Ocular motor nerve palsy in patients with diabetes: High-resolution MR imaging of nerve enhancement

OBJECTIVE

To evaluate the extent of signal abnormality in impaired ocular motor nerves using high signal and spatial resolution MRI sequences and to discuss the involvement of inflammatory or microvascular impairment in patients with diabetic ophthalmoplegia.

METHODS

We conducted a retrospective study of 10 patients referred for acute ocular motor nerve palsy in the context of diabetes mellitus from September 15th, 2021 to April 24th, 2022. 3T MRI evaluation included diffusion, 3D TOF, FLAIR, coronal STIR and post-injection 3D T1 SPACE DANTE sequences.

RESULTS

Ten patients were included: 9 males and 1 female aged from 46 to 79 years. Five patients presented with cranial nerve (CN) III palsy, and 5 presented with CN VI palsy. Third nerve palsy was pupil-sparing in 4 patients and pupil-involved in 1 patient. Pain was associated in all patients with CN III deficiencies and in 2 patients CN VI deficiencies. In all patients, MRI sequences ruled out mass effect and vascular pathology, such as acute stroke or aneurysm. Eight patients presented with STIR hypersignals, some with enlargement of the involved nerve. The diagnosis was confirmed through a post-injection 3D T1 SPACE DANTE sequence, which showed extended enhancement along the abnormal portion of the nerve.

CONCLUSION

High-resolution MRI evaluation of diplopia in diabetic patients is used to rule out a diagnosis of acute stroke and contributes to the positive diagnosis of ocular motor nerve impairment, possibly combining the influences of inflammatory and microvascular phenomena. Dedicated MR imaging should be included in the initial diagnosis and longitudinal follow-up of patients with diabetic ophthalmoplegia.

Is there a difference in pelvic floor muscle tone between women with and without pelvic pain? A systematic review and meta-analysis

BACKGROUND

Alterations in pelvic floor muscle (PFM) function have been observed in women with persistent noncancer pelvic pain (PNCPP) as compared with women without PNCPP; however, the literature presents conflicting findings regarding differences in PFM tone between women with and without PNCPP.

AIM

To systematically review the literature comparing PFM tone in women with and without PNCPP.

METHODS

MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Scopus were searched from inception to June 2021 for relevant studies. Studies were included that reported PFM tone data in women aged ≥18 years with and without PNCPP. The risk of bias was assessed with the National Heart, Lung, and Blood Institute Quality Assessment Tool. Standardized mean differences (SMDs) for PFM tone measures were calculated via random effects models.

OUTCOMES

Resting PFM tone parameters, including myoelectrical activity, resistance, morphometry, stiffness, flexibility, relaxation, and intravaginal pressure, measured by any clinical examination method or tool.

RESULTS

Twenty-one studies met the inclusion criteria. Seven PFM tone parameters were measured. Meta-analyses were conducted for myoelectrical activity, resistance, and anterior-posterior diameter of the levator hiatus. Myoelectrical activity and resistance were higher in women with PNCPP than in women without (SMD = 1.32 [95% CI, 0.36-2.29] and SMD = 2.05 [95% CI, 1.03-3.06], respectively). Women with PNCPP also had a smaller anterior-posterior diameter of the levator hiatus as compared with women without (SMD = -0.34 [95% CI, -0.51 to -0.16]). Meta-analyses were not performed for the remaining PFM tone parameters due to an insufficient number of studies; however, results of these studies suggested greater PFM stiffness and reduced PFM flexibility in women with PNCPP than in women without.

CLINICAL IMPLICATIONS

Available evidence suggests that women with PNCPP have increased PFM tone, which could be targeted by treatments.

STRENGTHS AND LIMITATIONS

A comprehensive search strategy was used with no restriction on language or date to review studies evaluating PFM tone parameters between women with and without PNCPP. However, meta-analyses were not undertaken for all parameters because few included studies measured the same PFM tone properties. There was variability in the methods used to assess PFM tone, all of which have some limitations.

CONCLUSION

Women with PNCPP have higher PFM tone than women without PNCPP; therefore, future research is required to understand the strength of the relationship between pelvic pain and PFM tone and to investigate the effect of treatment modalities to reduce PFM tone on pelvic pain in this population.

