Dermatology and Venerology

Herpes zoster ophthalmicus: clinicodemographic characteristics and outcomes of 64 Egyptian patients Mohammed Abu El-Hamd, Soha Aboeldahab Egyptian Journal of Dermatology and Venerology 2019 39(2):49-56 Background Herpes zoster ophthalmicus (HZO) accounts for 10–20% of all patients with herpes zoster. Objectives This study aimed to evaluate demographic features, clinical presentations, and outcomes of HZO patients. Patients and methods In a prospective cross-sectional clinical study, it included 64 patients with clinically evident HZO. All patients underwent a detailed medical history and complete dermatological and ophthalmological examinations. Results This study included 64 patients with HZO; 41 (64.1%) were females and 23 (35.9%) were males. Of female patients with HZO, 30 (73.2%) were married, 20 (48.7%) were urban, 35 (85.4%) were housewives, 17 (41.4%) had medium socioeconomic levels, 41 (100%) were nonsmokers, 13 (31.70%) had diabetes mellitus, six (14.63%) had hypertension, 30 (73.2%) had eruption on the left side, 11 (26.8%) had conjunctivitis and lid edema, 13 (31.7%) had postherpetic neuralgia, 29 (70.7%) had posttreatment scars, and six (14.6%) had a reduced visual outcome. Of male patients with HZO, 20 (87%) were married, 12 (52.2%) were suburban, seven (30.4%) were worker, 14 (60.9%) had low socioeconomic levels, 15 (65.2%) were smokers, eight (34.8%) had diabetes mellitus, one (4.3%) had hypertension, 18 (78.3%) had eruption on the left side, nine (39.16%) had conjunctivitis and lid edema, seven (30.4%) had postherpetic neuralgia, 10 (43.5%) had post-HZO cutaneous scarring, and four (17.4%) had a reduced visual outcome. Limitations The sample size of this study was small. Conclusion This study concluded that HZO is a common and potentially ruinous disease that may show a significant ophthalmic morbidity if not adequately diagnosed and treated.

Real-life experience of secukinumab injection in difficult chronic plaque-type psoriasis: a multicenter experience GK Singh, Rajiv Sekhri, Manas Chatterjee, Sukriti Baveja, Neha Akhoon Egyptian Journal of Dermatology and Venerology 2019 39(2):57-65 Background Secukinumab, a fully human monoclonal antibody that selectively targets interleukin-17A, has been proven highly efficacious in the management of moderate to severe psoriasis with early response and sustained effects in many phase III clinical trials. However, data on real-life experience is lacking. Patients and methods A multicentric, retrospective study in routine clinical setting was conducted in cases of chronic plaque type of psoriasis during November 2016 to December 2017. Patients who had received 300-mg secukinumab injection subcutaneously at 0, 1, 2, 3, and 4 months and then every 4 weekly for at least 6 months were recruited for the study. Assessment of severity of psoriasis was done by psoriasis area severity index (PASI) and dermatological life quality index (DLQI). Results A total of 32 patients, comprising 24 males and 8 females, with mean age of 42.31 years (SD 11.32) and mean baseline PASI of 20.72 (SD 7.53) and DLQI of 15.31 (SD 5.25), were studied. Achievement of PASI 75/90/100 at 12 weeks was 81.25/59.37/9.3, respectively. PASI 75 at the end of 52 weeks was maintained at 65.62. DLQI reduced to 2.56 (SD 5.19) (16.72% of baseline) at the end of 12 weeks. Differences between baseline scores and each subsequent visit were statistically significant (P<0.001). Only mild adverse effects were noticed in six (18.7%) patients. Conclusion Secukinumab is a very promising new molecule in the management of chronic plaque type of psoriasis that is resistant to conventional modalities in routine clinical setting even in an Indian scenario. A retrospective analysis, with few cases, was inherent limitation of this study.

Serum levels of interleukin-38 in sufferers with atopic eczema Fathia M Khattab, Elsayed M Khater, Hoda A Ibraheem Egyptian Journal of Dermatology and Venerology 2019 39(2):66-70 Background The relation between interleukin-38 (IL-38) and atopy is not precisely regarded yet. The current study has a look at set to assess the serum level of IL-38 in atopy patients and controls in order to illustrate the disease association and correlation with severity. Objective The aim of this study was to quantify serum IL-38 titers in atopic dermatitis patients and to observe relationships with disease severity‏‏. Patients and method s Twenty-six atopic cases along with 26 healthy controls were attributed in this case–control study. Clinical severity was evaluated by SCORing Atopic Dermatitis index. Serum level of IL-38 was measured by enzyme-linked immunosorbent assay for all participants. Also, peripheral eosinophilic count and total immunoglobulin E were measured in participating patients only. Results IL-38 serum concentrations were extensively higher in atopic sufferers than controls (P<0.05). Moreover, there is a statistically significant correlation between IL-38 levels and both atopic severity and inflammatory markers as peripheral eosinophilic count and total immunoglobulin E. Conclusion IL-38 represents a mirror for atopic severity and its inflammatory state.

Association of human leukocyte antigen-DRB1 with the response in patients with vitiligo Mohamed Abdel Kader Toama, Fathia M Khattab, Ayman Marei Egyptian Journal of Dermatology and Venerology 2019 39(2):71-77 Background Vitiligo is a pigmentary disorder associated with the selective destruction of the skin melanocytes. Among the many human leukocyte antigen (HLA) alleles claimed to be incriminated in establishing vitiligo, HLA-DRB1 is included in many dermatological diseases and has been widely investigated in different studies worldwide. Aim To examine the susceptibility between HLA-DRB1 gene polymorphism and the therapeutic response of vitiligo. Patients and methods We performed a cohort study at Dermatology and Venereology Department, Zagazig Institution Hospitals from January 2018 to January 2019 on 80 patients with vitiligo who were subjected to treatment. Response to therapy was observed, and we followed up patients for 6 months. HLA-DRB1 genotyping using real-time PCR was performed once. Results The results showed that there was a significant statistical association regarding the therapeutic response in our study. Conclusion Our findings advise that DRB1 *0701 and *0413 are associated with good therapeutic response, whereas DRB1 *8 and *12 alleles are associated with worse therapeutic response among Egyptians.

Topical calcipotriol mixed with topical steroid versus topical steroid alone in treatment of alopecia areata Mohamed I El-Ghareeb Egyptian Journal of Dermatology and Venerology 2019 39(2):78-82 Background Alopecia areata (AA) is an autoimmune T-cell mediated disease characterized by a localized patchy hair loss from scalp and other hairy body parts. Topical steroid is one of the traditional therapeutic options for AA. It is considered as a recommended tool in the treatment of mild-to-moderate AA, especially when used early in the course of the disease. Calcipotriol is a vitamin D analog and acts as a potent immunomodulatory agent and can be used in the treatment of AA. Rationale Recently, vitamin D deficiency was observed in patients with autoimmune diseases including patients with AA. Calcipotriol is emerging as a novel agent in the treatment of AA in many published studies. The therapeutic effect of the mixture of topical calcipotriol and topical steroid in the treatment of AA was not mentioned in previous studies. Aim The aim of this study is to evaluate the efficacy and safety of topical calcipotriol mixed with topical steroid in the treatment of AA in comparison with topical steroid alone. Patients and methods A total of 40 patients with mild-to-moderate AA were involved in this study throughout a 12-week trial. Institutional review board (IRB) approval was obtained with informed consents from all patients. The patients were divided into two groups: 20 patients in group A and another 20 patients in group B. Group A patients had been treated with topical steroid (betamethasone valerate 0.1%) twice daily throughout the 12 weeks. Group B patients had been treated with a topical gel preparation containing calcipotriol 0.005% mixed with betamethasone dipropionate 0.05%. This gel preparation was applied to the affected area twice daily throughout the 12 weeks. Severity of Alopecia Tool (SALT) score was calculated at baseline and at 3, 6, 9, and 12 weeks. Results There was a statistically highly significant decrease in SALT scores after the 3-month treatment in group A, and there was a statistically significant decrease in SALT scores after the 3-month treatment in group B. Conclusion Topical calcipotriol mixed with topical steroid in a gel formulation is a novel therapeutic tool of AA with efficacy nearly the same as of topical steroid alone and with less adverse effects.

Insulin resistance in androgenetic alopecia and acne vulgaris M. Yousry Abdelmawla, Abdulla M Esawy, Elsayed Khater, Naglaa A Khalifa Egyptian Journal of Dermatology and Venerology 2019 39(2):83-88 Background Insulin resistance (IR) is the inability of a known quantity of exogenous or endogenous insulin to increase glucose uptake and utilization in an individual as much as it does in a normal population. Some conditions strongly associated with IR such as acanthosis nigricans, acne, and psoriasis. Some conditions potentially associated with IR such as androgenetic alopecia (AGA), hirsutism, and hyperandrogenism. Some conditions anecdotally linked to IR such as alopecia areata and vitiligo. We aimed to analyze the relationship between IR and AGA and acne vulgaris, in comparison to controls. Patients and methods The study was carried out on 54 AGA and 54 acne vulgaris patients selected from Dermatology, and Venereology Department, Zagazig University Hospitals, 54 volunteers as a control, general, and dermatological examination were done. IR was estimated by the Homeostasis Model Assessment of Insulin Resistance. Results Statistically no significant differences between cases and control regarding sociodemographic distribution, blood glucose, and insulin. Nonsignificant differences between AGA and acne groups regarding sociodemographic distribution and duration of the disease. Nonsignificant differences between AGA and acne regarding blood glucose and insulin. Conclusion There is a role of insulin in the etiopathogenesis of AGA and acne.

