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SIGNIFICANCE: Information about the spatial organization of fibers within a nerve is crucial to our understanding of nerve anatomy and its response to neuromodulation therapies. A serial block-face microscopy method [three-dimensional microscopy with ultraviolet surface excitation (3D-MUSE)] has been developed to image nerves over extended depths ex vivo. To routinely visualize and track nerve fibers in these datasets, a dedicated and customizable software tool is required. AIM: Our objective was to develop custom software that includes image processing and visualization methods to perform microscopic tractography along the length of a peripheral nerve sample. APPROACH: We modified common computer vision algorithms (optic flow and structure tensor) to track groups of peripheral nerve fibers along the length of the nerve. Interactive streamline visualization and manual editing tools are provided. Optionally, deep learning segmentation of fascicles (fiber bundles) can be applied to constrain the tracts from inadvertently crossing into the epineurium. As an example, we performed tractography on vagus and tibial nerve datasets and assessed accuracy by comparing the resulting nerve tracts with segmentations of fascicles as they split and merge with each other in the nerve sample stack. RESULTS: We found that a normalized Dice overlap ( Dice norm ) metric had a mean value above 0.75 across several millimeters along the nerve. We also found that the tractograms were robust to changes in certain image properties (e.g., downsampling in-plane and out-of-plane), which resulted in only a 2% to 9% change to the mean Dice norm values. In a vagus nerve sample, tractography allowed us to readily identify that subsets of fibers from four distinct fascicles merge into a single fascicle as we move ∼ 5    mm along the nerves length. CONCLUSIONS: Overall, we demonstrated the feasibility of performing automated microscopic tractography on 3D-MUSE datasets of peripheral nerves. The software should be applicable to other imaging approaches. The code is available at https://github.com/ckolluru/NerveTracker.

Background: The optimal intervention for managing low anterior resection syndrome (LARS) remains uncertain. This Bayesian network meta-analysis was conducted to compare and rank the effectiveness of various interventions on LARS. Methods: Randomized controlled trials (RCTs) addressing interventions for LARS were extracted from six electronic databases until September 2023. A network meta-analysis was performed using a Bayesian random-effects and consistency model. The results were presented as mean differences (MDs) with credible interval (CrI) or standardized mean differences (SMDs) with CrI. Results: A total of 11 RCTs were included. In the short term (≤ 6 months), transanal irrigation (TAI) had significant positive impacts on overall LARS symptoms (MD (95% CrI) −14.13 (−20.11, −7.83)) and the severity of bowel incontinence (SMD (95% CrI) −1.34 (−1.97, −0.71)) compared with the control group. Pelvic floor rehabilitation (PFR) also exhibited significant improvements in bowel incontinence as compared with the control group (SMD (95% CrI) −0.56 (−0.88, −0.23)). TAI was ranked highest for reducing LARS symptoms, followed by PFR, and percutaneous tibial nerve stimulation (PTNS). In the long term (> 6 months), the results indicated that TAI was most likely to rank first, followed by PTNS, and PFR; however, no significant differences were observed. Conclusions: In the short term, TAI was identified as the most effective treatment for managing LARS, followed by PFR. Both TAI and PTNS demonstrated promising potential in enhancing bowel function over the long term. Further trials are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: Overactive bladder syndrome is common, with a prevalence of 12–17% among adults. Posterior tibial nerve stimulation is the primary nonpharmacological and conservative treatment for overactive bladder syndrome. While several human brain imaging studies have shown the involvement of supraspinal centers in bladder control, a literature review has found that no research has specifically investigated cortical stimulation through transcranial direct current stimulation as a treatment for overactive bladder syndrome in women. Therefore, this study aims to assess the potential benefits of transcranial direct current stimulation (tDCS) and compare them with the effects of posterior tibial nerve stimulation on overactive bladder syndrome. Methods/design: The random allocation method will be used to divide the participants into two groups. Group 1 (n = 19) will undergo pelvic floor muscle training and transcutaneous tibial nerve stimulation. Group 2 (n = 19) will undergo pelvic floor muscle training and transcranial direct current stimulation. The transcranial direct current stimulation for group 2 will consist of 12 sessions occurring thrice a week, each lasting for 20 min. Anodal tDCS will be administered to FPz targeting the medial prefrontal cortex (mPFC) for 12 sessions, with the cathode electrode positioned between Oz and inion at an intensity of 2 mA for 20 min. Discussion: It is believed that utilizing an approach involving non-invasive electrical stimulation of the cortex could lead to a more efficient treatment for individuals with overactive bladder. Additionally, it is theorized that combining the effects of tDCS and pelvic floor muscle training could present an innovative technique for alleviating the negative impacts of overactive bladder syndrome. Ultimately, this new method could provide help for patients who have not responded to conventional therapy. Trial registration: Iranian Registry of Clinical Trials (IRCT) ID: IRCT20090301001722N26, registration date: May 17, 2023. https://en.irct.ir/. [ABSTRACT FROM AUTHOR]

