[Diagnostic workup for polyneuropathy]

Polyneuropathy is a disease of the peripheral nervous system that usually results in distally emphasized, often symmetrical sensory and motor stimulation and deficits. These are often extremely painful. They can be divided into hereditary and acquired causes; inflammatory and infectious causes should be further differentiated among the acquired causes. A careful diagnostic workup is essential. Clinical signs and distribution patterns of symptoms can often already provide clues to the underlying aetiology. This review describes this workup, which in addition to the medical history and clinical examination always includes thorough laboratory diagnostics, electrophysiological examination and cerebrospinal fluid diagnostics. In individual cases, further diagnostic steps may be necessary in order to make the correct diagnosis.

[Relationship of BMI and wrist joint index with carpal tunnel syndrome in manual laborers]

Objective: To evaluate the severity of median nerve damage in patients with carpal tunnel syndrome (CTS) , and to analyze its relationship with body mass index (BMI) and wrist joint index. Methods: From May 2016 to January 2017, 23 patients with mild CTS (mild group) and 35 patients with moderate to severe CTS (moderate to severe group) were enrolled in this study. And 22 healthy volunteers matched for sex and age were selected as control group. The neuroelectrophysiological monitor was used to measure the median nerve movement and sensory nerve conduction in the subjects. The BMI and wrist joint index were calculated. The relationship of neuroelectrophysiological parameters with BMI and wrist joint index was analyzed in the CTS patients. Results: Compared with the control group, the mild group and the moderate to severe group had significantly higher wrist joint index, significantly longer distal motor latency (DML) of the median nerve, and significantly lower sensory nerve conduction velocity (SNCV) and sensory nerve action potential (SNAP) amplitude of the finger 1-wrist and finger 3-wrist (P<0.01) ; the moderate to severe group had significantly higher BMI and significantly lower composite muscle action potential (CMAP) amplitude (P<0.01) . The wrist joint index and BMI were positively correlated with DML of the median nerve and negatively correlated with SCV and SNAP amplitude of the finger 1-wrist and finger 3-wrist (all P<0.05) . The patients with a wrist joint index of >0.73 had a significantly higher risk of CTS than those with a wrist joint index of <0.73 (odd ratio=30.67, 95% confidence interval: 3.79-248.36) . Conclusion: A wrist joint index of >0.73 is an independent risk factor for CTS in manual laborers. CTS should be prevented in the manual laborers with high wrist joint index and BMI.

A Simple Method to Differentiate Atrioventricular Node Reentrant Tachycardia from Orthodromic Reciprocating Tachycardia

Discrimination between atrioventricular node reentry tachycardia (AVNRT) and orthodromic reciprocating tachycardia (ORT) during an electrophysiological study is sometimes challenging. This study aimed to investigate if the difference in the local VA (ventricle-atrium) interval during ventricular entrainment pacing and during tachycardia (DVA, defined as the shortest local VA interval of coronary sinus [CS] during entrainment minus the shortest local VA interval of CS during tachycardia) was different in patients with AVNRT and patients with ORT.Diagnoses of AVNRT or ORT through a concealed accessory pathway (AP) were made according to conventional electrophysiological criteria and ablation results. Entrainment by right ventricular (RV) pacing was performed in each patient before ablation and patients with successful entrainment were included in the study. The DVA was compared between patients with AVNRT and patients with ORT. The DVA in patients with AVNRT was significantly longer than that in patients with ORT (120 ± 20 versus 5.7 ± 9; P < 0.001). In each patient with AVNRT of slow-fast type, fast-slow type, and slow-slow type, the DVA was more than 48 ms. In each patient with ORT using a left free wall accessory pathway (AP), right free wall AP, and septal AP, the DVA was less than 20 ms.DVA was found to be a rapid, useful test in distinguishing patients with AVNRT from those with ORT.

Utility of nerve conduction studies for diagnosis of injury to the medial branch of the superficial radial nerve

Introduction

The clinical utility of nerve conduction study (NCS) for the distal medial branch of the superficial radial nerve (SRN) has not yet been clarified. Therefore, we investigated the clinical utility of NCS in patients with suspected SRN injury and compared the results with those in healthy control subjects.

Methods

Bilateral NCS of the medial branch of the SRN was performed in two patients with suspected injury of the medial branch of the SRN, and in 20 healthy control subjects. A surface recording electrode was placed at the medial side of the metacarpophalangeal joint of the thumb. The SRN was then stimulated at a location 12 cm proximal from the recording electrode.