Efficacy and safety of topical spironolactone 5% gel versus placebo in the treatment of acne vulgaris Enayat M Attwa, Al Shimaa M Ibrahim, Marwa F Abd El-Halim, Hanan M Mahmoud Egyptian Journal of Dermatology and Venerology 2019 39(2):89-94 Background Acne is an inflammatory disorder of the pilosebaceous unit that imposes negative effects on the psychological state of patients. Indeed, even mild acne can adversely affect the patients’ quality of life. Therefore, successful management is needed. Spironolactone is one of the effective systemic treatments for acne, but its adverse effects limit its use. Objectives To assess the effectiveness and safety of 5% spironolactone gel in the treatment of acne. Patients and methods This study was a split-face study in which 22 adult patients with mild and moderate acne vulgaris were instructed to apply topical 5% spironolactone gel to their right hemifaces and topical placebo gel to their left hemifaces twice daily for 8 weeks. Results This study reported a statistically significant reduction in the total lesion count and acne severity index from the baseline. The improvement was significantly higher in the spironolactone side than the placebo side. Spironolactone mainly improves comedones and inflammatory papules. Minimal tolerable adverse effects were recorded in the form of stinging and mild erythema. Conclusion The data provided by this study support the use of topical spironolactone in the treatment of mild to moderate acne vulgaris.

Anonychia multiplex: methotrexate induced? Bharat Bhushan Mahajan, Lovleen Kaur, Chetna Singla, Parul Chojer, Varinder Kumar Egyptian Journal of Dermatology and Venerology 2019 39(2):95-97 Psoriasis is a chronic systemic inflammatory disease primarily involving skin, nails, and articular system with associated disease-related comorbidities including type 2 diabetes mellitus and metabolic syndrome. In the past, studies had hypothesized that rapid nail growth of psoriatic nail plate with associated parakeratosis does not allow the fungus to lodge in the nail keratin, thereby the incidence of onychomycosis should have been low in nail psoriasis. However, current studies mention that psoriatic nails are predisposed to secondary onychomycosis, but the end result of manifesting as anonychia multiplex of these two coexistent nail diseases, further complicated by methotrexate, has not been reported in the literature till date. We hereby, report a case of anonychia multiplex of psoriatic nails with coexisting onychomycosis, probably induced by methotrexate-related immunosuppression, for its rarity.

Chronic plaque psoriasis on diffuse systemic sclerosis: a rare association Parul Chojer, Bharat Bhushan Mahajan Egyptian Journal of Dermatology and Venerology 2019 39(2):98-101 Diffuse systemic sclerosis is a multisystem autoimmune disease that is characterized by generalized vascular involvement that results in tissue necrosis and secondary fibrosis. Psoriasis is a chronic inflammatory skin disease. Both of these diseases are autoimmune in origin. Psoriasis is, however, rarely associated with systemic sclerosis, but few cases have been reported, and a common genetic and immunological background shared by these diseases has been suggested. Here we report a case of a 20-year-old female patient with diffuse systemic sclerosis who developed chronic plaque psoriasis with Psoriasis area and severity Index (PASI) of 14.0 and body surface area of 32% with diffuse skin sclerosis and respiratory involvement.

Dermoscope as a diagnostic tool in pseudofolliculitis corporis: a dermatologist's viewpoint Jyoti Budhwar, Chetna Singla, Elga Muralidharan, Suresh K Malhotra Egyptian Journal of Dermatology and Venerology 2019 39(2):102-104 Pseudofolliculitis is an inflammatory condition of the hair follicle that mainly affects the beard area, but it can occur in any area of hair-bearing skin when hair removal methods like shaving or plucking are used. It occurs when the shaved hair curls inwards and repenetrates the skin surface inducing inflammatory changes. Sometimes, it is a simple cosmetic problem, but at other times it can present with intense itching or pain and can become quite debilitating for the patient. Here, we report a case of pseudofolliculitis corporis presenting to us with intractable itching. The patient used to rub his back against the wall and used combs and other things for itching. The diagnosis of pseudofolliculitis corporis was suspected clinically and confirmed by dermoscopy, which is a simple office procedure. Patient was advised not to rub his back against wall and was given emollients and topical adapalene gel and advised follow-up after 15 days.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Conservative Dentistry

With sincere prayers to all humanity Aditya Mitra, Chandrani Adhikari Journal of Conservative Dentistry 2019 22(3):215-215

Gutta-percha in endodontics - A comprehensive review of material science Vijetha Vishwanath, H Murali Rao Journal of Conservative Dentistry 2019 22(3):216-222 The complete and three-dimensional fluid tight seal of the root canal system is the final component of the endodontic triad. The long-standing and closest material which has fulfilled this criterion is gutta-percha (GP). Several materials have been tried and tested as an endodontic filling material, of which GP has been most extensively used for years and has established itself as a gold standard. In addition, it has proved itself successful with different techniques of obturation while maintaining its basic requisites. This article deals briefly with the history and evolution of GP, source, chemical composition, manufacturing, disinfection, cross-reactivity, and advancements in the material.

Efficacy of different endodontic irrigation protocols on shear bond strength to coronal dentin Soley Arslan, Hacer Balkaya, Nazire Nurdan Çakir Journal of Conservative Dentistry 2019 22(3):223-227 Aim: The purpose of this study was to evaluate the effect of etidronic acid on bond strength to coronal dentin. Materials and Methods: A total of 75 human mandibular molars were sectioned 3 mm below the occlusal surface and then randomly divided into five groups according to irrigation solution used (n = 15): Group 1: 5 ml 2.5% sodium hypochlorite (NaOCl) +5 ml distilled water; Group 2: 5 ml 2.5% NaOCl + 5 ml 17% ethylenediaminetetraacetic acid (EDTA); Group 3: 10 ml mixture of 5% NaOCl and 18% 1-hydroxyethylidene-1,1-bisphosphonate (HEBP); Group 4: 5 ml mixture of 5% NaOCl and 18% HEBP + 5 ml 17% EDTA; and Group 5: 5 ml mixture of 5% NaOCl and 18% HEBP + 5 ml distilled water. Thereafter, Clearfil SE bond was applied to the dentin surfaces and then, composite build-ups were created using Tygon tubes for the microshear bond strength test. Data were analyzed using the one-way analysis of variance and Tukey test. Results: When compared to Groups 3, 4, and 5, Groups 1 and 2 showed significantly higher bond strength values (P < 0.05). However, there was no statistically significant difference between Groups 1 and 2 and between Groups 3, 4, and 5 (P > 0.05). Conclusion: HEBP adversely affected the bond strength of the tested adhesive to coronal dentin.

Influence of type of cement and their thickness on stress distribution at dentin-cement interface of computer-aided designed glass fiber post: A three-dimensional finite element analysis Sonali Taneja, Pragya Kumar, Nitin Gupta, Rabab Khan Journal of Conservative Dentistry 2019 22(3):228-232 Aim: This study aims to evaluate the effect of type of cement, and their thickness on stress distribution at dentin-cement interface of computer-aided designed glass fiber post using three-dimensional finite element analysis. Materials and Methods: Nine 3D models of endodontically treated maxillary second premolar were divided into three groups according to the adhesive cement used PermaCem (Group I), Variolink II (Group II), and ParaCore (Group III). Each group was further divided into subgroup a, b, and c on the basis of the thickness of the adhesive cement 50 μm, 200 μm, and 300 μm, respectively. All the models were simulated to be cemented with computer-aided designed glass fiber post and core followed by zirconia crown. The core was modeled with incomplete ferrule. The load of 200N at 45° at lingual and central fossa was applied. Maximum von Mises stresses distribution was calculated. Results: Maximum and minimum stresses in dentin were seen in the Ic and IIIa, respectively. Maximum and minimum stresses in cement were seen in IIIc and Ia, respectively. Conclusion: The von Mises stresses in dentin can be minimized by keeping the cement thickness minimum and selecting the cement whose modulus of elasticity is closest to that of dentin.

Morphological measurements of anatomical landmarks in human maxillary first molar pulp chambers and evaluation of number of pulp canal orifices using spiral computed tomography: An in vitro study Chakshu Gaba, Anuraag Gurtu, Rashmi Bansal, Pramod Kumar Journal of Conservative Dentistry 2019 22(3):233-236 Context: Comprehensive understanding of the anatomic position of pulp canal orifices and the measurements of the molar pulp space may maintain the pulp health during conservative tooth preparation and minimize the possibility of mishaps during endodontic therapy. Aims: The idea of the present study was to analyze the morphological measurements of anatomical landmarks in human maxillary first molar pulp chambers and evaluation of number of pulp canal orifices using three-dimensional spiral computed tomography (SCT). Subjects and Methods: One hundred and thirty extracted intact human adult maxillary first molars were chosen from the North Indian population and were analyzed using SCT in axial and coronal sections. Statistical Analysis Used: Standard deviation, mean, and coefficient of variance were calculated. Interobserver reliability was evaluated using kappa value to avoid any bias. Results: The results from our study showed that 69.23% of the sample teeth had four canal orifices, the mesial and distal pulp horns were present at an average distance of 0.80 ± 0.36 mm and 0.41 ± 0.34 mm, respectively, above the cementoenamel junction (CEJ), and the mean distance from the central groove of central fossa to furcation and the central groove of central fossa to the pulp chamber's roof was 8.37 ± 0.33 mm and 3.87 ± 0.29 mm, respectively. The average distance of the pulp chamber's floor from the furcation was found to be 2.47 ± 0.11 mm. The highest degree of variance was observed in case of relation of CEJ to pulp horns, i.e., 44.85% and 82.60%. Conclusions: The dimensions observed in this study and its resemblance to the various studies reported in literature shift the fundamental anatomic approach to a more systemic quantifiable approach to the endodontic maxillary first molar access preparation.