A 42-year-old female presented with acute onset of asymmetric lower extremity weakness, bilateral lower extremity areflexia and sensory loss, and urinary incontinence. Initial investigation with a spine MRI for a spinal cord process was negative, leading to further investigation with nerve conduction studies/electromyography (NCS/EMG). This revealed absent F waves bilaterally in the fibular nerves, and there was only one isolated F wave with decreased amplitude and increased latency in the left tibial nerve and had lack of heterogeneity in the right tibial nerve. Given the early presentation of her symptoms, this led to a working diagnosis of Guillain–Barré Syndrome, which was treated with plasmapheresis without improvement. After plasmapheresis, the diagnosis was revisited, and a repeat spine MRI revealed an extensive lower thoracic and lumbar spinal cord infarction. In this unique scenario, the properties and abnormalities of F waves are discussed and reviewed, along with the influence of acute central nervous system lesions on their configuration. [ABSTRACT FROM AUTHOR]

Aim: This study aims to investigate the role of activated partial thrombin time (APTT) as a potential mediator in the relationship between suboptimal glycemic control and diabetic peripheral neuropathy (DPN) in individuals with type 2 diabetes mellitus (T2DM). Methods: A total of 183 T2DM patients were enrolled in this study. Comprehensive clinical data, including coagulation parameters and nerve conduction velocity, were collected and compared between patients with and without DPN. Subsequent correlation and regression analyses were conducted to explore the associations among APTT, HbA1c levels, and nerve conduction velocities. Moreover, mediation analyses were performed to evaluate the total, direct, and indirect effects of HbA1c on specific nerve conduction velocities, with APTT serving as a mediator. Results: In comparison to 101 patients without DPN, 82 patients with DPN exhibited significantly elevated levels of HbA1c and decreased levels of APTT. Notably, levels of APTT and HbA1c were correlated with conduction velocities of Tibial nerve motor fibers, as well as sensory fibers of the Ulnar nerve, Median nerve, and Sural nerve. Furthermore, both elevated HbA1c and decreased APTT were identified as risk factors for DPN in T2DM individuals. Mediation analysis showed that APTT mediated the indirect effect of HbA1c on the conduction velocities of sensory fibers in both the ulnar nerve and sural nerve (95% CI: -0.3448, -0.0135; -0.3523, -0.0180). APTT mediated the relationship between HbA1c and the conduction velocities of sensory fibers in the ulnar nerve or sural nerve by 34.66% or 22.03%, respectively. Conclusions: In patients with T2DM, uncontrolled HbA1c and shorter APTT emerges as risk factors for DPN. Additionally, the effect of increased HbA1c upon DPN, especially for influenced conduction velocities of sensory fibers in both the ulnar nerve and sural nerve may partly medicated by decreased APTT. [ABSTRACT FROM AUTHOR]

