Травматические повреждения плечевого сплетения: современные способы хирургической коррекции. Часть II. Тактика лечения повреждений плечевого сплетения

The task of this paper is to familiarize practicing neurologists, neurosurgeons, traumatologists, and orthopedists with the current principles of diagnosis and treatment of different brachial plexus (BP) injuries. Part I describes the anatomy of BP in detail, considers the main mechanisms of its injuries, and gives their current classification (Nervno-Myshechnye Bolezni (Neuromuscular Diseases) 2012;4:19–27).Part II presents the author's approach to treatment of brachial plexus injuries according to the type of lesion and period of denervation: nonoperative methods; rehabilitation; preoperative management; indications for surgical treatment. The tactics and techniques of primary brachial plexus reconstructions are discussed in detail.Задача настоящей публикации – познакомить практикующих неврологов, нейрохирургов, травматологов и ортопедов с современ ны ми принципами диагностики и лечения различных повреждений плечевого сплетения (ПС). В части I была подробно описана анатомия ПС, рассматривались основные механизмы его повреждения, была дана их современная классификация (Нервно-мышечные болезни 2012;4:19–27). В части II рассматриваются возможные варианты лечения пациентов на всех этапах оказания медицинской помощи: определение показаний для консервативного или хирургического лечения, предоперационное ведение, реабилитационное лечение. Подробно раз бираются тактика и техника первичных хирургических реконструкций

Роль электронейромиографии в оценке прогноза восстановления у детей с акушерским повреждением плечевого сплетения в практике специализированного центра

The aim of current publication – to present our own experience in use of electromyographic examination in prognosis for children with obstetric brachial plexus injury to practical neurologists and neurophysiologists. Review of literature shows that common approaches to electrotrophysiological diagnosis of obstetric brachial plexus injury do not exist. The aim of this study– to evaluate retrospectively electrophysiological and sonographic parameters of obstetric brachial plexus injury in children, determining the most informative variables. Since 2007 to 2014 we examined 218 children, 74 of them were operated. Electrophysiological investigation in young children have difficulties in performance.We present our algorithm of diagnostic of obstetric brachial plexus injury: 1) testing main muscles, which perform basic movementsin upper limb (needle EMG of supra- and infraspinatus muscles and cutaneous EMG of biceps muscles); 2) localization of injury (paralysis or Duchenne – Erb palsy and electrophysiological criteria of spinal cord root avulsion). We found out that the most crucial role in assessing prognosis plays an examination of motor unit potentials (MUPs) duration. Absence of MUPs within needle EMG from supraspinatus muscle and absence of interference curve from biceps muscle during first 6 months have poor prognosis. After 6 months careful, dynamic study of MUPs duration in infraspinatus muscle and co-contraction of agonist and antagonist muscles is needed. To decide whether reconstructive surgery in a patient with obstetric brachial plexus injury is necessary, surgeon must analyze clinical and instrumental data. The possibility of usage of the ultrasonogrophy in brachial plexus injury requires further investigation.Задача настоящей публикации – познакомить практических неврологов и нейрофизиологов с нашим опытом применения электронейромиографии (ЭНМГ) в оценке прогноза у детей с акушерским повреждением плечевого сплетения. Анализ отечественной и зарубежной литературы показал, что единого подхода к электрофизиологической диагностике акушерского повреждения плечевого сплетения не разработано. Цель исследования – ретроспективная оценка динамики электрофизиологических и сонографических показателей у детей с акушерским повреждением плечевого сплетения, определение наиболее информативных параметров. Всего за период с 2007 по 2014 г. нами осмотрено 218 детей, из них прооперировано 74. С учетом технических трудностей проведения электрофизиологического исследования у детей раннего возраста нами предложен следующий алгоритм: 1) оценка состояния ключевых мышц, ответственных за восстановление основных движений в верхней конечности: игольчатая ЭНМГ надостной и подостной мышц (с целью оценки состояния мышц, отвечающих за наружную ротацию плеча), накожная ЭНМГ двуглавой мышцы (сгибание руки в локтевом суставе); 2) топическая диагностика (исключение паралича и оценка электрофизиологических критериев отрыва корешка). При ретроспективной оценке электрофизиологических параметров у детей с разной степенью восстановления функции наиболее важным является оценка параметров длительности потенциалов двигательныхединиц (ПДЕ) в динамике. Прогностически неблагоприятным электрофизиологическим признаком при акушерском повреждении, по нашему мнению, служит отсутствие регистрации ПДЕ при игольчатом отведении в надостной мышце и отсутствие интерференционной кривой («биоэлектрическое молчание») с двуглавой мышцы плеча до 6 мес. После 6 мес целесообразно исследование длительности ПДЕ в подостной мышце в динамике, исследование коконтракции мышц агонистов и антагонистов. Решение о проведении реконструктивных операции хирургом принимается на основании совокупности клинико-инструментальных данных. Интересным представляется возможность использования ультразвукового исследования периферических нервов (оценка спинномозговых нервов на уровне выхода из межпозвонковых отверстий, величина невромы, сопутствующие повреждения окружающих тканей), однако эти данные требуют дальнейшего изучения