In vitro comparison of apical microleakage by spectrophotometry in simulated apexification using White Mineral Trioxide Aggregate, TotalFill Bioceramic Root Repair material, and BioDentine M Juez, ML Ballester, E Berástegui Journal of Conservative Dentistry 2019 22(3):237-240 Aim: The purpose of this study was to compare the sealing ability of various calcium silicate-based root-filling materials with a glucose leakage model after orthograde obturation using an open apex model. Materials and Methods: Thirty-two recently extracted human maxillary anterior teeth with single, straight root canals were selected and divided into four groups: Group 1 (G1), White Mineral Trioxide Aggregate; the material was delivered into the canal using the MAP system and further compacted with a specific plugger. Group 2 (G2), TotalFill bioceramic Root Repair material: the material was injected directly into the middle half of the root canal. Group 3 (G3), BioDentine; the material was delivered into the canal using the Hawe composite gun and prefitted pluggers. Statistical Analysis: Statistical analysis was performed using the SPSS 23.0 statistical software package. The Kruskal–Wallis nonparametric test was applied to compare the differences in glucose microleakage. Results: There were no significant differences among the three experimental groups. The results showed a tendency for leakage to increase from the 1st day to the end of experimental period. Conclusions: Within the parameters of this in vitro study, it may be concluded that the three materials evaluated present similar apical microleakage when treating teeth with open apices requiring orthograde delivery of an apical barrier.

Comparing the antimicrobial efficacy of pediocin with chlorhexidine and calcium hydroxide as intracanal medicaments against persistent root canal infections Hui Ying Ooi, Wan Yi Tee, Fabian Davamani, Venkateshbabu Nagendrababu Journal of Conservative Dentistry 2019 22(3):241-244 Introduction: The aim of this study is to compare the antimicrobial activity of pediocin with chlorhexidine (CHX) and calcium hydroxide (Ca(OH)2) against Enterococcus faecalis and Staphylococcus epidermidis biofilms. Materials and Methods: The prepared root canals of 80 teeth were contaminated with E. faecalis (n = 40) and S. epidermidis (n = 40) for 21 days to create biofilms. The samples in each group were allocated randomly into the following four subgroups (n = 10) according to the decontamination protocol: Group 1: 1% Pediocin, Group 2: 2% CHX, Group 3: Ca(OH)2, and Group 4: saline (negative control). At 5 days, the antimicrobial efficacy of the medicaments against E. faecalis and S. epidermidis was assessed by collecting dentin shavings from the canal walls created using Gates Glidden drill sizes 4 and 5, corresponding to a depth into the root canal walls of 200 μm and 400 μm, respectively. The total number of colony-forming units (CFUs) was counted. The Wilcoxon signed-rank test was used to compare the difference in CFUs between the two depths (P > 0.05). Results: There was no bacterial growth in samples treated with pediocin, CHX, or Ca(OH)2 at either depth. Conclusion: In this laboratory experimental model, pediocin exhibited the same antimicrobial properties against E. faecalis and S. epidermidis as CHX and Ca(OH)2.

Comparative evaluation of the effect of surface treatment of fiber-reinforced posts and prefabricated metal posts on adhesion of a resin-based luting cement: An in vitro study Zarir R Ruttonji, Preethi B Kusugal, Ajaykumar Nayak, Deepa Mahajan, KM Sushma, Viraj N Patil Journal of Conservative Dentistry 2019 22(3):245-248 Background: The purpose of this study was to evaluate the effect of surface treatment of fiber-reinforce post and metal post of adhesion of a resin luting cement. Materials and Methods: Sixty methyl methacrylate specimens were fabricated with a customized metal rod. The samples were segregated into six groups (F1, F2, F3, M1, M2, and M3) of 10 specimens (n = 10) each. The first three groups (F1, F2, and F3) were for fiber posts and (M1, M2, and M3) were for metal posts. The postspace preparation was done with dedicated drills supplied by the postmanufacturers to a length of 14 mm. F1 and M1 were the control groups. The posts in F2 and M2 groups were treated with airborne-particle abrasion with 70 μm Al2O3 particles for 5 s at a constant distance of 20 mm, cleaned with alcohol and cemented in the postspace. The posts in the F3 and M3 groups were treated with airborne-particle abrasion followed by primer application. After cementing the posts into the postspace, the acrylic blocks were sectioned with a motor-driven jigsaw to obtain four specimens each of 3-mm thickness. These sections were then subjected to push-out tests on a universal testing machine. Results: There was a statistically significant increase in the bond strength of both fiber and metal posts to resin cement after airborne-particle abrasion with Al2O3 particles and airborne abrasion followed by primer application. Conclusion: There is an increase in the bond strength of the resin cement with the prefabricated posts after the various surface treatments.

Biocompatibility evaluation of Jordanian Portland cement for potential future dental application Abubaker S Qutieshat, Ahmad S Al-Hiyasat, Homa Darmani Journal of Conservative Dentistry 2019 22(3):249-254 Background: The demand for novel Portland cement (PC)-based formulations to be used in dental applications is ever increasing in viewing the foregoing knowledge on the favorable effects of these formulations on cellular proliferation and healing, leading to treatment success. Aim: This study investigated the effect of white and gray mineral trioxide aggregate (W-MTA and G-MTA) and white and gray Jordanian PC (W-PC and G-PC) in their raw state on the viability of Balb/C 3T3 fibroblasts using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Materials and Methods: Materials were prepared in the form of disks, with a diameter of 5 mm and a thickness of 2 mm. In the first experiment, Balb/C 3T3 fibroblasts were cultured with the material disks using culture plate inserts. In the second experiment, material elutes were added to cultured cells. The elutes were prepared by adding 2 ml serum-free media to 10 disks of each material and then incubated at 37°C for different time intervals. Material elutes were analyzed using ion chromatography for traces of calcium. The data were analyzed using analysis of variance followed by Dunnett test (α = 0.05) or Tukey test (α = 0.05). Results: In response to material disks, G-PC had a proliferative effect on cells at day 1 and day 2 with a significant difference from the control at day 1. G-MTA reduced cell viability with a significant difference from the control level at day 2. Elutes of PC showed biocompatible and even proliferative effects on Balb/C 3T3 fibroblasts. Calcium ions were found to leach continuously over the measurement period for all the materials tested in this work. Conclusion: Jordanian PC in its raw state was found to be biocompatible, and the results of this work give promise of its wider use as a base for further development to improve the physiochemical and mechanical properties of the material.

In vitro assessment of interaction between lidocaine hydrochloride and sodium hypochlorite on root canal dentin before and after chemomechanical instrumentation procedures Balasubramanian Saravanakarthikeyan, Shari Devarajan, Kolli Sankeerthana, Venkatappan Sujatha, Sekar Mahalaxmi Journal of Conservative Dentistry 2019 22(3):255-259 Introduction: To investigate the effect of resultant precipitate formed on interaction between 2% lidocaine hydrochloride with adrenaline (LA) and 2.5% sodium hypochlorite (NaOCl) on root canal dentin before and after chemomechanical preparation, using scanning electron microscopy (SEM). Methods: Sixty mandibular premolars were decoronated, and the root length was standardized. All specimens were randomly distributed into the following three groups: Group I (control): 2% LA mixed with sterile water without root canal instrumentation, Group II: 2% LA with 2.5% NaOCl and no instrumentation, and Group III: 2% LA with 2.5% NaOCl, followed by mechanical instrumentation with rotary files. Teeth samples were sectioned into three parts, split and SEM analysis of the root canal wall was done at cervical, middle, and apical root thirds. Results: SEM images revealed patent dentinal tubules with no precipitate occlusion in the control group, whereas there was occlusion of dentinal tubules with a precipitate in all the specimens in Group II and Group III at all the three root levels studied. Conclusions: The precipitate formed on the interaction between 2% LA solution and 2.5% NaOCl tends to occlude the dentinal tubules at the coronal, middle, and apical root thirds. The chemomechanical rotary instrumentation procedure did not effectively remove the precipitate from all the three levels of the root specimens studied. LA/sterile water group did not result in any precipitate formation on root canal dentin.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Medicine & Science in Sports & Exercise

