Myofascial release as a treatment choice for neuromuscular conditions : three randomized controlled trials and a systemic literature review

Introduction: Myofascial release (MFR) is a form of manual therapy that involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function. MFR is being used to treat patients with a wide variety of conditions, but there is a scarcity of evidence to support its efficacy. Studies are emerging in this field with varying results and conclusions. Analysis of the recent research trials and reviews will be a better way to appraise the quality and reliability of such works. Objective: This work attempts to analyse and summarise the evidence from three randomised controlled trials (RCTs) and one systematic review of the effectiveness of MFR on various neuromuscular conditions and pain. Methodology: Effectiveness of MFR on tension type headache, lateral epicondylitis and chronic low back pain were the RCTs identified for the analysis. The systematic review selected analysed the published RCTs on MFR till 2014. The methodological qualities of the studies were assessed using the PEDro, Centre for Evidence-Based Medicine's (CEBM) Level of Evidence Scale, Risk of Bias (RoB) Analysis Tool and AMSTAR 2. Results: The RCTs analysed in this study were of moderate to high methodological quality (PEDro scale), with higher level of evidence (CEBM scale) and less bias (RoB). The effectiveness of MFR on tension type headache (TTH) was the first among the studies with a moderate methodological quality (6/10 in PEDro), with a 2b level of evidence on the CEBM scale. The study proved that direct technique or indirect technique MFR was more effective than the control intervention for TTH. The second RCT studied MFR for lateral epicondylitis (LE). The study was of a moderately high quality on the PEDro scale (7/10) with a 1b- level in CEBM. The MFR was found more effective than a control intervention for LE in computer professionals. The RCT on chronic low back pain (CLBP) also scored 7/10 in the PEDro scale and 1b in the CEBM scale. This study confirmed that MFR is a useful adjunct to specific back exercises and more helpful than a control intervention for CLBP. All three RCTs stated the usage of self-report measures and underpowered sample size as the major limitations along with a performance bias reported in the TTH trial. The systematic review demonstrated moderate methodological quality as per the AMSTAR 2 tool which analysed 19 RCTs for a result. The literature regarding the effectiveness of MFR was mixed in both quality and results. Omission of a risk of bias analysis was the major limitation of this review. The authors quoted that “MFR may be useful as either a unique therapy or as an adjunct therapy to other established therapies for a variety of conditions”. Conclusion: Critical appraisal is an important element of evidence-based medicine to carefully and systematically examine research to judge its trustworthiness, its value and relevance in a particular context. This review concludes that the three RCTs and the systematic review analysed were completed with moderate to good quality as per various quality measures, but with reported methodological flaws and interpretation biases. These studies with the critical appraisal can act as ‘pavements’ on which high quality future MFR trials and evidence can be built on

Evaluation of the prognostic significance of regulatory T cells und killer T cells in Glioblastoma

