Does botulinum toxin treatment affect the ultrasonographic characteristics of post-stroke spastic equinus? A retrospective pilot study

Equinovarus/equinus foot is a pattern most commonly treated with botulinum toxin type A in patients with post-stroke spasticity involving the lower limbs; the gastrocnemius is the muscle most frequently injected. Spastic equinovarus/equinus can present a mixture of conditions, including spasticity, muscle/tendon shortening, muscle weakness and imbalance. In this study, we wanted to determine whether botulinum toxin treatment affects the ultrasonographic characteristics of post-stroke spastic equinus. The same dose of AbobotulinumtoxinA was injected into the gastrocnemius medialis and lateralis of 21 chronic stroke patients with spastic equinus. Clinical (Ashworth scale and ankle range of motion) and ultrasound (conventional and sonoelastography) evaluation of the treated leg was carried out before and 4 weeks after injection. No significant effects of botulinum toxin treatment on the ultrasonographic characteristics of spastic equinus were observed. As expected, there were significant improvements in ankle passive dorsiflexion range of motion and calf muscle spasticity at 1 month after treatment. There was a direct association between Achilles tendon elasticity and calf muscle spasticity at baseline evaluation. Larger studies with a long-term timeline of serial evaluations are needed to further investigate the possible effects of botulinum toxin injection on spastic muscle characteristics in patients with post-stroke spasticity

Effects of deep heating modalities on the morphological and elastic properties of the non-insertional region of achilles tendon: a pilot study

Background: Over the last 20 years, both diathermy and ultrasound have been popular choices for many clinicians in treating musculoskeletal disorders. However, there is a lack of clinical evidence of deep heating modalities to treat tendon pathology, There is no study to investigate the effects of such as physical modalities on morphological and elastic properties on the human tendons. Objective: the objective of the present study was to compare the effects of diathermy and ultrasound therapies on cross sectional area, transversal height and hardness percentage of the non-insertional region of the Achilles tendon in able-bodied subjects. Methods: healthy volunteers were divided in diathermy and ultrasound group received six 15-min treatment sessions. Before and after treatment a sonographic assessment was conducted by mean of ultrasonography and the following parameters were recorded: cross sectional area, transversal height and hardness percentage. Results: thirty-two subjects were enrolled. Between-group comparisons showed a significant change on hardness percentage (p = 0.004) after treatment in diathermy therapy group. Within-group comparison showed a significant improvement in the hardness percentage for the diathermy (p = 0.001) and ultrasound (p = 0.046) after two weeks of treatment. Conclusion: this pilot study demonstrated larger effects on morphological and elastic properties of the non-insertional region of the Achilles tendon after diathermy than ultrasound therapy in normal tendons. Diathermy may be a useful deep heat modality for treating non-insertional Achilles tendinopathy

Importance of Different Types of Prior Knowledge in Selecting Genome‐Wide Findings for Follow‐Up

Biological plausibility and other prior information could help select genome‐wide association ( GWA ) findings for further follow‐up, but there is no consensus on which types of knowledge should be considered or how to weight them. We used experts’ opinions and empirical evidence to estimate the relative importance of 15 types of information at the single‐nucleotide polymorphism ( SNP ) and gene levels. Opinions were elicited from 10 experts using a two‐round Delphi survey. Empirical evidence was obtained by comparing the frequency of each type of characteristic in SNP s established as being associated with seven disease traits through GWA meta‐analysis and independent replication, with the corresponding frequency in a randomly selected set of SNP s. SNP and gene characteristics were retrieved using a specially developed bioinformatics tool. Both the expert and the empirical evidence rated previous association in a meta‐analysis or more than one study as conferring the highest relative probability of true association, whereas previous association in a single study ranked much lower. High relative probabilities were also observed for location in a functional protein domain, although location in a region evolutionarily conserved in vertebrates was ranked high by the data but not by the experts. Our empirical evidence did not support the importance attributed by the experts to whether the gene encodes a protein in a pathway or shows interactions relevant to the trait. Our findings provide insight into the selection and weighting of different types of knowledge in SNP or gene prioritization, and point to areas requiring further research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96262/1/gepi21705.pd