Exercise Intensity Matters in Chronic Nonspecific Low Back Pain Rehabilitation Introduction Exercise therapy (ET) is advocated as a treatment for chronic nonspecific low back pain (CNSLBP). However, therapy effect sizes remain low. In other chronic disorders, training at higher intensity has resulted in greater improvements on both general health related and disease specific outcomes compared to lower intensity ET. Possibly, high intensity training also improves effect sizes in CNSLBP. Objective To compare the effects of a high intensity ET program with a similar moderate intensity ET program on disability, pain, function, exercise capacity, and abdominal/back muscle strength in persons with CNSLBP. Methods In a randomized controlled trial, persons with CNSLBP performed a 12-week ET program (24 sessions, 1.5hours/session, 2x/week) at high (HIT) or moderate intensity (MIT). Questionnaires to assess disability (Modified Oswestry Index (MODI)), pain intensity (Numeric Pain Rating Scale (NPRS)), and function (Patient Specific Functioning Scale (PSFS)), a cardiopulmonary exercise test to assess exercise capacity (VO2max, cycling time), and a maximum isometric muscle strength test to assess abdominal/back muscle strength (maximum muscle torque) were administered at baseline and after the training program. Results Thirty-eight participants (HIT: n=19, MIT: n=19) were included (mean age: 44.1y, SD=9.8, 12 males). Groups did not differ at baseline. Between group differences (p<0.01) in favor of HIT were found for MODI, VO2max, and cycling time. Within group improvements (p<0.01) were found in both groups on MODI (HIT:-64%, MIT:-33%), NPRS (HIT:-56%, MIT:-39%), PSFS (HIT:+37%, MIT:+39%), VO2max (HIT:+14, MIT:+4%), cycling time (HIT:+18%, MIT:+13%), and back muscle strength (HIT:+10%, MIT:+14%). Conclusion HIT proved to be a feasible, well tolerated, and effective therapy modality in CNSLBP. Moreover, it shows greater improvements on disability and exercise capacity than a similar ET performed at moderate intensity. Corresponding author: Jonas Verbrugghe, Hasselt University, Faculty of Rehabilitation Sciences, REVAL, Gebouw A, Agoralaan 5, 3590, Diepenbeek, Belgium, Tel: +003211269239, jonas.verbrugghe@uhasselt.be This project is funded by the UHasselt research fund BOF New initiatives (project number R-5211). This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results. The authors would like to thank all the persons with CNSLBP that participated in this study. Conflict of Interest. The authors report no conflict of interest. Accepted for Publication: 24 June 2019 © 2019 American College of Sports Medicine

Lower Trapezius Weakness and Shoulder Complex Biomechanics during the Tennis Serve PURPOSE This study aimed to assess the effect of lower trapezius (LT) weakness on humeral and scapular kinematics and shoulder muscle activity during the tennis serve. METHODS Fifteen competitive male tennis players (age: 23.8 ± 3.4 years; height: 182.8 ± 6.7 cm; mass: 76.6 ± 8.7 kg; tennis experience: 15.6 ± 4.9 years) performed two tennis serves before and after selective fatigue of the LT (25-min electric muscle stimulation). During each tennis serve, racket, humeral and scapular kinematics and the activity of 13 shoulder muscles were recorded using an optoelectronic system synchronized with indwelling and surface electromyography. The serve was split into five phases, i.e., early and late cocking, acceleration, early and late follow-through. RESULTS Selective fatigue led to a 22.5 ± 10.4% strength decrease but did not alter maximum racket speed and humerothoracic joint kinematics. However, increased scapular upward rotation was observed in the acceleration (p=0.02) and early follow-through (p=0.01) phases. Decreased muscular activity was observed during the early cocking phase for the LT (p=0.01), during the acceleration phase for the LT (p=0.01), anterior deltoid (p=0.03), pectoralis major (p=0.04) and subscapularis (p=0.03), and during the early follow-through phase for the anterior deltoid (p=0.03) and LT (p=0.04). CONCLUSION LT weakness altered neither serve velocity nor humerothoracic joint kinematics, but impaired scapulothoracic kinematics and anterior shoulder muscle activation. Such alterations may reduce the subacromial space and jeopardize humeral head stability. These findings shed new light on the consequences of LT weakness, highlighting the importance of monitoring and strengthening this muscle in overhead athletes. Corresponding author: Isabelle Rogowski, UCB Lyon 1 – UFRSTAPS, 27-29, bd du 11 novembre 1918, 69622 Villeurbanne Cedex France, E-mail: isabelle.rogowski@univ-lyon1.fr This study was supported by Auvergne-Rhône-Alpes with the explora'doc program and by Mitacs with the globalink program. Conflict of interest. The authors declare no conflict of interest. Accepted for Publication: 21 June 2019 © 2019 American College of Sports Medicine

Reduced Active Muscle Stiffness after Intermittent Submaximal Isometric Contractions Purpose Whether muscle stiffness is influenced by fatigue remains unclear. Classical methods used to assess muscle stiffness provide a global measure at the joint level. As fatigue may selectively affect specific muscles, a joint-level approach may not be sensitive enough to detect potential changes in muscle stiffness. Taking advantage of ultrasound shear wave elastography, this study aimed to determine the influence of a fatiguing protocol involving intermittent submaximal isometric contractions on muscle shear modulus (an index of stiffness). Methods Shear modulus was measured on either the vastus lateralis (VL; n=9) or the abductor digiti minimi (ADM; n=10) before and after 15-mins of intermittent submaximal isometric contractions at 60% of maximal voluntary contraction (MVC; 4 s ON, 4 s OFF). An index of active muscle stiffness was estimated PRE and POST-fatigue as the slope of the linear regression established between shear modulus and absolute joint force up to 60% MVC. Results After the fatiguing exercise, MVC was significantly decreased by 22 ± 7 % and 32 ± 15 % for knee extension and little finger abduction, respectively (p<0.001). When compared to PRE-fatigue, the index of active muscle stiffness was 12 ± 15 % lower for the VL (p < 0.031) and 44 ± 19 % lower for the ADM (p < 0.001) POST-fatigue. Conclusion Although the present results cannot clearly determine the involved mechanisms, they demonstrate a decreased active muscle stiffness after a fatiguing task involving intermittent submaximal isometric contractions. Further studies should now determine whether this change in stiffness affects performance and risk of injury. CORRESPONDING AUTHOR: Thomas LAPOLE, Laboratoire Interuniversitaire de Biologie de la Motricité, Bâtiment IRMIS, 10 rue de la Marandière, 42270 Saint Priest en Jarez, thomas.lapole@univ-st-etienne.fr The authors declare they have no conflict of interest. The authors did not receive any funding for this study. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by ACSM. Accepted for Publication: 21 June 2019 © 2019 American College of Sports Medicine

High-Intensity Interval Training is Feasible in Women at High Risk for Breast Cancer Purpose This trial aimed to demonstrate feasibility of high-intensity interval training (HIIT) in post-menopausal, overweight/obese women at high-risk of invasive breast cancer, and explore HIIT on changes in cardiorespiratory fitness (CRF), body weight, and body mass index (BMI) compared to moderate-intensity continuous training (MICT) and usual care (UC). Methods Forty-four women were randomized to HIIT, MICT or UC for a 12-week, thrice weekly, supervised exercise intervention. HIIT included a 5-minute warm-up at 50-70% peak heart rate (HR), four cycles of four minutes at 90-100% peak HR followed by three minutes at 50-70% peak HR. MICT consisted of 41 minutes at 60-70% peak HR. Feasibility was assessed by consent, adherence, compliance and retention rates. CRF, body weight and BMI were measured at baseline and end-of-study. Repeated measures linear mixed models were used to assess within- and between-group differences. Results Average age was 63.9±8.8 years. BMI was 30.9±5.7 kg/m2. Participants completed 90% and 89% of HIIT and MICT workouts respectively, with 100% compliance to the exercise prescriptions. No serious adverse events were reported. Compared to MICT and UC, HIIT exhibited improvements in change in treadmill time (101 seconds greater than MICT, and 125 seconds greater than UC, respectively, p<0.001). Compared to UC, HIIT exhibited improvement in changes in absolute and relative VO2peak (a 0.15 increase in L/min, p=0.005; and 2.3 increase in ml/kg/min, p=0.004). There were no significant differences between groups for body weight or BMI (p>0.05). Conclusions HIIT is feasible, safe, and appears to promote greater improvements in CRF compared to MICT and UC in women at high risk for breast cancer. Correspondence: Susan C Gilchrist, MD; The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1360, Houston TX 77230-1439; Phone: 713-745-6251; Fax: 713-794-4403; sgilchrist@mdanderson.org The authors thank the NCI R25 Cancer Prevention Research Training Program (CA057730, PI: Shine Chang PhD), the MD Anderson Cancer Center/Energy Balance Assessment Supplemental Funding (PI: Susan Gilchrist MD), and the MD Anderson Cancer Center, Center for Energy Balance in Cancer Prevention and Survivorship. The authors declare that they have no conflicts of interest to disclose. The results of the present study do not constitute endorsement by the ACSM, and are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for publication: 10 May 2019. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 American College of Sports Medicine

Data-informed Intervention Improves Football Technique and Reduces Head Impacts Introduction Although sport participation is a key contributor to the physical and mental health of children and youth, exposure to sub-concussive head impacts in football has raised concerns about safety for athletes. Purpose To demonstrate the efficacy of incorporating targeted football drills into a team's practice routine with the goal of improving players' technique, and reduce exposure to sub-concussive head impacts. Methods Seventy high-school football players (age=16.4±1.1years) were tested PRE-season using a sport-specific functional assessment. Results from the testing were used to inform the design of a pre-practice intervention aimed at improving tackling and blocking techniques, while reducing exposure to head impacts. The assessment included drills which evaluated the players' ability to safely tackle, and block, while simulating game-like situations. Testing was repeated at MID-season (internal control) without an intervention, and again at POST-season (experimental), following introduction of the pre-practice intervention between these timepoints, administered twice weekly. All testing sessions were recorded, and subsequently reviewed by trained graders based on selected criteria defined by football coaches. A subset of nineteen participants wore in-helmet accelerometers to assess the effectiveness of the intervention in decreasing head impacts during practice. Results Significant improvements in blocking and tackling techniques were observed following the introduction of the intervention (P<0.0001). Participating athletes also showed better techniques when evaluated in new game-like situations, post-season, providing evidence for proper acquisition and generalizability of these safer habits. Finally, frequency of head impacts (>15g) per practice was significantly reduced by ~30% after one month of training. Conclusion Our results suggest that data-informed methods can be used to improve coaching practices, and promote safer play, which can have a positive public health impact moving forward. Corresponding author: Douglas J. Cook, Department of Surgery, Queen's University, Room 232, 18 Stuart St. Kingston, ON K7L 3N6. Phone: 613-549-6666 ext. 3696. Fax: 613-548-1346. dj.cook@queensu.ca Results from this study are presented clearly, honestly and without fabrication, falsification, or inappropriate data manipulation. Results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare no conflict of interest. Funding from the Southeastern Ontario Academic Medical Organization (SEAMO) helped making this project possible. Accepted for publication: 7 May 2019. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 American College of Sports Medicine