Drug-eluting balloons and drug-eluting stents in the treatment of small vessel coronary artery disease: a systematic review and metanalysis of long-term clinical and angiographic outcomes

Introduction

Coronary artery disease is a leading cause of mortality and morbidity worldwide. For those undergoing PCI, there are 20–30% with disease of the small coronary arteries on presentation [1]. Small coronary artery disease asserts a significant risk factor for adverse events. It is often diffuse and multi-vessel on presentation and confers higher rates of major adverse cardiac events, (MACE) and target lesion failure after intervention [2,3]. Best practice guidelines on the management of SvCAD interventions remain limited.

Drug-eluting balloons are a novel therapy, which has shown promise in treating in-stent restenosis (ISR), however their use in small coronary arteries when compared to drug-eluting stents remains unclear.

Purpose

This systematic review and meta-analysis compare long-term outcomes (>1 year), of drug-eluting balloons (DEB), vs. drug-eluting stents (DES), in the treatment of small coronary artery disease (<3mm).

Methods

A systematic review was completed within PRISMA guidelines. The primary outcome was non-inferiority of DEB Vs. DES in major adverse cardiac events (MACE). Secondary outcomes include all-cause mortality, MI, vessel thrombosis, major bleeding and target vessel revascularization at one, two and three years follow-up. Two independent reviewers extracted data. All outcomes used the Mantel-Haenszel and Random effect model. Odds ratios (OR), were presented with a 95% confidence interval (CI).

Result

Of 4661 articles, four RCTs were included (1414 patients). DEB demonstrated reduced rates of non-fatal MI at one year, OR 0.44 (95% CI 0.2, 0.94) and Basket-2 small reported a significant reduction in two-year bleeding rates OR 0.3 (95% CI 0.1, 0.91). DEBs were non-inferior to DES for all other outcomes.

Conclusion

Long duration follow-up of DEB and DES use in small coronary arteries demonstrates DEB to be non-inferior to DES in all outcomes across all years of follow-up. There was a significant reduction in rates of non-fatal MI at one year in the DEB arm and a reduction in major bleeding episodes at two years in the Basket Small 2 trial. These data highlight the potential utility and long-term safety of novel DEBs in small coronary artery disease revascularization.

Funding Acknowledgement

Type of funding sources: None.

Adaptation of a clinical reasoning model for use in inflammatory conditions of the lactating breast: a retrospective mixed-methods study

Background

Many potential factors associated with Inflammatory Conditions of the Lactating Breast (ICLB) have been reported in the literature, by lactating mothers and clinicians. Clinicians, including general practitioners, lactation consultants and physiotherapists, require a clinical reasoning model that summarises associated or linked factors, to aid in the assessment, treatment, and prevention of ICLB. Thus, we aimed to adapt the existing Breastfeeding Pain Reasoning Model (BPRM), for use in the management of ICLB, using prior research and clinical audit data to guide adaptation. The existing BPRM categorises contributing factors for breastfeeding nipple pain, rather than ICLB.

Methods

Factors linked with ICLB were identified from prior research and considered for inclusion into the existing model. Clinical data from a retrospective audit of ICLB patient notes at a private physiotherapy practice were also examined. Any factors identified from prior research that could not be identified in the clinical notes were not considered for inclusion into the existing model. Additional factors from the clinical notes that appeared repeatedly were considered for inclusion into the adaptation of the BPRM. A draft adapted model was created comprising all eligible factors, considering their counts and percentages as calculated from the clinical data. The research team iteratively examined all factors for appropriate categorisation and modification within the adapted model.

Results

Prior research and data from 160 clinical notes were used to identify factors for inclusion in the adapted model. A total of 57 factors, 13 pre-existing in the BPRM and 44 extra identified from the prior research or clinical audit, comprised the draft adapted model. Factor consolidation and terminology modification resulted in a total of 34 factors in the final proposed adapted ICLB model. The three main categories, CNS modulation, External influences and Local stimulation, from the existing model were maintained, with one minor terminology change to the former Local stimulation category, resulting in 'Local influences' category. Terminology for five subcategories were modified to better reflect the types of factors for ICLB. The most common factors in the adapted model, calculated from the clinical audit population of mothers with ICLB, were employment (85%), high socioeconomic status (81%), antibiotic use during breastfeeding (61%), history of an ICLB (56%), any breast pump use (45%), multiparity (43%), birth interventions (35%), decreased milk transfer (33%), breastfeeding behaviour and practices (33%), nipple pain (30%) and fit and hold (attachment and positioning) difficulty (28%).

