Physical Frailty/Sarcopenia as a Key Predisposing Factor to Coronavirus Disease 2019 (COVID-19) and Its Complications in Older Adults

The tremendously rising numbers of aged populations are associated with a heightened risk for motor and functional declines. Sarcopenia is an active age-related process that involves progressive losses of skeletal muscle mass, muscle strength, and muscle function. Muscle failure is a major cause of frailty, disability, falls, hospitalization, dependency, institutionalization, and low quality of life in older seniors. Therefore, sarcopenia considerably heightens the annual cost of care worldwide. This narrative review elaborates on sarcopenia as a deleterious condition in old age while spotting the light on its association with the coronavirus disease 2019 (COVID-19). It discusses its pathophysiology and the most possible options for preventing and treating sarcopenia. The literature shows that the dynamic of sarcopenia is complex, involving multifaceted physiological alterations relevant to aging, unhealthy behaviors (e.g., undernutrition or inadequate dietary intake and physical inactivity/immobility or sedentary lifestyle), and multiple pathogenic conditions such as metabolic, inflammatory, and endocrinal disorders. Frail individuals express nutritional deficiencies, immune deficit, oxidative stress, metabolic alterations, gut microbial alterations, neurological insult, etc. Such physiological dysfunctions are closely linked to increased vulnerability to COVID-19 among older adults and people with non-communicable diseases such as diabetes mellitus, cardiovascular disorders, and obesity. Available studies report higher occurrence of severe COVID-19 and COVID-19-related complications (ICU admission, mechanical ventilation, and in-hospital mortality) among frail compared with non-frail and prefrail individuals. Effective pharmacological treatments of sarcopenia are not currently available. However, physical activity and nutritional interventions (e.g., fast digestive proteins, vitamin D, and natural products such as bee products) may prevent the development of sarcopenia in early stages of the disease or limit disease progress. Such interventions may also lower vulnerability to COVID-19.

Treatment of Pain Due to Winged Scapula with Spinal Cord Stimulation: A Case Report

BACKGROUND: Winged scapula (WS) is a protrusion of the scapula giving the appearance of a wing and can be due to either a musculoskeletal or neurological insult. Pain associated with WS is multifactorial, including myofascial and neuronal mechanisms, and may be difficult to treat. CASE REPORT: In a case of WS refractory to conservative management with physical therapy and medications and not a candidate for nerve repair, we treated the pain with a spinal cord stimulator. We report significant pain reduction and improvement in function with the procedure. CONCLUSION: This case suggests a role for neuromodulation in WS and requires further investigation. KEY WORDS: Winged scapula, spinal accessory nerve injury, spinal cord stimulation, neuromodulation

Severe hypotension with loss of motor evoked potentials during cervical surgery prompting immediate cardiovascular resuscitation

Background: Intraoperative neuromonitoring (IONM) is a well-established adjunct to spinal surgery to ensure safety of the neural elements.IONM has extremely high sensitivity and specificity for impending neurologic damage. In very rare instances, hypoperfusion of the cord may lead to a loss of IONM modalities that may be reversed if blood pressure issues responsible for the drop out of potentials are immediately addressed. Case Description: The authors describe a case in which IONM documented hypoperfusion of the cord intraoperatively due to hypotension. Recognition of this problem and reversal of the hypotension resulted in normalization of postoperative function. Conclusion: The use of IONM allowed for quick recognition of an impending neurological insult during spinal deformity surgery. Prompt response to signaling changes allowed for the correction of hypotension and favorable neurologic outcome.

8-Year-Old Child with Cerebral Palsy Treated with Pelvic Osteotomies Using 3.5 MM Blade Plate Having Subsequent Bilateral Implant Aseptic Loosening: A Case Report

Background: Cerebral palsy (CP) is a central problem of the brain due to neurological insult that affects muscle posture, tone, and movement, resulting in poor motor control and dysfunctional muscle balance affecting hip joints in the growing child. Surgical treatment of hip and, if present, acetabular dysplasia addresses the femoral neck-shaft angle, appropriate muscle lengthening, and deficiency of acetabular coverage, as necessary. The surgeons perform proximal femoral osteotomies (PFOs) mostly with fixed angled blade plates (ABP) with proven success. The technique using an ABP is common and requires detailed attention to perform and to teach. The Case: In this case, an eight-year-old ambulatory patient with CP underwent bilateral proximal varus femoral derotational and pelvic osteotomies for the neuromuscular hip condition with a 3.5 mm Locking Cannulated Blade System (OP-LCP) by OrthoPediatrics Corp instead of the use of the conventional 4.5 mm ABP procedure, resulting in aseptic loosening. Conclusion: Due to the child’s underdeveloped posture, the surgeon utilized the 3.5 mm instrumentation for a child-size implant, which worked sufficiently for the surgery but may not have loosened if a similar child-size blade plate system of 4.5 mm screws was implanted. While the ABP and OP-LCP systems are fruitful and safe for internal corrections of PFOs, the OP-LCP system may aid the residents in learning the procedure with higher confidence, fewer technical inaccuracies, and refined outcomes. Both systems are safer and viable for the treatment of neuromuscular hip conditions.