Motor Strategies Learned during Pain Are Sustained upon Pain-free Re-exposure to Task Introduction Pain affects movement planning and execution, and may interfere with the ability to learn new motor skills. Variations among previous studies suggest task-specific effects of pain on the initial acquisition and subsequent retention of motor strategies. Methods The present study assessed how acute pain in the anterior deltoid muscle affects movement accuracy of fast arm-reaching movements during force field perturbations, and upon immediate pain-free repetition of the same task. Results Despite having slower initial rate of improvement, individuals who experienced pain during training achieved the same final performance as pain-free controls. However, pain altered the strategy of muscle activation adopted to perform the task, which involved less activity of the shoulder and arm muscles. Strikingly, motor strategies developed during the first exposure to the force field were retained upon re-exposure to the same perturbation, after resolution of pain. Conclusion Although reduced muscle activation may be interpreted as metabolically efficient, it reduces joint stability and can have negative consequences for joint integrity. These results demonstrate that alternative motor strategies developed in the presence of pain can be maintained when training is resumed after resolution of pain. This effect could have deleterious consequences if it applies when learning motor skills in sports training and rehabilitation. Corresponding author: Dr Paul W. Hodges, School of Health and Rehabilitation Sciences, The University of Queenslandm, Brisbane QLD 4072, Australia, Phone: +61 7 3365 2008, E-mail: p.hodges@uq.edu.au Disclosures and Acknowledgements This study was funded by a Program Grant (APP1091302), a Senior Principal Research Fellowship (APP1102905) from the National Health and Medical Research Council (NHMRC) of Australia, and a Future Fellowship grant to TC (FT120100391). The authors have no conflicts of interest to declare. All the authors are properly listed, and all have contributed substantially to the manuscript. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and statement that results of the present study do not constitute endorsement by ACSM. Accepted for Publication: 29 May 2019 © 2019 American College of Sports Medicine

Cytokine and Sclerostin Response to High-Intensity Interval Running versus Cycling Purpose This study examined whether the exercise-induced changes in inflammatory cytokines differ between impact and no-impact high intensity interval exercise, and whether they are associated with post-exercise changes in sclerostin. Methods Thirty-eight females (n=19, 22.6±2.7 years) and males (n=19, 22.3±2.4 years) performed two high-intensity interval exercise trials in random order (cross-over design): running on a treadmill and cycling on a cycle ergometer. Trials consisted of eight repetitions of 1 min running or cycling at ≥90% maximal heart rate, separated by 1 min passive recovery intervals. Blood was collected pre-exercise, and 5 min, 1h, 24h and 48h post-exercise, and was analyzed for serum levels of interleukins (IL-1β, IL-6, IL-10), tumor necrosis factor alpha (TNF-α) and sclerostin. Results Inflammatory cytokines significantly increased over time in both sexes with some differences between trials. Specifically, IL-1β significantly increased from pre- to 5 min after both trials (23%, p<0.05), IL-6 increased 1h following both trials (39%, p<0.05), IL-10 was elevated 5 min after running (20%, p<0.05) and 1h after both running and cycling (41% and 64%, respectively, p<0.05), and TNF-α increased 5 min after running (10%, p<0.05). Sclerostin increased 5 min following both trials, with a greater increase in males than in females (62 vs 32 pg/ml in running, p=0.018; 63 vs 30 pg/ml in cycling, p=0.004). In addition, sclerostin was significantly correlated with the corresponding changes in inflammatory cytokines and 34% of the variance in its post-exercise gain score (Δ) was explained by sex and the corresponding gain scores in TNF-α, which was the strongest predictor. Conclusion A single bout of either impact or no-impact high-intensity exercise induces changes in inflammatory cytokines, which are associated with the post-exercise increase in sclerostin. Corresponding author: Panagiota Klentrou Department of Kinesiology Faculty of Applied Health Sciences Brock University 1812 Sir Isaac Brock Way St. Catharines, ON, L2S 3A1, Canada E-mail: nklentrou@brocku.ca This study was funded by a National Science Engineer Research Council of Canada (NSERC) grant to P. Klentrou (grant # 2015-04424). R. Kouvelioti holds an Ontario Trillium Scholarship. N. Kurgan holds an NSERC Doctoral Scholarship. W. Wards holds a Canada Research Chair in Bone and Muscle Development. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by ACSM. Conflicts of interest: The authors have no conflict of interest to declare. Accepted for publication: 14 June 2019. © 2019 American College of Sports Medicine

Extended Sleep Maintains Endurance Performance better than Normal or Restricted Sleep Purpose The cumulative influence of sleep time on endurance performance remains unclear. This study examined effects of three consecutive nights of both sleep extension and restriction on endurance cycling performance. Methods Endurance cyclists/triathletes (n=9) completed a counterbalanced crossover experiment with three conditions; sleep restriction (SR), normal sleep (NS), and sleep extension (SE). Each condition comprised seven days/nights of data collection (-2, -1, D1, D2, D3, D4, +1). Sleep was monitored using actigraphy throughout. Participants completed testing sessions on days D1-D4 that included an endurance time-trial (TT), mood, and psychomotor vigilance assessment. Perceived exertion (RPE) was monitored throughout each TT. Participants slept habitually prior to D1, however, time in bed was reduced by 30% (SR), remained normal (NS), or extended by 30% (SE) on nights D1, D2, and D3. Data were analysed using Generalised Estimating Equations. Results On nights D1, D2, and D3, total sleep time was longer (P<0.001) in the SE condition (8.6±1.0; 8.3±0.6; 8.2±0.6h, respectively), and shorter (P<0.001) in the SR condition (4.7±0.8; 4.8±0.8; 4.9±0.4h) compared with NS (7.1±0.8; 6.5±1.0; 6.9±0.7h). Compared with NS, TT performance was slower (P<0.02) on D3 of SR (58.8±2.5 vs 60.4±3.7min) and faster (P<0.02) on D4 of SE (58.7±3.4 vs 56.8±3.1min). RPE was not different between or within conditions. Compared with NS, mood disturbance was higher-, and psychomotor vigilance impaired, following SR. Compared with NS, psychomotor vigilance improved following SE. Conclusion Sleep extension for three nights led to better maintenance of endurance performance compared with normal and restricted sleep. Sleep restriction impaired performance. Cumulative sleep time affects performance by altering the perceived exertion of a given exercise intensity. Endurance athletes should sleep >8 hours per night to optimise performance. Corresponding author: Spencer S. H. Roberts, PhD Candidate School of Exercise and Nutrition Sciences, Deakin University. 221 Burwood Hwy, Burwood, Victoria, Australia, 3125 Email: rspen@deakin.edu.au The results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Results do not constitute endorsement by the American College of Sports Medicine. Spencer Roberts, Wei-Peng Teo, Brad Aisbett, and Stuart Warmington declare they have no conflict of interest. The authors acknowledge the School of Exercise and Nutrition Sciences at Deakin University for funding the study. Accepted for publication: 9 June 2019. © 2019 American College of Sports Medicine

Methodological Recommendations for Menstrual Cycle Research in Sports and Exercise Introduction The aim of this review is to provide methodological recommendations for menstrual cycle research in exercise science and sports medicine based on a review of recent literature. Research in this area is growing, but often reports conflicting results and it is proposed that some of this may be explained by methodological issues. Methods This review examined the menstrual cycle verification methodologies used in recent literature on exercise performance over the menstrual cycle identified through a literature search of PubMed and SportDiscus from 2008 until 2018. Results Potential changes over the menstrual cycle are likely related to hormone fluctuations, however, only 44% of the selected studies measured the actual concentrations of the female steroid hormones estrogen and progesterone. It was shown that the likely inclusion of participants with anovulatory or luteal phase deficient cycles in combination with small participant numbers has impacted results in recent menstrual cycle research and consequently our understanding of this area. Conclusion To improve the quality of future menstrual cycle research it is recommended that a combination of three methods is used to verify menstrual cycle phase: the calendar-based counting method combined with urinary luteinizing hormone surge testing and the measurement of serum estrogen and progesterone concentrations at the time of testing. A strict luteal phase verification limit of >16 nmol·L-1 for progesterone should be set. It is also recommended that future research focusses on the inclusion of the late follicular estrogen peak. It is envisaged that these methodological recommendations will assist in clarifying some of the disagreement around the effects of the menstrual cycle on exercise performance and other aspects of exercise science and sports medicine. Corresponding author: Xanne Janse de Jonge Exercise & Sport Science Faculty of Science The University of Newcastle, Australia Central Coast Campus PO Box 127 Ourimbah NSW 2258 Australia E: X.Jansedejonge@newcastle.edu.au ORCID 0000-0003-3657-5298 Xanne Janse de Jonge, Belinda Thompson and Ahreum Han declare that they have no conflicts of interest relevant to the content of this review. The results of the present study do not constitute endorsement by ACSM. The results of this review are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. No funding was received for this review. Accepted for publication: 22 May 2019. © 2019 American College of Sports Medicine

