and function, and linear scars were left at the donor site without obvious complications.

CONCLUSION

Free lobed perforator flap is an alternative method to repair complex wounds of limbs with high safety, good effectiveness, and less complications.

Gross anatomy of the musculature of the thoracic limb of the aulacod

Objective

The cane rat is a wild rodent appreciated for its meat. Currently domesticated, its breeding is expanding in sub‐Saharan Africa where it originates. However, the pathological problems already identified during the domestication phase of the cane rat on station still constitute a major constraint to the development of aulacodiculture. Our study aims at filling the lack of illustrations on the myology of the thoracic limb of the cane rat

Methodology

We used 16 adults cane rats ranging in age from 3 to 4 years

Results

The study of the different muscles of the thoracic limb reveals many similarities in the Glires (rodents and lagomorphs). However, some particularities are noteworthy. Indeed, in the cane rat, the deltoid muscle, as well as the muscles of the forearm, are very developed with its three portions, the biceps brachii and brachialis muscles are fusiform and the triceps brachii muscle has a very bulky long part (caput longum)

Conclusion

These illustrations will be very effective tools for understanding the muscles of the thoracic limbs and a reliable technical support for veterinary students and practitioners.

Congenital anomaly epidemiological correlates of Δ8THC across USA 2003-16: panel regression and causal inferential study

Δ8-Tetrahydrocannabinol (Δ8THC) is marketed in many US states as 'legal weed'. Concerns exist relating to class-wide genotoxic cannabinoid effects. We conducted an epidemiological investigation of Δ8THC-related genotoxicity expressed as 57 congenital anomaly (CA) rates (CARs) in the USA. CARs were taken from the Centers for Disease Control, Atlanta, Georgia. Drug exposure data were taken from the National Survey of Drug Use and Health, with a response rate of 74.1%. Ethnicity and income data were taken from the US Census Bureau. National cannabinoid exposure was taken from Drug Enforcement Agency publications and multiplied by state cannabis use data to derive state-based estimates of Δ8THC exposure. At bivariate continuous analysis, Δ8THC was associated with 23 CAs on raw CA rates, 33 CARs after correction for early termination for anomaly estimates and 41 on a categorical analysis comparing the highest and lowest exposure quintiles. At inverse probability weighted multivariable additive and interactive models lagged to 0, 2 and 4 years, Δ8THC was linked with 39, 8, 4 and 9 CAs. Chromosomal, cardiovascular, gastrointestinal, genitourinary, limb, central nervous system (CNS) and face systems were particularly affected. The minimum E-values ranged to infinity. Both the number of anomalies implicated and the effect sizes demonstrated were much greater for Δ8THC than for tobacco and alcohol combined. Δ8THC appears epidemiologically to be more strongly associated with many CAs than for tobacco and alcohol and is consistent with a cannabinoid class genotoxic/epigenotoxic effect. Quantitative causality criteria were fulfilled, and causal relationships either for Δ8THC or for cannabinoid/s, for which it is a surrogate marker, may be in operation.

Descending neuron population dynamics during odor-evoked and spontaneous limb-dependent behaviors

Deciphering how the brain regulates motor circuits to control complex behaviors is an important, long-standing challenge in neuroscience. In the fly, Drosophila melanogaster, this is coordinated by a population of ~ 1100 descending neurons (DNs). Activating only a few DNs is known to be sufficient to drive complex behaviors like walking and grooming. However, what additional role the larger population of DNs plays during natural behaviors remains largely unknown. For example, they may modulate core behavioral commands or comprise parallel pathways that are engaged depending on sensory context. We evaluated these possibilities by recording populations of nearly 100 DNs in individual tethered flies while they generated limb-dependent behaviors, including walking and grooming. We found that the largest fraction of recorded DNs encode walking while fewer are active during head grooming and resting. A large fraction of walk-encoding DNs encode turning and far fewer weakly encode speed. Although odor context does not determine which behavior-encoding DNs are recruited, a few DNs encode odors rather than behaviors. Lastly, we illustrate how one can identify individual neurons from DN population recordings by using their spatial, functional, and morphological properties. These results set the stage for a comprehensive, population-level understanding of how the brain’s descending signals regulate complex motor actions.

Accuracy of X-Ray and Magnetic Resonance Imaging in Defining the Tumor Margin in Primary Bone Sarcoma

BACKGROUND

Limb-salvage surgery for primary bone sarcomas are preceded by X-ray and MRI for surgical planning. However, the accuracy of X-ray and MRI predicted margins are not well described. Our study examined these questions: (1) How accurately do X-ray and MRI margin measurements reflect the true margin on pathology reports? (2) Do X-ray or MRI margin measurements have smaller differences compared to pathology reports? (3) How many X-ray or MRI margin measurement differences were greater than 1 cm, 2 cm, and 3 cm from pathology reports? (4) Is there an X-ray or MRI view that consistently results in a smaller difference from pathology reports?