SNP Prioritization Using a B ayesian Probability of Association

Prioritization is the process whereby a set of possible candidate genes or SNP s is ranked so that the most promising can be taken forward into further studies. In a genome‐wide association study, prioritization is usually based on the P ‐values alone, but researchers sometimes take account of external annotation information about the SNP s such as whether the SNP lies close to a good candidate gene. Using external information in this way is inherently subjective and is often not formalized, making the analysis difficult to reproduce. Building on previous work that has identified 14 important types of external information, we present an approximate B ayesian analysis that produces an estimate of the probability of association. The calculation combines four sources of information: the genome‐wide data, SNP information derived from bioinformatics databases, empirical SNP weights, and the researchers’ subjective prior opinions. The calculation is fast enough that it can be applied to millions of SNPS and although it does rely on subjective judgments, those judgments are made explicit so that the final SNP selection can be reproduced. We show that the resulting probability of association is intuitively more appealing than the P ‐value because it is easier to interpret and it makes allowance for the power of the study. We illustrate the use of the probability of association for SNP prioritization by applying it to a meta‐analysis of kidney function genome‐wide association studies and demonstrate that SNP selection performs better using the probability of association compared with P ‐values alone.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96317/1/gepi21704.pd

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

Background Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons’ knowledge and perception of using AI-based tools in clinical decision-making processes. Methods An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society’s website and Twitter profile. Results 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. Discussion The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI

Population Health Strategies to Support Hospital and Intensive Care Unit Resiliency During the COVID-19 Pandemic: The Italian Experience

Italy was one of the countries most affected by the number of people infected and dead during the first COVID-19 wave. The authors describe the rapid rollout of a population health clinical and organizational response in preparedness and capabilities to support the first wave of the COVID-19 pandemic in the Italian province of Modena. The authors review the processes, the challenges faced, and describe how excess demand for hospital services was successfully mitigated and thus overwhelming the healthcare services avoided the collapse of the local health care system. An analysis of bed occupancy in the region predicted during the first weeks of the epidemic. The SEIR model estimated the number of infected people under different containment measures. Community resources were mobilized to reduce provincial hospitals' burden of care. A population health approach, based on a radical reorganization of the workflow and emergency patient management, was implemented. The bed saturation of the Modena Healthcare Agency was measured by an ad hoc, newly implemented intensive care unit (ICU) bed occupancy and COVID-19 centralized governance dashboard. ICU bed occupancy increased by 114%, avoiding saturation of the Modena Healthcare Agency system. The Emilia-Romagna region achieved a higher rate of ICU bed availability at 2.15 ICU beds per 10,000 inhabitants as compared with community 1 ICU bed availability prior to the pandemic. Rapid and radical local reorganization of regional efforts helped inform the successful development and implementation of strategic choices within the hospital and the community to prevent the saturation of key facilities

Combined effects of backward treadmill training and botulinum toxin type A therapy on gait and balance in patients with chronic stroke: A pilot, single-blind, randomized controlled trial

Background: Backward walking is recommended to improve the components of physiological gait in neurological disease. Botulinum toxin type A is an effective safe first line-treatment for post-stroke spasticity. Objective: To compare the effects of backward treadmill training (BTT) versus standard forward treadmill training (FTT) on motor impairment in patients with chronic stroke receiving botulinum toxin type A therapy. Methods: Eighteen chronic stroke patients were randomly assigned to receive BTT (n = 7) or FTT (n = 11) as adjunct to botulinum toxin type A therapy. A total of twelve 40-minute sessions (3 sessions/week for 4 weeks) of either BTT or FTT were conducted. A blinded assessor evaluated the patients before and after treatment. The primary outcome was the 10-meter Walking Test (10 MWT). Secondary outcomes were the modified Ashworth Scale, gait analysis, and stabilometric assessment. Results: Between-group comparison showed a significant change on the 10 MWT (P = 0.008) and on stabilometric assessment [length of centre of pressure CoP (P = 0.001) and sway area (P = 0.002) eyes open and length of CoP (P = 0.021) and sway area (P = 0.008) eyes closed] after treatment. Conclusions: Greater improvement in gait and balance was noted after BTT than after FTT as an adjunct to botulinum toxin therapy in patients with chronic stroke