Estimated Cardiorespiratory Fitness and Risk of Atrial Fibrillation: The HUNT Study Purpose To investigate the association between estimated cardiorespiratory fitness (eCRF) and risk of atrial fibrillation (AF), and examine how long-term changes in eCRF affects the AF risk. Methods This prospective cohort study includes data of 39 844 men and women from the HUNT2 (August 15, 1995 - June 18, 1997) and the HUNT3 study (October 3, 2006 – June 25, 2008). The follow-up period was from HUNT3 until AF diagnosis or November 30, 2015. AF diagnoses were retrieved from hospital registers and validated by medical doctors. A non-exercise test based on age, waist circumference, resting heart rate and self-reported physical activity was used to estimate CRF. Cox regression was performed to assess the association between eCRF and AF. Results The mean age was 50.6 ± 14.6 years for men and 50.2 ± 15.2 years for women. Mean follow-up time was 8.1 years. 1 057 cases of AF were documented. For men, the highest risk reduction of AF was 31% in the 4th quintile of eCRF when compared to the 1st quintile (HR, 0.69; 95% CI, 0.53-0.89). For women, the highest risk reduction was 47% in the 5th quintile when compared to the 1st quintile (HR, 0.53; 95% CI, 0.38-0.74). One metabolic equivalent increase in eCRF over a 10-year period was associated with 7% lower risk of AF (HR, 0.93; 95% CI, 0.86-1.00) Participants with improved eCRF had 44% lower AF risk compared to those with decreased eCRF (HR, 0.56; 95% CI, 0.36-0.87). Conclusion eCRF was inversely associated with AF, and participants with improved eCRF over a 10-year period had less risk of AF. These findings support the hypothesis that fitness may prevent AF. Correspondence and reprints to: Lars E. Garnvik, Department of Circulation and Medical Imaging, NTNU, Medisinsk Teknisk Forskningssenter, Post box 8905, 7491 Trondheim, Norway. E-mail: lars.e.garnvik@ntnu.no This work was supported by grants from the The Liaison Committee for education, research and innovation in Central Norway. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and statement that results of the present study do not constitute endorsement by ACSM. The Nord-Trøndelag Health Study (The HUNT Study) is a collaboration between HUNT Research Centre, (Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology), Trøndelag County Council, Central Norway Regional Health Authority, and the Norwegian Institute of Public Health. We would like to thank all the participants and technicians of the HUNT study for their contributions. Conflict of interest: None declared. Accepted for publication: 14 June 2019. © 2019 American College of Sports Medicine

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Physical Medicine & Rehabilitation

Influence of anxiety and depression, self-rated return-to-work problems, and unemployment on the outcome of outpatient rehabilitation following shoulder arthroscopy Objective The objective was to research the influence of psychosocial confounders on outpatient rehabilitation after arthroscopic shoulder surgery. Design: This retrospective study included patients who underwent such rehabilitation in a single center between 01/2014 and 10/2016. Shoulder function (CSS - Constant Shoulder Score) and pain (VAS – visual analogue scale), improvements in these scores, and patient satisfaction were evaluated with regard to anxiety and depression (HADS – Hospital anxiety and depression scale), self-rated return-to-work problems (WBS - Würzburg screening), and employment status. Results The analysis included 176 patients. The mean CSS and VAS improved from 53.9±18 to 75.4±16.5 and 4.6±2.1 to 2.9±2.4cm, respectively. 84.1% of the patients were satisfied with the outcome. Unemployed patients (p=0.001) and HADS-positive ones (p=0.014) were less satisfied than their counterparts. Patients with a WBS-positive screening showed less improvement in pain (p=0.015), function (p=0.016), and satisfaction (p=0.002) than those without. Unemployed reported more pain (p=0.008) than employed patients when starting rehabilitation. At the end of rehabilitation, all psychosocial scores (HADS p=0.002; WBS p=0.001; unemployment p<0.001) negatively influenced pain, WBS (p=0.007) and unemployment (p=0.008) function. Conclusions Because we identified psychosocial factors that influence the success of outpatient shoulder rehabilitation, rehabilitation setup should be adjusted in patients with such problems. Corresponding author: PD Dr. Patrick Strube, Klinik für Orthopädie, University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany, Tel. +49 (36691) 8 1439, Fax +49 (36691) 8 1856, e-mail: patrick.strube@uni-jena.de Author Disclosures: None of the authors has to report any competing interests or financial benefits. No funding, grant, or equipment was received for the present study. The study was not presented or published before. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Constraint-induced Movement Therapy for improving motor function of the paretic lower extremity after stroke: a case report A 56-year-old woman with chronic stroke and gait dysfunction was recruited for this study. A Lower-Extremity Constraint-Induced Movement Therapy (LE-CIMT) protocol was given consisting of 3.5 hours/day of supervised intervention activities on 10 consecutive weekdays. Motor training was intensive and involved shaping. In addition, a group of behavior management strategies was employed to induce further unsupervised practice and transference of motor skills from the laboratory to real world situations. Changes in functional mobility, walking speed, balance, level of assistance, perceived quality of movement and level of confidence while performing daily activities were assessed five times in both the baseline and intervention phases. The outcomes observed after the intervention were determined by calculating the difference between the average scores obtained in both phases. Changes in perceived quality of movement, level of confidence, level of assistance, and balance were observed. Correspondence: Sarah dos Anjos, University of Alabama at Birmingham, 1720 2nd Avenue South, SHPB360. Birmingham, AL, USA. 35.294-0001. Disclosures: The authors have no conflict of interest. No funding was received. Clinicaltrials.gov: NCT03114046 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effects of Whole Body Vibration on Motor Impairments in Patients with Neurological Disorders: A Systematic Review Objective This systematic review was conducted to examine the effects of whole body vibration (WBV) training on motor impairments among patients with neurological disorders, and to investigate which the whole body vibration training parameters induced improvement in motor impairments. Design PubMed, SCOPUS, PEDro, REHABDATA, and web of science were searched for randomized controlled trials and Pseudo- randomized controlled trials investigated the effect of WBV on motor impairments in patients with neurological disorders. The methodological quality was rated using the Cochrane Collaboration's tool Results Twenty studies were included in this systematic review. Four studies included patients with multiple sclerosis, cerebral palsy (n=2), stroke (n=9), Parkinson's disease (n=3), spinal cord injuries (n=1), and spino-cerebellar ataxia (n=1). The results showed different evidence of benefits and non-benefits for WBV training in motor impairments outcomes. Conclusion There is weak evidence for a positive effect of short-term WBV training on spasticity of lower extremities, mobility, balance and postural control. Besides, positive effect of the long-term effect of WBV training on mobility in patients with neurological disorders. The optimal WBV training parameters in treating patients with neurological disorders remain unclear. Anas Alashram, MSc, Doctorate Student in Neurology Department, Faculty of Medicine and Surgery, University of Rome "Tor Vergata", Italy, anasalashram@gmail.com Elvira Padua, PhD, Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy. elvira.padua@unisanraffaele.gov.it Giuseppe Annino, PhD, Department of Medicine System, University of Rome "Tor Vergata", Italy, g_annino@hotmail.com Correspond author: Anas R. Alashram, Deperatment of Neurology University of Rome Tor Vergata, Rome, Italy E-mail: anasalashram@gmail.com Sources of funding/acknowledgements: The authors have no source of funding or any potential conflicts of interest to disclose. Funding or grants or equipment provided for the project from any source: None. Financial benefits to the authors: None. Details of any previous presentation of the research, manuscript, or abstract in any form: None. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Ultrasound Imaging for Lateral Elbow Pain: Pinpointing the Epicondylosis No abstract available