Background: Rectal cancer incidence is increasing. Low anterior resection is currently the gold standard surgical management. Postoperatively, patients may present with symptoms indicative of low anterior resection syndrome (LARS). LARS can be debilitating and is difficult to treat with low efficacy of treatment modalities. This systematic review aims to highlight the current evidence regarding LARS management. Methods: Systematic review of Medline, Cochrane and Embase used the following terms: "low anterior resection syndrome" AND "management", "low anterior resection syndrome" AND "treatment". Articles that focus solely of low anterior resection syndrome management in patients > 18 years were included. Bias risk was assessed via the Newcastle-Ottawa quality assessment scale for cohort studies and the JBI critical appraisal tool for randomized controlled trials. Due to heterogeneity of methodology, no statistical analysis was performed. Results: Thirty-eight articles with a total of 1914 patients were included in this review. Ninety-five per cent underwent surgery for malignancy. Treatment options included pharmacology, pelvic floor rehabilitation (PFR), transanal irrigation (TAI), sacral nerve modulation (SNM), percutaneous tibial nerve stimulation (PTNS) and "treatment programs" starting from the least invasive procedures escalating to more invasive treatments upon failure. The most common published medical therapies report Ramoestron use; however, studies are low impact. PFR showed significant improvement in LARS mostly in those with symptoms of faecal incontinence. However, long-term outcomes are inconsistent. TAI supplies pseudo-continence with its greatest benefit reported in those with incomplete evacuation. TAI has significant short-term effects on LARS but little long-term effect. TAI is also associated with a significant drop-out rate. SNM's hypothesised benefit is extrapolated from non-LARS associated FI. Results show improvements in FI but a high rate of explantation. PTNS evidence suggests little if any significant LARS improvement. A single "stepwise programme" study reported that 77 per cent did not progress further than diet and medication. Little evidence suggests benefit regarding diet or acupuncture. Discussion: There is no consensus as to the optimal treatment strategy for LARS. LARS is multifactorial and requires sensitive discussion between patient and surgeon to address the most prominent symptom. It requires physical and psychological input. No single treatment option provides superior results. Treatment is based on symptom control and patient acceptance. [ABSTRACT FROM AUTHOR]

Background: Although total intravenous anesthesia (TIVA) with propofol and remifentanil is frequently used to optimize intraoperative neurophysiological monitoring (IONM), the exact effect of remimazolam on IONM remains unknown. Here, we compared the effects of propofol and remimazolam along with remifentanil on IONM during TIVA. Methods: In this prospective, double-blind, randomized controlled trial, 64 patients requiring IONM during cervical spine surgery were administered either propofol (Group P) or remimazolam (Group R). The preoperative latencies of the somatosensory-evoked potentials (SEP; N20 for the median nerve and P37 for the tibial nerve) were measured. SEP latencies and amplitudes and motor-evoked potential (MEP) amplitudes were measured 30 min after anesthetic induction (T1), 30 min after surgical incision (T2), after laminectomy or discectomy (T3), immediately after plate insertion or pedicle screw fixation (T4), and before surgical wound closure (T5). The primary outcome was the between-group difference in the N20 latency changes measured at T1 and preoperatively. Results: The change in SEP latencies including N20 and P37 at T1 compared with preoperative time was not significantly different between Groups P and R. Except for the amplitude of the right abductor brevis, there was no significant group-by-time interaction effect for intraoperative MEP amplitudes or SEP latencies and amplitudes. Conclusions: TIVA with remimazolam and remifentanil for cervical spine surgery yielded stable IONM, comparable to those observed with conventional TIVA with propofol and remifentanil. Further clinical trials are needed in other surgical contexts and with more diverse patient populations to determine the effects of remimazolam on IONM. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the efficacy and safety of a non-invasive low-frequency tibial nerve stimulator (TNS-01) vs sham control in relieving the symptoms of overactive bladder (OAB) patients. Patients: Participants who were diagnosed with primary OAB or exhibited at least one OAB symptom. All participants underwent three 30-min intervention sessions weekly. Methods: The subjects were 1:1randomized (block randomization with a block size of 4) to either active treatment (TNS-01 group) or sham treatment (sham group). Based on the randomization, the subject will be given either an active or sham device system (systems will only differ in the Instructions for Use and electrode size/shape). During the 12-week study period, all participants underwent three 30-min intervention sessions weekly. The primary endpoint was the change in Overactive Bladder Symptom Score (OABSS) at week 12 from the baseline. Results: Of the 109 recruited OAB patients. In the TNS-01 group, the OABSS change from baseline at week 12 was significantly higher than that in the sham group (2.83 ± 2.53 vs 1.62 ± 2.59, p = 0.02). The absolute and percent changes of average UUI episodes per day from baseline at week 8 in the TNS-01 group were significantly lower from those in the sham group (0.11 ± 1.33 vs 0.68 ± 2.14, p = 0.01; − 27.82% ± 167.33% vs 87.18% ± 25.20%, p = 0.04). One treatment-related adverse event (hematuria) was reported by one patient (1.8%) in the sham group. Conclusions: The TNS-01 device is effective and safe in relieving OAB symptoms after 12 weeks of stimulation. Trial registration number: NCT04999657. [ABSTRACT FROM AUTHOR]