Robot-assisted arm training for treating adult patients with distal radius fracture: a proof-of-concept pilot study

BACKGROUND: Fracture of the distal radius is a common wrist injury. As to its management after orthopedic (conservative or surgical) treatment, there is weak evidence for conventional rehabilitation interventions. Despite the increasing interest for robot-assisted arm therapy as to neurological disabilities and its growing diffusion in rehabilitation facilities, no previous study investigated the feasibility of robotic training on arm orthopedic impairment. Aim. To evaluate the feasibility in terms of efficacy of robot-assisted arm training on upper limb impairment in patients with fracture of the distal radius. DESIGN: Proof-of-concept, pilot, randomized controlled trial. SETTING: University hospital. POPULATION: Twenty adult outpatients with distal radius fracture due to wrist injury. METHODS: All participants underwent ten, 1-hour (40 minutes of arm training + 20 minutes of conventional occupational therapy) training sessions, five days a week for two consecutive weeks. They were randomly assigned to two groups: patients allocated to the Robotic Arm Training group received arm training by means of a robotic device and patients allocated to the Conventional Arm Training group performed arm training following a conventional rehabilitation program. All patients were evaluated before, immediately after treatment and at four weeks of follow-up. The following outcomes were considered at the affected arm: forearm pronation/supination and wrist extension/flexion passive and active range of motion; maximal pinch and grip strength; the Patient-Rated Wrist and Hand Evaluation. RESULTS: No difference was found between groups as to the primary (wrist active and passive range of motion) and secondary (pinch and grip strength; Patient-Rated Wrist and Hand Evaluation score) outcomes at all time points. Within-group comparisons showed similar improvements at all time points as to all outcomes considered in both groups. CONCLUSIONS: Our preliminary findings support the hypothesis that robot-assisted arm training might be a feasible tool for treating upper limb impairment in adult patients with distal radius fracture treated conservatively or surgically. CLINICAL REHABILITATION IMPACT: The treatment of arm impairment consequent to distal radius fractures by means of robot-assisted arm training may allow therapists to focus on functional rehabilitation during occupational (individual) therapy and supervise (more than one) patients simultaneously during robotic training sessions

Combined transcranial Direct Current Stimulation and robot-assisted arm training in patients with stroke: a systematic review

Background: Upper limb motor deficits in patients with severe stroke often remain unresolved over time. Combining transcranial Direct Current Stimulation with robotic therapy is an innovative neurorehabilitation approach that holds promise to improve upper limb impairment after stroke. Objective: To investigate the effects of robotic training in combination with transcranial Direct Current Stimulation for treating poststroke upper limb impairment. Methods: PubMed, MEDLINE, Cochrane Library, and EMBASE electronic databases were searched using keywords, MeSH terms, and strings: "Stroke"[MeSH] AND ("Upper Extremity"[MeSH] OR "upper limb") AND ("Transcranial Direct Current Stimulation" [MeSH] OR "tDCS") AND ("robotics" OR "robotic therapy"). Full-text articles published in English up to October 2020 were included. Each was rated for quality according to the Physiotherapy Database (PEDro) score: eight out of eleven scored more than 8 points; their results were considered reliable for this review. Results: Of the total of 171 publications retrieved, 11 met the inclusion criteria. The results of studies that examined the same outcome measures were pooled to draw conclusions on the effectiveness of transcranial Direct Current Stimulation and robot-assisted training in corticomotor excitability, upper limb kinematics, muscle strength and tone, function, disability, and quality of life after stroke. Conclusions: To date, there is insufficient evidence to support the hypothesis that transcranial Direct Current Stimulation enhances the effects of robot-assisted arm training in poststroke patients. Further studies with more accurate, comparable and standardized methodology are needed in order to better define the effects of robotic training in combination with transcranial Direct Current Stimulation on poststroke upper limb impairment. Therefore, given the scarce resources available to rehabilitation researches, other, more promising approaches should be given attention