METHODS

This retrospective chart review examined patients with primary bone sarcoma treated with limb-salvage surgery. Reviewers used electronic measurement tools to determine margins from X-ray or MRI based on the resection length of the pathologic specimen. Mean differences of margin measurements to pathology reports were calculated. We determined outliers of imaging margin measurements at 1 cm, 2 cm, and 3 cm differences to pathology reports.

RESULTS

In the total cohort of 39 patients, the mean difference of X-ray and MRI margins compared to pathology reports were 1.09 cm (st dev 0.79 cm) and 0.71 cm (st dev 0.70 cm), respectively. MRI margin measurements had smaller differences compared to pathology reports than X-ray in 32 of 38 cases (84%) with complete imaging. X-ray outliers at 1 cm, 2 cm, and 3 cm differences were 36, 14 and 2 respectively for 70 margin measurements and MRI outliers at 1 cm, 2 cm, and 3 cm differences were 17, 6, and 0 respectively for 66 margin measurements. The views with the smallest difference were anterior-posterior X-rays and MRI views with the closest predicted margin.

CONCLUSION

Electronic MRI margin measurements with the closest predicted margin provided the smallest differences with pathology reports and are therefore the most accurate for preoperative planning. When there is adequate residual diaphysis for reconstructive fixation, surgeons should plan for a 3 cm bone margin using MRI measurements to ensure complete removal of the intramedullary extent of sarcoma.Level of Evidence: IV.

Caspase Inhibition Affects the Expression of Autophagy-Related Molecules in Chondrocytes

Objective. Caspases, cysteine proteases traditionally associated with apoptosis and inflammation, have recently been identified as important regulators of autophagy and reported within the growth plate, a cartilaginous part of the developing bone. The aim of this research was to identify novel autophagy-related molecules affected by inhibition of pro-apoptotic caspases in chondrocytes. Design. Chondrocyte micromasses derived from mouse limb buds were treated with pharmacological inhibitors of caspases. Autophagy-related gene expression was examined and possible novel molecules were confirmed by real-time polymerase chain reaction and immunocytofluorescence. Individual caspases inhibitors were used to identify the effect of specific caspases. Results. Chondrogenesis accompanied by caspase activation and autophagy progression was confirmed in micromass cultures. Expression of several autophagy-associated genes was significantly altered in the caspases inhibitors treated groups with the most prominent decrease for Pik3cg and increase of Tnfsf10. The results showed the specific pro-apoptotic caspases that play a role in these effects. Importantly, use of caspase inhibitors mimicked changes triggered by an autophagy stimulator, rapamycin, linking loss of caspase activity to an increase in autophagy. Conclusion. Caspase inhibition significantly affects regulation of autophagy-related genes in chondrocytes cultures. Detected markers are of importance in diagnostics and thus the data presented here open new perspectives in the field of cartilage development and degradation.

Outcomes After Receipt of Neuraxial or Regional Anesthesia Instead of General Anesthesia for Lower Limb Revascularization Surgery: Protocol for a Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients.

OBJECTIVE

The aim is to conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization.

METHODS

We will search electronic bibliographic databases (MEDLINE, EMBASE, the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review papers identified during the search, and included article bibliographies. We will include randomized and nonrandomized studies comparing the use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate the risk of bias. The primary outcome will be short-term (in-hospital or 30-day) mortality. Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, renal, and limb events; delirium; deep vein thrombosis or pulmonary embolism; neuraxial or regional anesthesia-related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios (ORs) and standardized mean differences (SMDs) using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using the Begg and Egger tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to make an overall rating of the quality of evidence in our effect estimates.

RESULTS

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30, 2021, and plan to complete the review of full-text papers by September 30, 2021. We will complete full-text study data extraction and the risk-of-bias assessment by November 15, 2021, and conduct qualitative and then quantitative data synthesis and GRADE assessment of results by January 1, 2022, before drafting the manuscript. We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022.

CONCLUSIONS

This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial.

TRIAL REGISTRATION

Prospero CRD42021237060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=237060.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/32170.

Dynamic Expression of Membrane Type 1-Matrix Metalloproteinase (Mt1-mmp/Mmp14) in the Mouse Embryo

MT1-MMP/MMP14 belongs to a subgroup of the matrix metalloproteinases family that presents a transmembrane domain, with a cytosolic tail and the catalytic site exposed to the extracellular space. Deficient mice for this enzyme result in early postnatal death and display severe defects in skeletal, muscle and lung development. By using a transgenic line expressing the LacZ reporter under the control of the endogenous Mt1-mmp promoter, we reported a dynamic spatiotemporal expression pattern for Mt1-mmp from early embryonic to perinatal stages during cardiovascular development and brain formation. Thus, Mt1-mmp shows expression in the endocardium of the heart and the truncus arteriosus by E8.5, and is also strongly detected during vascular system development as well as in endothelial cells. In the brain, LacZ reporter expression was detected in the olfactory bulb, the rostral cerebral cortex and the caudal mesencephalic tectum. LacZ-positive cells were observed in neural progenitors of the spinal cord, neural crest cells and the intersomitic region. In the limb, Mt1-mmp expression was restricted to blood vessels, cartilage primordium and muscles. Detection of the enzyme was confirmed by Western blot and immunohistochemical analysis. We suggest novel functions for this metalloproteinase in angiogenesis, endocardial formation and vascularization during organogenesis. Moreover, Mt1-mmp expression revealed that the enzyme may contribute to heart, muscle and brain throughout development.