Objective: The surgical team in this study examined the efficacy of a modified reverse sural neurocutaneous flap repair in treating soft tissue defects of the ankle and foot caused by accidents. Methods: This study enrolled 89 patients treated for soft tissue defects of the ankle or foot between January 2007 and December 2023. The patients were divided into two groups: 44 patients underwent a modified reverse sural neurocutaneous flap repair, while 45 received traditional treatment. The modified technique involved repairing various anatomical structures, including fascia, the saphenous nerve, the great saphenous vein, subcutaneous tissue, and skin, with flap sizes ranging from 14 to 152 cm². In the traditional treatment group, the distal perforator of the peroneal artery was identified 5 cm above the lateral malleolus. Island fasciocutaneous flaps were designed along the sural nerve and lesser saphenous vein, elevated subfascially, rotated 180 degrees, and inset without tension. Donor sites were closed with grafts or direct sutures. Results: Of the 44 patients, who underwent the modified technique, 35 were male and 9 were female. Follow-up periods ranged from 2 to 24 weeks to monitor outcomes and recovery. The average size of the affected soft tissue was 71 cm2. Thirty-nine flaps survived completely, while three experienced partial necrosis and two had marginal necrosis. No cases of severe venous congestion were reported. The complication rate was lower with the modified method compared to the traditional repair (p < 0.05). Conclusion: The modified reverse neurocutaneous flap repair is a reliable and structured approach to treating soft tissue defects of the ankle and foot. This method has demonstrated favorable patient outcomes and presents a promising avenue for future studies and clinical practice. [ABSTRACT FROM AUTHOR]

(1) Background: Stretching has been shown to improve flexibility, muscle activation, and coordination, but its effects may depend on neural tension during the stretch. This study evaluated the short- and medium-term effects of hamstring stretching with and without neural load on flexibility, tibial nerve pressure pain threshold, and maximum isometric strength. (2) Methods: Seventy-eight healthy participants (mean age: 24.96 ± 6.11 years) were randomly assigned to stretching programs with (n = 39) or without neural load (n = 39). Flexibility, pressure pain threshold, and maximum isometric strength were assessed at baseline, after the first session, at the end of the intervention, and one month later. (3) Results: The group using neural load showed significant flexibility improvements after the first session (MD = −5.2; p < 0.001), which were maintained at two months (MD = −8.6; p < 0.001) and follow-up (MD = −6.4; p < 0.001). In the control group, flexibility gains diminished at follow-up (MD = −3.9; p = 0.052). Other variables showed no significant changes across time points. (4) Conclusions: Since neither treatment showed superior efficacy, no specific stretching type could be recommended. [ABSTRACT FROM AUTHOR]

Background Foot drop is the common endpoint for a diverse set of nerve injuries, affecting over 128,000 in the United States each year. The level of injury, finite pace of regeneration, and/ exponential decay in the percentage of motor end-plates reinnervated over time may explain the limited success with natural recovery. Past nerve techniques have also been met with limited success. Methods This narrative review explores why past nerve techniques have failed to correct foot drop. Results Previously described nerve transfer techniques suffer from incompletely balancing the foot and ankle, poor donor-target nerve synergy, and/or not effectively bypassing the wide and oftentimes underappreciated zone of injury. For maximal stability, one should look to balance the foot in both dorsiflexion and eversion. Detailed descriptions and illustrations of the branching anatomy for the peroneal and tibial nerves are provided, with specific application to nerve transfer reconstruction. Conclusion Based on an understanding of why past nerve techniques have failed to correct foot drop, a set of surgical principles can be codified to optimize functional outcomes. A surgical technique should be versatile enough to address foot drop from any of the three common pathways of injury (lumbar spine, sciatic nerve, and common peroneal nerve). With increasing familiarity using this once poorly understood anatomical region, limitations with past nerve transfer techniques may be overcome. [ABSTRACT FROM AUTHOR]