Neonatal Respiratory Distress Secondary to Meconium Aspiration Syndrome

Infants born through meconium-stained amniotic fluid (MSAF) are 100 times more likely than infants born through clear amniotic fluid to develop respiratory distress in the neonatal period. Meconium aspiration syndrome (MAS) is a common cause of respiratory distress in term and post-mature neonates. MAS is defined as respiratory distress accompanied by a supplemental oxygen requirement in an infant born with MSAF, in the absence of any other identified etiology to explain the symptoms. Therapy for MAS is supportive, and should be tailored to each infant’s specific pathophysiology. In cases of MAS with severe persistent pulmonary hypertension of the newborn (PPHN), patients may remain hypoxic despite aggressive ventilation, and in these cases surfactant, inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) can be life-saving. Long-term prognosis for MAS is more related to severity of initial hypoxemia and possible neurological insult than to the pulmonary pathology.

RATS: A Robotic Arm Training System Designed for Rats

This paper presents a novel robotic system to characterize and retrain reaching in rats. This robot is intended to be a research platform for rehabilitation of forelimb movements in rats. In this paper, we focus on the design of this robotic system. We present the design requirements, mathematical models, and details of the physical device. A parallel mechanism with a special alignment of the component chains is used to accommodate observed reaching motions of a rat's forelimb. Additionally, we demonstrate the use of this robot to record forelimb trajectories. Three healthy rats were used to record repeated reaching motions while the robot applied nearly zero force. We believe that this robotic system can be used in future training studies with rats who have impaired arm motions due to a neurological insult.

An Observational Cross-sectional Study on Dermatological Co-morbidities in Patients with Hemiplegia Secondary to Cerebral Stroke in a Tertiary Care Teaching Hospital in Eastern India

Introduction: Hemiplegia due to cerebral stroke is associated with various dermatological co-morbidities, arising out of motor, sensory and autonomic dysfunctions. Aim: To find out the different dermatological conditions prevalent in patients of hemiplegia secondary to cerebral stroke. Materials and Methods: An observational cross-sectional study was conducted in the Department of Neurology in collaboration with the Department of Dermatology at Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha from July 2017 to June 2020. Patients with hemiplegia of more than one month duration were included. The skin findings present before the neurological insult and patients with systemic conditions like atopic dermatitis, diabetes mellitus and thyroid disorders causing skin changes were excluded. Relevant tests for diagnostic confirmation of the skin lesions were done wherever needed. The software Statistical Package for the Social Sciences (SPSS) version 16.0 was used for the statistical analysis. Results: Study included 411 patients of cerebral stroke. A total of 382 (92.9%) patients were found to have dermatological manifestation. The male:female ratio in the study population was 2.6:1. A total of 549 and 128 skin conditions were diagnosed in the paralysed and non paralysed limbs, respectively. The common dermatological conditions diagnosed in the affected limbs were, xerosis {371 (97.12%)}, tinea corporis/cruris {61 (15.97%)}, onychomycosis {31 (8.12%)}, tinea pedis {28 (7.33%)} and nail dystrophy abnormalities {27 (7.07%)} patients. Conclusion: Knowledge of various dermatological conditions associated with hemiplegia helps in early intervention and better management during rehabilitation phase of patients with hemiplegia.

Development of an Antiepileptogenesis Drug Screening Platform: Effects of Everolimus and Phenobarbital

Objective: The kainic acid (KA)-induced status epilepticus (SE) model in rats is an etiologically-relevant animal model of epileptogenesis. Just as in patients, who develop temporal lobe epilepsy (TLE) following SE, this rat model of KA-induced SE very closely recapitulates many of the clinical and pathological characteristics of human TLE that arise following SE or another neurological insult. Spontaneous recurrent seizures (SRS) in TLE can present after a latent period following a neurological insult (TBI, SE event, viral infection, etc.). Moreover, this rat model of TLE is ideally suited for preclinical studies to evaluate the long-term process of epileptogenesis and screen putative disease-modifying/antiepileptogenic agents. This report details the pharmacological characterization and methodological refinement of a moderate-throughput drug screening program using the post KA-induced SE model of epileptogenesis in male Sprague Dawley rats to identify potential agents that may prevent or modify the onset or severity of SRS. Specifically, we sought to demonstrate whether our protocol could prevent the development of SRS, or lead to a reduced frequency/severity of SRS. Methods: Rats were administered everolimus (2-3 mg/kg, P.O. commencing at 1, 2, or 24-hrs after SE onset) or phenobarbital (60 mg/kg, beginning 1 hr after SE onset). The rats in all studies (n=12/treatment dose/study) were then followed intermittently by video-EEG monitoring; i.e., 2-weeks on/2-weeks off, 2-weeks on epochs to determine latency to onset of SRS, and disease burden following SRS onset. Results: While there were no adverse side effects observed in any of our studies, no treatment conferred a significant disease modifying effect, nor did any agent prevent the presentation of SRS by 6 weeks post-SE onset. Conclusions: While neither phenobarbital nor everolimus administered at several time points post-SE onset prevented the development of SRS, we herein demonstrate a moderate-throughput screen for potential antiepileptogenic agents in an etiologically-relevant rodent model of TLE.

Pathophysiology of Cerebral Edema—A Comprehensive Review

Cerebral edema is a condition where an excess of cerebral water accumulates due to primary neurological or non-neurological causes. Cerebral edema complicates many brain pathologies causing additional injury often in excess of the original neurological insult. Classic descriptions divide cerebral edema into cytotoxic, vasogenic, interstitial, and osmotic subtypes. The interplay of different mechanisms is important in the clinical manifestations. Recent research has advanced our understanding of the molecular pathophysiology of cerebral edema, exposing the central role of aquaporins and specific ion channels. The aim of this review is to provide a comprehensive overview of the molecular pathophysiology of cerebral edema including unique disease specific mechanisms.