Since the introduction of Stupp protocol about 17 years ago that significantly raised the two-year survival rate of GBM patients to 26.5 percent as compared to 10.4 percent with radiotherapy alone there has not been any further development that turned out advantageous to the patients apart from the vascular endothelial growth factor antibody, bevacizumab, that could prolong progression-free, but not overall survival. Over the last few decades the interaction between cancers and immune system has been a subject of intense research. With regard to GBM, the most notorious of the central nervous system tumors, this opens up new doors, which could lead to the development of an effective immunotherapy that improves survival and quality of life of patients. In our study we analyzed the impact of two subgroups of TILs, namely the CD8+ cytotoxic T cells and the FoxP3+ regulatory T cells on the prognosis in GBM. Tumor specimens from 104 GBM patients treated in Klinikum Lichtenfels and Klinikum Bayreuth between 2002 and 2014 were studied. The tumor microenvironment was divided into 5 different ROI based on microscopic characteristics. The CD8+ and FoxP3+ TILs were stained using a double staining method and then counted semi automatically supported by the software “Biomas-Count”. Thus a topographical understanding of the immunological structure in tumor microenvironment in each ROI was obtained. Then Kaplan-Meier plots were constructed correlating TIL density and survival. We found out that the CD8+ cells are present in a much larger number as compared to FoxP3+ cells in each ROI. The density of each cell type didn’t vary much between the 4 ROI containing tumor (tumor core, necrosis, infiltration zone and peripheral zone). The normal brain tissue adjacent to tumor showed significantly lesser number of both these subgroup of TILs. Only the density of CD8+ TIL in the tumor core was found to be of prognostic significance in our study. The patients with a lower CD8+ cell density than the median seemed to have a better overall survival (p=0.028).Seit Einführung des Stupp-Protokolls vor etwa 17 Jahren, welches die Zwei-Jahres-Überlebensrate von GBM-Patienten signifikant auf 26,5 Prozent gegenüber 10,4 Prozent bei alleiniger Strahlentherapie steigerte, gab es außer der vaskulären endothelialen Wachstumsfaktor Bevacizumab keine Weiterentwicklung zum Vorteil der Patienten. Bevacizumab hat das progressionsfreie, aber nicht das Gesamtüberleben verlängern können. In den letzten Jahrzehnten war die Wechselwirkung zwischen Krebs und Immunsystem Gegenstand intensiver Forschung. Im Hinblick auf GBM, den berüchtigtsten Tumor des zentralen Nervensystems, öffnet dies neue Türen, die zur Entwicklung einer wirksamen Immuntherapie führen könnten, die das Überleben und die Lebensqualität der Patienten verbessert. In unserer Studie haben wir den Einfluss zweier Untergruppen von TILs, nämlich der CD8+ zytotoxischen T-Zellen und der FoxP3+ regulatorischen T-Zellen, auf die Prognose bei GBM analysiert. Es wurden Tumorproben von 104 GBM-Patienten untersucht, die zwischen 2002 und 2014 im Klinikum Lichtenfels und im Klinikum Bayreuth behandelt wurden. Die Tumormikroumgebung wurde basierend auf mikroskopischen Merkmalen in 5 verschiedene ROI unterteilt. Die CD8+ und FoxP3+ TILs wurden mit einem Doppelfärbeverfahren gefärbt und dann halbautomatisch unterstützt durch die Software „Biomas-Count“ gezählt. Somit wurde ein topographisches Verständnis der immunologischen Struktur in der Tumormikroumgebung in jedem ROI erhalten. Dann wurden Kaplan-Meier-Plots erstellt, die die TIL-Dichte und das Überleben korrelierten. Wir fanden heraus, dass die CD8+-Zellen im Vergleich zu den FoxP3+-Zellen in jeder ROI in viel größerer Zahl vorhanden sind. Die Dichte jedes Zelltyps variierte nicht sehr zwischen den 4 ROI enthaltenden Tumoren (Tumorkern, Nekrose, Infiltrationszone und periphere Zone). Das an den Tumor angrenzende normale Gehirngewebe zeigte eine signifikant geringere Anzahl dieser beiden Untergruppen von TILs. Nur die Dichte von CD8+ TIL im Tumorkern war in unserer Studie von prognostischer Bedeutung. Die Patienten mit einer niedrigeren CD8+-Zelldichte als Median schienen ein besseres Gesamtüberleben zu haben (p=0,028)

A Prototype Of Virtually Interactive Hand Activating Devise-Low Cost Portable Head Mounted System (vihad Plus) For Neurological Rehabilitation