This study investigated torque production resulting from the combined application of wide-pulse neuromuscular electrical stimulation (NMES), delivered over the posterior tibial nerve, and muscle lengthening at two distinct amplitudes. Wide-pulse NMES (pulse duration: 1 ms; stimulation intensity: 5–10% of maximal voluntary contraction) was delivered at both low- (20 Hz) and high- (100 Hz) stimulation frequencies, either alone (NMES condition) or combined with a muscle lengthening at two amplitudes (10 or 20° ankle joint rotation; NMES + LEN10 and NMES + LEN20 conditions, respectively). For each frequency, the torque-time integral (TTI) and the muscle activity following the cessation of stimulation trains (sustained EMG activity) were calculated. At 20 Hz, TTI was higher (P = 0.007) during NMES + LEN10 (233.2 ± 101.5 Nm·s) and NMES + LEN20 (229.2 ± 92.1 Nm·s) than during the NMES condition (187.5 ± 74.5 Nm·s), without any change in sustained EMG activity (P = 0.54). At 100 Hz, TTI was higher (P = 0.038) during NMES + LEN10 (226.6 ± 115.3 Nm·s) than during NMES + LEN20 (180.6 ± 84.0 Nm·s) and NMES (173.9 ± 94.9 Nm·s). This torque enhancement was accompanied by a higher sustained EMG activity (P = 0.045) in the NMES + LEN10 condition. These findings show that, for low-frequency NMES, significant torque increases were observed with both a 10- or a 20-degree lengthening amplitude, probably linked to increased afferents' activation. In contrast, with high-frequency NMES, a significant TTI enhancement was observed only with the 10-degree amplitude, accompanied by increased sustained EMG activity, suggesting neural mechanisms' involvement. When a greater lengthening amplitude was superimposed during high-frequency NMES, these mechanisms were probably inhibited, precluding torque enhancement. NEW & NOTEWORTHY: This study demonstrates that combining wide-pulse low-frequency NMES and muscle lengthening can increase torque production compared with the sole application of NMES. Torque enhancement is most likely linked to the persistent firing of muscle afferents. Although muscle lengthening superimposition also permitted torque increases during wide-pulse high-frequency NMES, increasing the muscle lengthening amplitude did not allow further torque enhancements, probably due to presynaptic inhibitory mechanisms. [ABSTRACT FROM AUTHOR]

Background: Peripheral nerve injuries are a significant clinical challenge, often resulting in functional impairments due to the disruption of nerve continuity and the subsequent loss of muscle innervation. The purpose of the study was to assess the effect of supercharge end-to-side (SETS) nerve transfer on peripheral nerve regeneration in male albino rats. Methods: This experimental study involved 12 male albino rats, each weighing between 200-350 grams. The rats are divided into two groups based on the surgical procedure performed: Group A: End-to-end nerve repair (n=6). Group B: SETS nerve transfer (n=6). All rats underwent surgery under proper anesthesia, administered as ketamine intraperitoneally. After 12 weeks postoperation, the rats were sacrificed, and the posterior tibial nerves were extracted. A 1 cm segment proximal and distal to the epineurial repair site will be examined histopathologically. The nerves were stained with Toluidine blue to assess the myelinated axons number and calculate the neurotization index in all groups. Results: The study results showed significant differences in the neurotization index and the number of regenerating nerve fibers between the groups, particularly in the distal segment, where the SETS nerve transfer (Group B) and RETS neurorrhaphy (Group B) demonstrated superior outcomes compared to traditional end-to-end repair (Group A). Conclusion: This study demonstrates the value of SETS nerve transfer in enhancing peripheral nerve regeneration in male albino rats, which resulted in significantly improved nerve regeneration, particularly in distal segments, compared to the traditional end-to-end repair method. The findings suggest that these techniques hold promise for improving outcomes in clinical settings where robust nerve regeneration is critical for functional recovery. [ABSTRACT FROM AUTHOR]