[The ABC's of the tactical tourniquet]

Uncontrolled bleeding is the leading cause of preventable death. After rapid diagnosis of the injury, early stoppage of the bleeding and maintenance of effective coagulation are, in the pre-hospital setting, the two mainstays of treatment of hemorrhagic shock. The latter requires a trained and experienced medical and paramedical team to prevent patient morbidity and mortality.

Maggot debridement therapy in critical limb ischaemia: a case study

OBJECTIVE

In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT.

METHOD

We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (<25%), NT 2+ (25-50%), NT 3+ (50-75%) or NT 4+ (>75%).

RESULTS

When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of <25% and/or exposed necrotic bone in the wound, a decrease in SPP was observed after three (37.5%) of eight cycles. Wound healing was accelerated in the presence of increased SPP.

CONCLUSION

Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.

Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis

Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.

The mechanism of curcumin post-treatment relieving lung injuries by regulating miR-21/TLR4/NF-κB signalling pathway

Objective

To investigate the mechanism by which curcumin prevents lung injury in a rat model of limb ischaemia-reperfusion injury.

Methods

Rats were randomized into four groups (n = 20): control group (sham group); ischaemia-reperfusion group (I/R group); curcumin group (I/R+Cur group); and inhibitor of agomir-21 group (I/R+Cur+antagomir-21 group). At 3 h after reperfusion, lung tissues were collected for histopathology and immunohistochemistry to determine the apoptosis index (AI). Lung injury score (LIS) and lung wet/dry (W/D) ratio were determined. Lung microRNA-21 (miR-21) mRNA levels were measured using reverse transcription–polymerase chain reaction. Toll-like receptor 4 (TLR4) and nuclear factor kappa-B p65 (NF-κB p65) protein levels were measured by Western blot analysis. Tumour necrosis factor (TNF)-α and interleukin (IL)-1β levels were determined by enzyme-linked immunosorbent assays.

Results

In the I/R group, the W/D, LIS, AI, miR-21 mRNA, TLR4, NF-κB p65, TNF-α and IL-1β were significantly increased and the PaO₂ was decreased compared with the sham group. Evidence of lung injury was observed in the I/R group and this was alleviated in the I/R+Cur group. An inhibitor of miR-21 (antagomir-21) reversed the protective effects of curcumin.

Conclusion

Curcumin post-treatment can alleviate the lung injuries induced by limb ischaemia-reperfusion via downregulating the levels of miR-21 mRNA.

Thrombosis of the abdominal aorta in newborn: About two cases

BACKGROUND

Aortic thrombosis in neonates is a rare phenomenon, and in most cases iatrogenic. An early recognition of the clinical features and an immediate intervention can offer a better prognosis, and thus preventing morbidity such as limb amputation, and even mortality.

METHODS

We present two cases of full-term newborns with a thrombosis of the abdominal aorta hospitalized in the neonatal intensive care unit of Mohammed VI University Hospital in Marrakech in 2017 and 2019.

RESULTS

The two patients presented swelling and cyanotic lower limbs. Doppler ultrasound revealed a pathological lower limb blood flow as a result of a thrombosis of the abdominal aorta. Both patients underwent an anticoagulant therapy, the first one benefited from a surgical thrombectomy, he developed a reperfusion syndrome with alveolar hemorrhage, and passed away as a result of a cardiorespiratory arrest. However the second patient got amputated of the right foot, his clinical evolution was favorable with a good healing of the surgical wound without recurrence of any thrombosis.

CONCLUSION

Through those cases clinicians should be aware of the first clinical signs of this condition in order to offer a rapid and successful management.

Rehabilitation of limb apraxia in patients following stroke: a systematic review

Apraxia is widely used to describe one of the more disabling deficits following left strokes. The role of rehabilitation in treating apraxic stroke patients remains unclear. This systematic review was conducted to study the impacts of various rehabilitation interventions on the limb apraxia post-stroke. PubMed, SCOPUS, PEDro, CINAHL, MEDLINE, REHABDATA, and Web of Science were searched for the experimental studies that investigated the effects of the rehabilitation interventions on apraxia in patients with stroke. The methodological quality was rated using the Physiotherapy Evidence Database scale (PEDro). Six studies met our inclusion criteria in this systematic review. Four were randomized controlled trials, pilot (n = 1), and case study (n = 1). The scores on the PEDro scale ranged from two to eight, with a median of seven. The results showed some evidence for the effects of strategy training and gesture training interventions on the cognitive functions, motor activities, and activities of daily livings outcomes poststroke. The preliminary findings showed that the effects of the strategy training and the gesture training on apraxia in patients with stroke are promising. Further randomized controlled trials with long-term follow-ups are strongly needed.