Creation and initial validation of a picture-based version of the limitations of activity domain of the SF-36 Those with limited language comprehension or literacy face problems completing written questionnaires evaluating their health or physical status on which treatment plans are based. This brief report describes how a picture-based version of the 10 items in the limitations of activities (LoA) section of the SF-36 was developed iteratively and then piloted. Study participants: 101 community-living volunteers (58 female 43 male aged 18-93 years) educated to post-secondary level (52) high school grades 10-12 (44) and grade 9 or less (5). They first completed the picture-based SF-36LoA and described verbally and in writing what they understood each picture to mean, and then completed the English text version of the SF-36LoA domain for comparison assessment. Additional feedback suggested where pictures could be altered to increase information capture. Subjects rated their health as 26.7% excellent, 25.7% very good, 29.8% good, 10.9% fair and 6.9% poor. Analysis showed strong correlation between text-based SF-36LoA questions and the picture-based visual score – VSF-36LoA - (ICC=0.98) with question 10 correlating highest (ICC=0.90) and question 2 lowest (ICC=0.82). The VSF-36LoA is the first picture-based version of the SF-36; good correlation with the text-based version and global need warrants further development to aid those with limited literacy or language comprehension. Corresponding author: Macnab, Andrew John MD (London), Department of Pediatrics, University of British Columbia, Room C234, BC Children's Hospital, 4500 Oak Street, Vancouver, BC Canada V6H 3N1, phone: 604 875 2850, fax: 604 875 2530, ajmacnab@gmail.com Submitted to: American Journal of Physical Medicine and Rehabilitation Funding: none received Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Usefulness of Basic Movement Scale in Hip Fracture Patients – Construct Validity from a Cross-Sectional Study Objective To investigate the validity of using total score and to examine the constitution and characteristics of the Basic Movement Scale (BMS) in post-surgery patients with hip fracture. Design The dimensionality and the threshold difficulty intervals between each score and item difficulty hierarchy of the BMS were examined using factor analysis and Rasch analysis in 37 patients admitted to our hospital between April and November 2015. Results For factor analysis, the contribution ratio of the first factor was 78.9%, that of the second factor was 6.5%, and there were no items that fit the Rasch analysis. The threshold was reversed at six of the 48 locations. The difficulty of the 12 BMS items was distributed roughly evenly among all 9 lots, with some deviation. There was one very easy item, and there were some items almost overlapping in difficulty. Conclusions The results showed a unidimensional association between the items and evaluation index. The difficulty threshold of each score was approximated to the interval scale. Therefore, the BMS has evident construct validity and enables quantitative evaluation of physical ability, assessment of the effects of daily training, and general predictions of the feasibility of patients' clinical goals. (190words) All correspondence and requests for reprints should be addressed to: Tai Takahashi, MD, PhD, Department of Social Services and Healthcare Management, School of Health and Welfare, International University of Health and Welfare, Akasaka 4-1-26, Minato-ku, Tokyo, Japan Phone: 03-5574-3900 FAX: 03-5574-3961 e-mail: taiiuhw@gmail.com) Author Disclosures: The authors have no conflicts of interest directly related to the content of this work. No funds, grants, or facilities were obtained for this project from any sources of funding, and there was no financial gain. This manuscript has not been published previously in any form. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Caring for Patients with Physical Disabilities: Assessment of an Innovative Spinal Cord Injury Session that Addresses an Educational Gap Despite the fact that one-fifth of Americans live with disability, caring for these patients is not routinely part of the undergraduate medical student curriculum. An innovative session addressing care of patients with spinal cord injury (SCI) was developed for medical students and led by physiatrists, faculty experts in communications and individuals with SCI. A mixed-method design was utilized in evaluating students' knowledge, skills and attitudes following this curriculum. Quantitative evaluation was performed with a written essay question and checklist items from an objective structured clinical examination (OSCE) station. The session was given to 296 students from 2016 to 2018. On the OSCE, 94% asked about sexual function, 85% asked about activities of daily living (ADL), 77% asked about instrumental activities of daily living (IADL) and 47% of students evaluated skin health. Students demonstrated respectful (99%) and non-judgmental (99%) attitudes with SCI standardized patients (SPs) and 91% interacted with the SP's caretaker appropriately. Themes emerged from the student survey including: the value of having real patients present during the session, exposure to physical medicine and rehabilitation (PM&R) as a specialty, and the advantage of a small group format. This session provided students with tools necessary to care for patients with SCI. Corresponding author: Janice Thomas John, DO, MS, MPH, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, Phone: 516-463-7577 Fax: 516-463-5631; email: janice.t.john@hofstra.edu Author disclosures:Janice Thomas John DO, MS, MPH- nothing to disclose. Lauren Block MD, MPH - nothing to disclose. Adam Stein MD- nothing to disclose. Elizabeth Vasile, MPH- nothing to disclose. Maria-Louise Barilla-LaBarca MD-nothing to disclose Sources of funding: None Previous presentations: 2017 data was presented at: 1. Directors of Clinical Skills (DOCS) Annual Meeting, 2017. Boston, MA (poster). 2. Association of Academic Physiatrist (AAP) Annual Meeting, 2018 Atlanta, GA (platform presentation) Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Does performance on the American Board of Physical Medicine and Rehabilitation initial certification examinations predict future physician disciplinary actions? Objective To determine the relationship between performance on the American Board of Physical Medicine and Rehabilitation (ABPMR) primary certification examinations and the risk of subsequent disciplinary actions (DAs) by state medical boards over a physician's career. The hypothesis is that physicians who do not pass either or both of the two initial specialty certification examinations are at higher risk of disciplinary action (DA) from a state medical licensing board. Design This is a retrospective cohort study which analyzed board certification examination data from all physicians who completed Physical Medicine and Rehabilitation (PM&R) residency between 1968 and 2017. Results Matching examination and license data were available for 9,889 PM&R physicians, who received a total of 547 DA reports through the Federation of State Medical Boards. The results showed a significant correlation between failing an ABPMR certification examination and the risk of subsequent DA by a state medical board. Failure to pass either the written (Part I) or oral (Part II) examination increased the risk of subsequent DA by 5.77-fold (p< 0.0001, 95% Cl 4.07, 8.18). Conclusion Physicians in PM&R who do not pass initial certification examinations and become Board Certified are at higher risk of DA from a state medical licensing board throughout their careers. Dr. Kinney and Dr. Raddatz are employees of the American Board of Physical Medicine and Rehabilitation. No other disclosures. No funding was received for this study. Corresponding author: Carolyn L. Kinney, MD, American Board of Physical Medicine and Rehabilitation, 3015 Allegro Park Ln SW, Rochester, MN 55902, 507-282-1776, Ext. 1743, Email : ckinney@abpmr.org, Fax : 507-282-9242 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Vague Posterior Knee Discomfort in a Soccer Player: A Case Report A 24-year-old male soccer player presented with a 7-year history of left posterior knee "looseness." Evaluation 7 years ago, at the time of initial injury, revealed atraumatic ACL and PCL sprains. On re-presentation, the patient described the pain as a constant, dull ache, 3/10, but his biggest complaint was this feeling of "instability" and "looseness" where his knee would "buckle" 3-4 times a week. Physical exam was positive for grade 1 posterior drawer and grade 1 posterior sag signs. Reverse KT-1000 testing showed a 3 mm side-to-side difference. Sonographic evaluation confirmed MRI findings of PCL laxity and buckling and a small cystic lesion abutting the posteromedial margin of the distal 1/3 of the PCL. After a trial of physical therapy, the patient elected to undergo experimental injection of dextrose hyperosmolar solution. This resulted in resolution of the cyst and reverse KT-1000 measurements improved to a side-to-side difference of 1 mm. The patient's subjective feeling of "looseness" and "instability" resolved by 7 weeks. No funding was received for this study. Corresponding Author: Allison Schroeder, 2626 Tunnel Boulevard Apt 326, Pittsburgh, PA 15203, Email: aschroe1@alumni.nd.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Subtle dysmetria after a hemorrhage in the basal ganglia and lentiform nucleus No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Neurology

No evidence of disease activity (NEDA) in multiple sclerosis - Shifting the goal posts Lekha Pandit Annals of Indian Academy of Neurology 2019 22(3):261-263 A combined endpoint measure to define no evidence of disease activity (NEDA) is becoming increasingly appealing in the treatment of multiple sclerosis (MS). Initial efforts using a 3 parameter NEDA monitored disease activity using clinical and MRI lesion data. Later refinements, introduced more recently, include brain atrophy measurement and cognitive function analysis in defining NEDA-4. Using these stringent criteria clearly differentiated the usefulness of different disease modifying agents (DMDs) in achieving and sustaining NEDA over time. This in turn has changed attitudes and strategies in management of MS.

The neurologist and artificial intelligence: Titans at crossroads Venugopalan Y Vishnu, Pulikottil Wilson Vinny Annals of Indian Academy of Neurology 2019 22(3):264-266 Clinical judgment to reach final diagnosis has remained a challenge since time immemorial. The present times are witness to artificial intelligence (AI) and machine learning programs competing to outperform the seasoned physician in arriving at a differential diagnosis. We discuss here the possible roles of AI in neurology.

The Ape's Tail Ajith Cherian Annals of Indian Academy of Neurology 2019 22(3):266-266

Neurodegeneration with brain iron accumulation Amit Batla, Chandana Gaddipati Annals of Indian Academy of Neurology 2019 22(3):267-276 The term NBIA encompasses a heterogeneous group of inherited disorders characterized clinically by progressive extra pyramidal syndrome and pathologically by excessive iron deposition in brain, primarily affecting the basal ganglia (globus pallidus mainly).The hallmark of this syndrome is the age specific phenotypic presentation and intraphenotypic heterogeneity. NBIAs at present include ten subtypes with genes identified in nine subtypes. They form an important differential diagnosis for the phenotype of global developmental delay in infancy/childhood to dystonia-parkinsonism or isolated parkinsonism at all ages and also for the isolated craniocervical dystonia of adult onset. There needs to be a high index of clinical suspicion for this syndrome and the evaluation includes MRI brain T2* weighted imaging which reveal symmetrical iron deposition in bilateral globus pallidi and other basal ganglia. The T2 * imaging pattern of iron deposition varies amongst the different subtypes and the combination of clinical phenotype and MRI signature makes it easier to confidently make a diagnosis of NBIA and to recommend genetic testing. The treatment to date is mostly symptomatic with targeted therapies on the horizon.