Background and Purpose: Restoring function in individuals who have severe paralysis of the upper extremity secondary to stroke is challenging. Recent technologies have made it possible to use robotic devices as novel tools for assisting the therapists to provide safe and intensive rehabilitation with repeated motions. However, most of the training robots are types of Continuous Passive Motion (CPM) devices that produce slower and stereotyped movement patterns. Earlier works have shown that passive or slow movements do not significantly benefit motor improvement. Several studies reveal that even the use of ipsilateral electromyographic (EMG) pattern recognition approaches might not be practical to decode movement intention and, may negatively affect re-mapping of the neural pathways in the brain. To have a successful hand rehabilitation system, the system should be able to produce a wide variety of unpredicted and challenging movement patterns of various degrees of speed and range of motion with increasing complexity, sufficient enough to produce the necessary neurological plasticity of the affected brain. Current rehabilitation devices are not sufficient to produce such a range of complex activities which enables maximum neurological plasticity. Objective: In this work, we describe a prototype of the contralateral EMG-based Interactive Hand Activating Devise for Stroke (IHADS) system that can detect a hemiplegic person's intention for bilaterally executed hand activities using his/her surface EMG signals from the non-affected side (contralateral). Furthermore, this system can assist in bilateral hand activities through an exoskeleton attached to the hemiplegic upper extremity to initiate progressively challenging and unpredicted type of activities in a virtual reality (VR) world to obtain optimum functional recovery by inducing maximum neurological plasticity. Design: The IHADS system is made up of an embedded controller and a robotic exoskeleton, contralateral EMG sensors and a VR interface with a semi-immersed VR system, where the patient will be seeing progressively impulsive activities that would force the brain to activate the affected extremity to manipulate through the remaining neural networks and mirror neuronal system which in turn will optimize the neurological recovery. This means that the paralyzed arm will be following the motion of the healthy arm whose motion is picked up by the EMG sensors and are translated as actuation signals for the exoskeleton to execute virtually created challenging activities. Conclusion: Contralateral EMG-based 'IHADS' system is a unique, cost effective, highly innovative and portable robotic device. If incorporated into the stroke rehabilitation, this system will be capable of autonomous guidance through the use of real-time feedback from the contralateral upper limb, integrated via the VR interface and the hand activating device to make rehabilitation more intense, functional, motivating, and capable of inducing maximum neurological plasticity

Computational modeling of locoregional recurrence with spatial structure identifies tissue-specific carcinogenic profiles

IntroductionLocal and regional recurrence after surgical intervention is a significant problem in cancer management. The multistage theory of carcinogenesis precisely places the presence of histologically normal but mutated premalignant lesions surrounding the tumor - field cancerization, as a significant cause of cancer recurrence. The relationship between tissue dynamics, cancer initiation and cancer recurrence in multistage carcinogenesis is not well known.MethodsThis study constructs a computational model for cancer initiation and recurrence by combining the Moran and branching processes in which cells requires 3 or more mutations to become malignant. In addition, a spatial structure-setting is included in the model to account for positional relativity in cell turnover towards malignant transformation. The model consists of a population of normal cells with no mutation; several populations of premalignant cells with varying number of mutations and a population of malignant cells. The model computes a stage of cancer detection and surgery to eliminate malignant cells but spares premalignant cells and then estimates the time for malignant cells to re-emerge.ResultsWe report the cellular conditions that give rise to different patterns of cancer initiation and the conditions favoring a shorter cancer recurrence by analyzing premalignant cell types at the time of surgery. In addition, the model is fitted to disease-free clinical data of 8,957 patients in 27 different cancer types; From this fitting, we estimate the turnover rate per month, relative fitness of premalignant cells, growth rate and death rate of cancer cells in each cancer type.DiscussionOur study provides insights into how to identify patients who are likely to have a shorter recurrence and where to target the therapeutic intervention

Evaluation of serum sex hormones and CD4+ count among HIV patients on HAART, HAART naive patients and apparently healthy subjects in Sokoto, Nigeria

Background: Acquired Immunodeficiency Syndrome (AIDS) is a chronic disease associated with Human Immunodeficiency Virus (HIV) which progressively induces depletion of CD4+ T cells, and increased vulnerability to opportunistic infections. Previous reported studies associated HIV-infected men with sexual dysfunction; hypogonadism is the most common endocrinological disorders. Its prevalence remains poorly defined and widely ranging from different studies.Methods: This study evaluated a total of 135 serum sex hormones (testosterone, estrogen, follicle stimulating hormone and luteinizing hormone) and its correlation with CD4+ counts among HIV patients on HAART, HAART naïve patients and negative control subjects (n=45). CD4+ cell counts were estimated using standard flow cytometry method and serum sex hormones by competitive enzyme immunoassay technique.Results: There were significantly lower testosterone and CD4+ levels (p<0.05) among HIV positive HAART naïve men compared to negative control. LH and FSH indicated significant increased (p<0.05) among HIV positive men on HAART.Conclusions: Antiretroviral therapy improves sexual functions in males infected with human immunodeficiency virus. Hence, further study to evaluate its effects on other sexual behaviors

General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multi-centre observational study

There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%)