Results

The mean sensory nerve action potential in the two patients was significantly lower than that of the controls (6.75 ± 0.92 vs. 23.8 ± 8.2 μV, P < 0.05). The side-to-side differences in sensory nerve action potential in the two patients were significantly higher than in the controls (55 ± 7.1 vs. 11 ± 7.8%, P < 0.05).

Conclusions

NCS may be useful for diagnosing injury of the medial branch of the SRN.

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Nerve conduction was studied in the medial branch of the superficial radial nerve.

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The subjects were two patients with suspected medial branch injury and 20 controls.

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A recording electrode was placed at the medial side of the thumb.

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Mean sensory nerve action potential was lower in patients than controls.

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Nerve conduction study may be useful for diagnosing injury of the medial branch.

Two in one is better than one plus one: comparison of adverse events between combining electrophysiological examination and coronary angiography versus performing them consecutively

PURPOSE

In some patients, both an electrophysiological examination (EPS) and a coronary angiography (CA) are necessary. It might be preferable to choose a combined approach of EPS and CA versus performing them consecutively. The purpose of this study is to evaluate the type and rate of adverse events between both approaches.

METHODS

Patients were eligible if they underwent a CA and an EPS in a combined approach or in a time interval of at most 2 months. In all patients, clinical adverse events were recorded.

RESULTS

A total of 1184 patients were included. CA and EPS were performed in a combined procedure (comb) in 492 patients, whereas they were performed consecutively in 692 patients (cons). The acute major complication rate was 0.67%, showing no differences between both groups. In the comb 6.9% and in the cons 6.6% of vascular complications were observed (p = 0.20). The rates of AV fistula and hematoma needing transfusion showed a significantly higher rate in the cons group (p = 0.018 and p = 0.045, respectively). In a multivariate logistic regression analysis, age was a significant predictor for groin complications. After propensity matching, AV fistula occurred significantly more often in the cons group (p = 0.002).

CONCLUSION

Overall, serious adverse events were rare and there were no differences between the combined approach of EPS and CA and the consecutive approach; however, the occurrence of AV fistula and groin hematoma needing transfusion occurred significantly less in the combined procedure group. Therefore, a combined approach is preferable to a consecutive one.

The Effect of Radial Extracorporeal Shock Wave Stimulation on Upper Limb Spasticity in Chronic Stroke Patients: A Single-Blind, Randomized, Placebo-Controlled Study

The main purpose of this study was to determine the clinical, electrophysiological and thermal effects of radial extracorporeal shock wave (rESW) stimulation on upper limb muscles affected by spasticity in patients with chronic stroke. Patients included in the study were randomly assigned into the following two groups: 30 patients stimulated with active rESW (A); and 30 patients stimulated with placebo rESW (B). All patients were analyzed using the Modified Ashworth Scale (MAS) to test the spasticity levels of the elbow (E), radio carpal (RC) and fingers (FF) joints; surface electromyography (sEMG) was performed for the resting bioelectrical activity registration of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) muscles; and infrared thermal imaging (IRT) was used to assess the temperature distributions of the carpal flexor muscles (CFM). All assessments were performed at baseline (t0), immediately after rESW (t1) as well as 1 and 24 h following its finalization (t2 and t3). Patients treated with active rESW showed a statistically significant reduction in the MAS score for the RC joint at t1 and for the FF joints at t1, t2 and t3 (p < 0.05). A significant decrease in sEMG activity was observed in the FCR and FCU muscles at t1, t2 and t3 (p < 0.05); significant increases in the mean and maximum values of the IRT detection was observed using inter-group comparisons in t2 and t3 (p < 0.05). No significant alterations were observed in patients after placebo rESW stimulation (p > 0.05). Applications of rESW demonstrating positive effects at reducing the level of spastic hypertonia of the upper limb muscles in patients with chronic stroke. ESW treatments should be considered as a potential anti-spastic effect to regulate vasculature.

[Fascicular ventricular tachycardia in a 49-year-old patient]

We report a 49-year-old patient who presented with tachycardia in our emergency room. The 12-lead ECG showed a wide complex tachycardia with a heart rate of 234 beats per minute. After structural heart disease was excluded via echocardiography, coronary angiography and magnetic resonance imaging, an electrophysiological study was performed. During programmed ventricular stimulation, a fascicular tachycardia was induced, which was successfully treated by radiofrequency ablation. Fascicular ventricular tachycardia is a rare tachycardia that occurs in patients without structural heart disease. Radiofrequency ablation can be performed safely and shows a high success rate. Differential diagnoses of fascicular ventricular tachycardias are substrate-based ventricular tachycardia and supraventricular tachycardia.