Association of serum levels of calcitonin gene-related peptide and cytokines during migraine attacks Dawei Han Annals of Indian Academy of Neurology 2019 22(3):277-281 Background: During a migraine attack, trigeminal activation results in the release of calcitonin gene-related peptide (CGRP), which stimulates the release of inflammatory cytokines playing an important role in migraine. Objective: We analyze the relation between CGRP and cytokines during attacks to explore the possible mechanism of migraine. Materials and Methods: Migraine patients and healthy control were recruited at the Department of Neurology, the Sixth People's Hospital of Fuyang City, between March 2018 and July 2018. The protein levels of interleukin (IL)-1β, IL-2, IL-6, IL-10, tumor necrosis factor-alpha (TNF-α), and CGRP were determined from the sera of patients with migraine and control subjects by enzyme-linked immunosorbent assay kits. Spearman's rank correlation coefficient was also determined to calculate the correlation between CGRP and inflammatory factors levels. Results: The level of IL-1β, IL-6, TNF-α, and CGRP in migraine group were significantly higher than normal group (P < 0.05). The level of CGRP was significantly correlated with IL-1 β (r = 0.30, P < 0.05) and IL-6 (r = 0.94, P < 0.05), but not significantly correlated with IL-2 (r =−0.047, P = 0.75), IL-10 (r = 0.12, P = 0.43), and TNF-α (r = 0.05, P = 0.72). Conclusions: In our study, we found migraine patients had a higher IL-6, IL-1β, and TNF level than healthy controls and the level of CGRP was related significantly with the level of IL-1β and IL-6. In conclusion, our results suggest that IL-1β and IL-6 may be involved in the pathogenesis of migraine attacks and CGRP related with the secretion of cytokines.

Cranial Autonomic symptoms, neck pain: Challenges in pediatric migraine Zeliha Haytoglu, Mihriban Ozlem Herguner Annals of Indian Academy of Neurology 2019 22(3):282-285 Objectives: More than just a headache, migraine attack is a severe, prolonged head pain preceded and/or followed by a constellation of symptoms. Getting a proper diagnosis will be the most challenging step of migraine care. When cranial autonomic symptoms (CASs), and/or neck pain are observed, children are often exposed to advanced tests for additional diseases. The aim of this study was to investigate the frequency of these symptoms in migraine and to compare the clinical characteristics of patients with and without these symptoms. Frequency of the patients that exposed to the additional investigations was searched. Materials and Methods: In this prospective study between February 2016 and March 2017, 170 pediatric patients who were referred to our tertiary teaching hospital with migraine were enrolled. Results: A total of 170 children, 61 male (35.9%) and 109 female (64.1%) were included in the study. CASs were present in 68 patients (40%), single symptom in 31 (45.6%), and multiple symptoms in 37 (54.4%) patients. Of 68 patients with CAS, 24 (35%) patients were referred to allergists and all were tested for inhaler specific IgE and skin tests. Seventy (32.9%) patients had neck pain/stiffness in which 28 (40%) were exposed to radiation. CAS and neck pain were more frequent in patients with frequent attacks (P = 0.04 and P = 0.032, respectively). Neck pain was more frequent in patients with CAS (P = 0.029). Conclusions: It is important for pediatricians and primary care physicians to be aware of the common nature of CASs and neck pain/stiffness in children with migraine to prevent unnecessary procedures. High frequency of migrain attacks was associated with high frequency of CAS and neck pain.

Memantine ameliorates migraine headache Sundar Shanmugam, Kranthi Karunaikadal, Sathyanarayanan Varadarajan, Muthuraj Krishnan Annals of Indian Academy of Neurology 2019 22(3):286-290 Background and Objective: A significant number of migraine patients do not find effective and safe treatment to reduce the frequency and severity of their migraine attacks. Hence, a need for newer therapeutic agent exists. In this study, we examined the efficacy and safety of memantine for the treatment of migraine. Materials and Methods: It was a randomized, placebo-controlled, double-blind study including adult patients with 3–12 migraine headache for the last 6 months conducted in India. Patients received memantine (10 mg/day, once a day) or placebo for the period of 24 weeks after a washout period. Migraine frequency per month, the 50% responder rate, rescue medication use, and adverse events were recorded every 4 weeks. Results: Among 81 patients screened, 60 were enrolled for the study. Thirty patients received memantine and other 30 received placebo. Data were analyzed for 28 patients in memantine group and 29 patients in placebo group. At the baseline, all the parameters were similar in both groups. By 24 weeks, migraine frequency/4 weeks was memantine group versus placebo; 2.57 (±0.38) versus 5.07 (±0.69), P = 0.003 and rescue medication use was 0.75 (±0.23) versus 3.72 (±0.63) P = 0.0001. The 50% responder rate was 85.7% versus 51.7% (P = 0.005). Only a few mild adverse events were recorded in both the groups. No severe adverse events and death were recorded during the study. Conclusion: Memantine (10 mg oral, once daily) is effective, well tolerated, and safe for patients with migraine.

Prevalence and predictors of female sexual dysfunction in migraine R Pradeep, Harsha Sundarmurthy, Vivek Karan, Praveen Kulkarni Annals of Indian Academy of Neurology 2019 22(3):291-294 Background: Migraine is a common cause of primary headache, with women being affected thrice as common as men. Very few studies are available on sexual dysfunction in female migraineurs. There are no published studies done on the same in India till now. This study was done to look for the prevalence and predictors of sexual dysfunction disorder in females suffering from migraine. Materials and Methods: This is a cross-sectional study done to look for the prevalence and predictors of female sexual dysfunction in migraine. Sixty female patients with migraine were studied. The International Headache Society's International Classification of Headache Disorders, 3rd Edition, was followed to diagnose migraine with or without aura. Migraine disability assessment scale was used to assess migraine-related disability, and Female Sexual Function Index (FSFI) score was used to assess female sexual function. Results: Sexual dysfunction was found in 78.3% migraineurs. The mean FSFI score was 23.1 ± 4.76. The FSFI scores in all the domains were lower in the individuals studied. Acute headaches resulted in loss of sexual desire among all the migraineurs. Conclusion: Sexual dysfunction is common in migraine with all domains of sexual function being affected. There is a significant negative correlation of sexual function with duration of acute episodes of headache and increasing frequency of migraine attacks per month.

Clinical profile, prognostic indicators, and therapeutic outcomes of pediatric opsoclonus-myoclonus-ataxia syndrome: A single-center experience from South India Karthik Muthusamy, Maya Thomas, Sangeetha Yoganathan, Sniya Valsa Sudhakar Annals of Indian Academy of Neurology 2019 22(3):295-301 Background: Opsoclonus myoclonus syndrome (OMS) is a neuroinflammatory disorder. Indian literature on its clinical profile and outcome is sparse. Objectives: The objective of this study is to describe the clinical profile and analyze outcomes and prognostic predictors in a cohort of children with OMS. Materials and Methods: This was a retrospective study of children with OMS between 2007 and 2017. Results: Twenty-two children were included in the study. The mean age at onset of symptom was 20.9 months (standard deviation [SD]: 7.5). The mean duration of delay in diagnosis was 8.4 months (SD 1.26) with acute cerebellitis being the most common misdiagnosis. Eleven children (50%) were diagnosed with tumor during evaluation and follow-up and 11 children (50%) belonged to idiopathic/postinfectious group. Magnetic resonance imaging brain was normal in all children except for one revealing cerebellar atrophy on follow-up. One child in the paraneoplastic group (neuroblastoma) had a positive PNMA2/Ta onconeural antibody. Children in the tumor group had an earlier age of onset (mean 15.5 vs. 26.3 months), shorter time to onset of opsoclonus from initial symptom (2.54 vs. 7.27 weeks), and higher severity score at presentation (13.7 vs. 11.3) compared to the nontumor group. Children in the nontumor group attained their first remission with treatment earlier (10.9 weeks, SD: 4.5) than the children with tumor (18.72 weeks, SD: 5.8). There was no significant difference in the outcome between the groups. Children with multiple relapses (>3) and late surgical intervention for tumor (>6 months after symptom onset) had a poor outcome. Discussion: A high index of suspicion coupled with early diagnosis and periodic tumor surveillance (even in the initially negative cases) along with aggressive combined multimechanistic immunotherapies is the key in improving outcomes. Conclusion: A high index of suspicion in appropriate clinical circumstances and early aggressive immunomodulation might lead to a better outcome.

Increasing number of therapy sessions of repetitive transcranial magnetic stimulation improves motor development by reducing muscle spasticity in cerebral palsy children Bablu Lal Rajak, Meena Gupta, Dinesh Bhatia, Arun Mukherjee Annals of Indian Academy of Neurology 2019 22(3):302-307 Background: Repetitive TMS (rTMS), a non-invasive neuro-stimulation tool based on the principle of electromagnetic induction is recently being employed both for investigational and interventional purposes. The stimulating effect of rTMS on motor cortex areas of the brain leads to increased motor activity and decreased muscle tone in spastic cerebral palsy (CP) patients. Objective: This modulatory effect of rTMS is used in this study to evaluate its effect on motor function and spasticity by increasing the number of therapy session and keeping frequency of 10Hz and pulse train of 2500 constant. Methods: Total thirty spastic CP patients participated in this study after written informed consent from their parents/guardians. The participants were equally divided into three groups, namely, S-20, S-30 and S-40 depending on the number of therapy sessions. The mean age±SD of participants in different groups were 8.9±3.6, 9.5±2.9 and 8.4±3.5 in S-20, S-30 and S-40 respectively. Participants in S-20, S-30 and S-40 were provided 20, 30 and 40 sessions of rTMS therapy respectively followed by physical therapy of 30 minutes daily. Each rTMS session was of 25 minutes duration and was administered once daily for 5 days a week. Prior to start and after completion of the therapy, pre and post assessment of gross motor function measure (GMFM) for motor function and modified Ashworth scale (MAS) for muscle spasticity was performed on all the participants. Outcomes: The result of pre-versus-post GMFM score showed that 4.27%, 3.12% and 2.36% motor gain was obtained after 40, 30 and 20 sessions of therapy respectively. In addition, significant reduction in spasticity in both upper and limb muscles was also observed in all the three groups.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com