Introduction: The efficacy of unilateral versus bilateral Transcutaneous Tibial Nerve Stimulation (TTNS) for women with Overactive Bladder Syndrome (OAB) remains uncertain. Objective: To compare the efficacy of unilateral and bilateral TTNS in the tibial region in women with OAB. Methods: This randomized, controlled, triple‐blind clinical trial included women with OAB or urgency‐predominant urinary incontinence (UUI). Participants were randomized (1:1) into the Unilateral Tibial Group or Bilateral Tibial Group. Before treatment, they underwent a pre‐assessment including peripheral sensitivity examination and completion of sociodemographic data and seven validated questionnaires on urinary symptoms, quality of life, sleep, and psycho‐emotional aspects. TTNS interventions were administered twice weekly (12 sessions, 30 min each). Posttreatment, participants underwent another physical examination and completed the same questionnaires, with a 30‐day follow‐up. Categorical variables were analyzed using Chi‐square or Fisher's Exact Test, while numerical variables were assessed with the Mann‐Whitney test. Group comparisons over time utilized intention‐to‐treat ANOVA (p < 0.05). Results: Thirty‐five women participated: 17 in the unilateral group and 18 in the bilateral group. Mean ages were 55.1 (±14.7) years and 52.7 (±12.6) years, respectively (p = 0.680). Initial OAB severity (ICIQ‐OAB) did not differ significantly between groups (p = 0.561). Both groups showed significant improvement in ICIQ‐OAB scores: unilateral group from 10.1 (±3.4) to 5.8 (±3.4) (p < 0.001), bilateral group from 9.3 (±3.3) to 5.1 (±4) (p < 0.001), with no intergroup difference (p = 0.395). Improvement in UUI symptoms was observed: unilateral group from 2.2 (±1.4) to 0.7 (±1.5), bilateral group from 1.5 (±1.9) to 0.2 (±0.5), without significant intergroup difference (p = 0.645). Quality of life scores improved similarly between groups (p = 0.055). Conclusion: TTNS appears to be effective in improving bladder storage and UUI symptoms in women with OAB, with no difference between unilateral and bilateral applications. Clinical Trial Registration: Brazilian Registry of Clinical Trials (REBEC) (RBR: 96f2fgkn). [ABSTRACT FROM AUTHOR]

Objective: To systematically evaluate the clinical efficacy of acupuncture in the treatment of diabetic peripheral neuropathy (DPN). Methods: Randomized controlled trial (RCT) of acupuncture for diabetic peripheral neuropathy in Chinese Knowledge Network (CNKI), Wanfang database, VIP database (VIP), PubMed, web of science, cochrane library, AMED and CINAHL were searched by computer since the establishment of the database. All publications in English and Chinese as of 30 December 2023 will be searched, without country or article type restrictions. Study selection, data extraction and evaluation were performed independently by two researchers. Risk of bias was assessed using the Cochrane risk assessment tool, and Meta-analysis was performed using RevMan5.3 software. Results: DPN has good effective rate in acupuncture than conventional western medicine alone. However, the above conclusions need to be verified by larger samples and higher quality randomized controlled trials. ① Acupuncture treated DPN more effective than drug (RR = 1.38, 95%CI = 1.26 ~ 1.51, Z = 6.93, p < 0.00001), DPN of patients with acupuncture plus drug (RR = 1.38, 95%CI = 1.05 ~ 1.82, Z = 2.28, p = 0.02), There was no significant difference between acupuncture and usual care (RR = 2.41, 95%CI = 0.70 ~ 8.29, Z = 1.39, p = 0.16); ② Acupuncture treatment is superior to drug group in improving the SNCV of the median nerve (MD = 1.65, 95%CI = 0.74 ~ 2.57,Z = 3.55, p = 0.0004), sham needle treatment (MD = 0.50, 95%CI = 0.17 ~ 0.83, Z = 2.95, p = 0.003), Acupuncture plus drug was superior to drug in improving the SNCV of the median nerve (MD = 3.29, 95%CI = 2.55 ~ 4.03, Z = 8.70, p < 0.00001); ③ Acupuncture treatment is superior to drug group in improving the MNCV of the median nerve (MD = 2.24, 95%CI = 0.50 ~ 3.98, Z = 2.52, p = 0.01), and sham needle treatment (MD = 0.20, 95%CI = −0.03 ~ 0.43, Z = 1.69, p = 0.09), Acupuncture plus drug was superior to drug group in improving the MNCV of the median nerve (MD = 2.63, 95%CI = 1.83 ~ 3.42, Z = 6.46, p < 0.00001); ④ Acupuncture is better to drug group in improving SNCV of common peroneal nerve (MD = 1.67, 95%CI = 0.21 ~ 3.13, Z = 2.24, p = 0.02); ⑤ Acupuncture treatment is superior to drug group in improving the MNCV of the common peroneal nerve (MD = 2.03, 95%CI = 1.37 ~ 0.69, Z = 6.04, p < 0.00001), Acupuncture plus drug outperformed MNCV in improving the common peroneal nerve (MD = 4.23, 95%CI = −0.16 ~ 8.62, Z = 1, 89, p = 0.06); ⑥ Acupuncture treatment is superior to drug group in improving the SNCV of the tibial nerve (MD = 1.58, 95%CI = 0.85 ~ 2.30, Z = 4.26, p < 0.0001); ⑦ There was no significant difference between acupuncture treatment and drug group in improving the MNCV of the tibial nerve (MD =1.55, 95%CI = −0.59 ~ 3.68, Z = 1.42, p = 0.16); ⑧ Acupuncture plus drug is better than medication in reducing VAS (MD = −2.35, 95%CI = -3.78 ~ −0.93, Z = 3.23, p = 0.001), Acupuncture plus usual care is superior to usual caret (MD = −28.70, 95%CI = -39.50 ~ 17.90, Z = 5.21, p < 0.00001), There was no significant difference between acupuncture and sham needle treatment (MD = −4.00, 95%CI = -18.32 ~ 10.32, Z = 0.55, p = 0.58). Conclusion: Compared with drug, usual care, and sham AT, AT has a better response rate and more favorable effect in improving nerve conduction velocity. The combination of AT and drug demonstrates a more significant improvement compared to drug alone. The combination of AT and usual care improves DPN symptoms more effectively than usual care. However, the above conclusions need to be verified by larger samples and higher quality randomized controlled trials. Systematic review registration: [https://www.crd.york.ac.uk/], identifier [CRD42023451575]. [ABSTRACT FROM AUTHOR]