Conclusion

An ICLB-specific linked factors model is proposed in this paper. Clinicians treating mothers with ICLB can use this model to identify influencing and determining factors of ICLB clinical presentations and provide targeted education and effective treatment plans.

Construct validity and internal consistency of the Breast Inflammatory Symptom Severity Index in lactating mothers with inflammatory breast conditions

Background

Inflammatory Conditions of the Lactating Breast (ICLB) affect more than one in five lactating mothers, yet no fully validated outcome measures exist to aid clinicians in their patient-centred care of women with ICLB. The Breast Inflammatory Symptom Severity Index (BISSI) is an ICLB-specific clinician administered patient-reported outcome measure, currently used by Australian clinicians, who treat mothers with ICLB. To date the BISSI has undergone partial psychometric development. This study, therefore, aimed to undertake the next stage of psychometric development by determining the construct validity and internal consistency of the BISSI.

Methods

A retrospective audit was conducted on patient records of 160 mothers who were treated for ICLB, at a private physiotherapy practice in Melbourne, Australia. An electronic data capture tool was used to collate BISSI scores and associated ICLB assessment variables. Construct validity was determined through factor analysis and discriminant performance. Reliability was determined by assessing measures of internal consistency.

Results

Factor analysis established that BISSI items (n = 10) loaded on to four factors, Wellness, Pain, Physical Characteristics of Affected Area (PCAA), and Inflammation, which together, explained 71.2% of variance. The remaining item (‘Wellness/sickness unspecified’) did not load. Wellness, Pain, PCAA and Inflammation factors individually and collectively displayed the ability to discriminate symptom severity, as scores were significantly higher in mothers with high symptom severity (assessed via AUC close to or >0.7 and P value <0.005 for each factor). The BISSI demonstrated internal consistency with an overall Cronbach alpha of 0.742.

Conclusions

The BISSI has adequate construct validity, demonstrating behaviour consistent with theoretical constructs of inflammation severity, via its dimensionality and ability to discriminate symptom severity. The BISSI also has adequate internal consistency demonstrating reliability. Therefore, clinicians can have confidence that the BISSI is valid, the individual item scores are correlated, and the concepts are consistently measured.

Exploring physiotherapists' clinical definition and diagnosis of inflammatory conditions of the lactating breast in Australia: a mixed methods study

Background

Differences in physiotherapy intervention practices for mastitis have been shown across Australian regions and facilities and it is unknown if this is associated with physiotherapists’ definition and diagnosis of Inflammatory Conditions of the Lactating Breast (ICLB). The aims were to determine how Australian physiotherapists’ define and diagnose ICLB and if there are regional or facility differences in their ICLB definition and diagnosis.

Method

A cross-sectional mixed methods design was used to investigate how physiotherapists construct a definition and diagnosis of ICLB, via online qualitative and quantitative questions. Participants included 63 Australian physiotherapists who treated at least one woman with ICLB per month, over the last year. Thematic analysis and descriptive statistics were used to analyse qualitative and quantitative responses, respectively.

Results

ICLB definition varied among physiotherapists (n = 63) with generated themes including definitions based on pathophysiology (57%), combination of local and systemic symptoms (38%), conditions (32%), local symptoms (25%) and breast function (16%). Overall, quantitative data supported these findings, as some physiotherapists considered blocked ducts an ICLB (83%), but some did not (17%), and some considered abscess and engorgement an ICLB (65%) and some did not (35%). For ICLB diagnosis, the main theme generated was lack of consensus between physiotherapists (n = 39) on the number or combination of local or systemic symptoms required. Quantitative data confirmed these themes, as 63% of physiotherapists (n = 63) indicated that more than one symptom was necessary to clinically diagnose ICLB, but 27% required only one symptom. For region and type of facility, consistency across the themes for region and facility was evident. Overall, quantitative data confirmed these findings, with no regional or facility differences, except physiotherapists from the Australian state of Victoria (96%) were more likely to consider blocked ducts as an ICLB, compared to those from the states of NSW (71%) or WA (71%) (n = 58; χ² = 6.49, p = 0.04).