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Traumatic injuries of brachial plexus: present methods of surgical treatment Part II. Treatment policy for brachial plexus injuries

The task of this paper is to familiarize practicing neurologists, neurosurgeons, traumatologists, and orthopedists with the current principles of diagnosis and treatment of different brachial plexus (BP) injuries. Part I describes the anatomy of BP in detail, considers the main mechanisms of its injuries, and gives their current classification (Nervno-Myshechnye Bolezni (Neuromuscular Diseases) 2012;4:19–27).Part II presents the author's approach to treatment of brachial plexus injuries according to the type of lesion and period of denervation: nonoperative methods; rehabilitation; preoperative management; indications for surgical treatment. The tactics and techniques of primary brachial plexus reconstructions are discussed in detail

MANAGEMENT OF ATYPICAL CLUBFOOT BY PONSETI METHOD

From May 2006 to August 2009 analyzed 28 clinical observations (34 feet) for children aged from 7 days to 1.5 years with severe atypical congenital clubfoot (Pirani 5,6 points), treated by the method of I. Ponseti. The average number of gypsum one foot to the full correction was - 6.3. It was written 38 achillotomy. Dates from the beginning of gypsum to achillotomy averaged - 34 days. All of the children undergoing treatment with us after the removal of plaster, dressed brace, fixing the foot fixed in position 45° abduction and 15° of flexion of the back and encouraged them to carry up to 3-4 years. All the children in this group achieved a complete correction of foot deformities without performing tenoligamentocapsulotomy. Results of treatment were evaluated according to the classification C. Pirani. Average score was 1.1 points. Follow-up was an average of 1 year 35 days

Hypothalamic-Pituitary and Other Endocrine Surveillance Among Childhood Cancer Survivors.

Endocrine disorders in survivors of childhood, adolescent, and young adult (CAYA) cancers are associated with substantial adverse physical and psychosocial effects. To improve appropriate and timely endocrine screening and referral to a specialist, the International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) aims to develop evidence and expert consensus-based guidelines for healthcare providers that harmonize recommendations for surveillance of endocrine disorders in CAYA cancer survivors. Existing IGHG surveillance recommendations for premature ovarian insufficiency, gonadotoxicity in males, fertility preservation, and thyroid cancer are summarized. For hypothalamic-pituitary (HP) dysfunction, new surveillance recommendations were formulated by a guideline panel consisting of 42 interdisciplinary international experts. A systematic literature search was performed in MEDLINE (through PubMed) for clinically relevant questions concerning HP dysfunction. Literature was screened for eligibility. Recommendations were formulated by drawing conclusions from quality assessment of all evidence, considering the potential benefits of early detection and appropriate management. Healthcare providers should be aware that CAYA cancer survivors have an increased risk for endocrine disorders, including HP dysfunction. Regular surveillance with clinical history, anthropomorphic measures, physical examination, and laboratory measurements is recommended in at-risk survivors. When endocrine disorders are suspected, healthcare providers should proceed with timely referrals to specialized services. These international evidence-based recommendations for surveillance of endocrine disorders in CAYA cancer survivors inform healthcare providers and highlight the need for long-term endocrine follow-up care in subgroups of survivors and elucidate opportunities for further research