Conclusion

Australian physiotherapists have varied definitions of ICLB and the required ICLB symptoms for clinical diagnosis. These results may prompt physiotherapists, who treat ICLB, to engage in explicit communication when discussing an ICLB in patient care, when delivering information in training courses and in developing treatment guidelines.

Home-based reach-to-grasp training for people after stroke: study protocol for a feasibility randomized controlled trial

BACKGROUND

This feasibility study is intended to assess the acceptability of home-based task-specific reach-to-grasp (RTG) training for people with stroke, and to gather data to inform recruitment, retention, and sample size for a definitive randomized controlled trial.

METHODS/DESIGN

This is to be a randomized controlled feasibility trial recruiting 50 individuals with upper-limb motor impairment after stroke. Participants will be recruited after discharge from hospital and up to 12 months post-stroke from hospital stroke services and community therapy-provider services. Participants will be assessed at baseline, and then electronically randomized and allocated to group by minimization, based on the time post-stroke and extent of upper-limb impairment. The intervention group will receive 14 training sessions, each 1 hour long, with a physiotherapist over 6 weeks and will be encouraged to practice independently for 1 hour/day to give a total of 56 hours of training time per participant. Participants allocated to the control group will receive arm therapy in accordance with usual care. Participants will be measured at 7 weeks post-randomization, and followed-up at 3 and 6 months post-randomization. Primary outcome measures for assessment of arm function are the Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT). Secondary measures are the Motor Activity Log, Stroke Impact Scale, Carer Strain Index, and health and social care resource use. All assessments will be conducted by a trained assessor blinded to treatment allocation. Recruitment, adherence, withdrawals, adverse events (AEs), and completeness of data will be recorded and reported.

DISCUSSION

This study will determine the acceptability of the intervention, the characteristics of the population recruited, recruitment and retention rates, descriptive statistics of outcomes, and incidence of AEs. It will provide the information needed for planning a definitive trial to test home-based RTG training.

TRIAL REGISTRATION ISRCTN

ISRCTN56716589.

Molecular pathways involved in neuronal cell adhesion and membrane scaffolding contribute to schizophrenia and bipolar disorder susceptibility

Susceptibility to schizophrenia and bipolar disorder may involve a substantial, shared contribution from thousands of common genetic variants, each of small effect. Identifying whether risk variants map to specific molecular pathways is potentially biologically informative. We report a molecular pathway analysis using the single-nucleotide polymorphism (SNP) ratio test, which compares the ratio of nominally significant (P<0.05) to nonsignificant SNPs in a given pathway to identify the 'enrichment' for association signals. We applied this approach to the discovery (the International Schizophrenia Consortium (n=6909)) and validation (Genetic Association Information Network (n=2729)) of schizophrenia genome-wide association study (GWAS) data sets. We investigated each of the 212 experimentally validated pathways described in the Kyoto Encyclopaedia of Genes and Genomes in the discovery sample. Nominally significant pathways were tested in the validation sample, and five pathways were found to be significant (P=0.03-0.001); only the cell adhesion molecule (CAM) pathway withstood conservative correction for multiple testing. Interestingly, this pathway was also significantly associated with bipolar disorder (Wellcome Trust Case Control Consortium (n=4847)) (P=0.01). At a gene level, CAM genes associated in all three samples (NRXN1 and CNTNAP2), which were previously implicated in specific language disorder, autism and schizophrenia. The CAM pathway functions in neuronal cell adhesion, which is critical for synaptic formation and normal cell signaling. Similar pathways have also emerged from a pathway analysis of autism, suggesting that mechanisms involved in neuronal cell adhesion may contribute broadly to neurodevelopmental psychiatric phenotypes.

[Thyroid orbital pathologies in ophthalmological settings]

OBJECTIVE

To illustrate the originality and diversity of an ophthalmologic pathology associated with a thyroid disease (OATD), we report 42 cases of patients hospitalised or having consulted an ophthalmologic department for this disease over a period of 4 years.

METHOD

Each patient was assessed by an endocrinologist and an ophthalmologist. Data included the OATD severity score, date of occurrence compared with the thyroid disease and determination of thyroid function and immune abnormalities.

RESULTS

Patients were aged a mean of 48.9 + 15.3 years; 65% were women and 39% smokers. OATD preceded the thyroid disease in 38% of cases, was concomitant in 40% and successive in 21%. Thirty-six percent of cases were mild, 45% moderate and 19% were severe. One patient out of 5 had exhibited a period of iatrogenic hypothyroidia. The majority (81%) presented with Basedow's disease; 14% Hashimoto's disease; 73% anti-TSH receptor antibodies and 56% anti-thyroperoxidase antibodies. Two profiles of patients with OAMT were identified. A first group with severe OATD: Basedow's disease, presence of anti-TSH receptor antibodies and a period of iatrogenic hypothyroidia in half of the cases. A second group in which the occurrence of OATD preceded diagnosis of a thyroid disease: generally non-severe forms with varying thyroid status, strongly related to the moment at which the patient consulted, compared with the progression of the ophthalmologic and thyroid affections.

CONCLUSION

When faced with signs evoking OATD, these data emphasize the need for an evaluation of thyroid status and determination of the antibodies implied in Basedow and Hashimoto's disease. After initiation of synthetic anti-thyroid or radioactive iodine therapy, the evolution of the thyroid and ophthalmologic status of hyperthyroid patients must be carefully monitored.

Intracerebral calcification in systemic sclerosis

BACKGROUND AND PURPOSE

Advanced cerebrovascular wall calcification was recently observed at autopsy in 2 patients with systemic sclerosis. To further investigate this issue, we conducted a prospective CT study of scleroderma patients to detect intracerebral calcification.

METHODS

Thirty-seven consecutive patients with systemic sclerosis underwent unenhanced brain CT. Images were blindly interpreted, together with those of 2 age-matched (+/-1 year) and sex-matched control subjects per patient.

RESULTS

Intracerebral calcification was found in 12 patients (32.4%) and 7 controls (9.5%) (P=0.006). Among the patients, intracerebral calcification was associated with the duration of Raynaud's phenomenon (P=0.005) and not with age (P=0.086).

CONCLUSIONS

Intracerebral calcification is closely associated with scleroderma, which suggests that scleroderma causes primary cerebrovascular changes.

Reactive hyperemia unmasks reduced compliance of cutaneous arteries in essential hypertension

To evaluate changes in distal cutaneous arteries during hypertension, we used a noninvasive method to assess the compliance and vascular resistance of the hand radial arteries, mainly distributed to the skin, in 10 normotensive and 10 hypertensive (HT) men. Radial artery diameter and blood velocity were measured by means of pulsed Doppler concomitantly with measurements of finger arterial pressure by photoplethysmography. Hand radial vascular resistance was calculated as the ratio of mean arterial pressure to mean radial blood flow. A simple resistive-capacitive model of large and small arteries of the hand allowed us to evaluate arterial compliance from the exponential slope of finger diastolic pressure decay and vascular resistance. Measurements were made at baseline and during reactive hyperemia after 5 min of complete occlusion of the brachial artery with a pneumatic cuff. Except for pressure, there were no baseline differences between the groups. In normotensive and HT subjects, hyperemia increased radial artery diameter and blood velocity (P < 0.001) and compliance (P < 0.01 and P < 0.05, respectively) and decreased mean pressure (P < 0.01 and P < 0.001, respectively) and resistance (P < 0.001). During hyperemia, the only difference between the groups, except for pressure, was lower compliance in HT subjects (P < 0.01). Moreover, compliance during hyperemia negatively correlated with baseline mean pressure (P = 0.001). Thus hyperemia unmasked reduced compliance in the HT patients but did not show abnormal resistance, suggesting that the elastic properties of the hand skin radial arteries might be more sensitive than their resistive properties to high blood pressure.

Thrombotic primary pulmonary hypertension in an HIV+ patient

We report a case of severe primary pulmonary hypertension occurring in an HIV+ patient in whom lung biopsy and post-mortem examination were consistent with thrombotic pulmonary arteriopathy. To the best of our knowledge, this histological pattern has not been previously reported in HIV+ patients with primary pulmonary hypertension.

Visual acuity and test performance

Evaluation of scholastic achievement (American College Testing Service) test scores confirms previous reports that persons with poor visual acuity perform better on these tests than individuals with normal or superior acuity.