INTRODUCTION. According to the literature, intraoperative electrical neurostimulation (IES) after autoneuroplasty (AN) accelerates the regenerative growth of axons. It is unknown whether sexual dimorphism occurs in peripheral nerve regeneration after AN and with single-dose IES. AIM. To identify possible gender-related differences in the regeneration of the sciatic nerve (SN) after AN resection of the defect of its tibial portion and a single IES in mature rats. MATERIALS AND METHODS. 72 male (n = 39) and female (n = 33) rats underwent resection and AN of the tibial portion of the SN. Series 1 — non-stimulated control, series 2 — IES session 40 minutes. The tibial functional index (TFI) was calculated from the paw prints; Histomorphometric parameters of myelinated nerve fibers (MF) of the tibial nerve (TN) were determined. RESULTS AND DISCUSSION. In series 1, 2 months after surgery, males were found to have higher values of the numerical density of MVs of the WBN and axon diameters (DA) than in females. After 4 months, YES and MV diameters are larger in females. After 6 months, females have greater myelin sheath (MS) thickness. TFI in series 1 decreases towards the end of the experiment, especially in males. In series 2, 2 and 4 months after surgery, in females the DA, MS, and MF diameters were greater than the values in series 1; after 6 months, only MS and MF diameters were greater. In series 2 males, 2 and 4 months after surgery, the MS and MF diameter are greater than in series 1, and after 6 months, all dimensional parameters in series 2 males are higher than in series 1 males. TFI in series 2 is greater than the values in series 1 and increases towards the end of the experiment, especially in males. CONCLUSION. 2 months after AN, the growth and differentiation of nerve fibers in males is faster than in females, then the differences are inverted. Despite the increase in histomorphometric indicators of regeneration, in unstimulated animals, by the end of the experiment, TFI decreases, especially in males. In stimulated rats, compared to unstimulated ones, the morpho-functional indicators of regeneration at all periods of the experiment are better, to a greater extent in males.

Background: Diabetic peripheral neuropathy (DPN) is a common and serious complication of diabetes occurring in about 50% of patients. It serves as a strong risk factor for disabling pain, foot ulcers and amputation that have a negative effect on the life quality and bring a heavy economic burden. Therefore, it is important to early diagnose DPN for taking influential targeted measures and preventing foot ulcers and amputations. The aim of this study was to assess the role of different high resolution ultrasound (HRUS) parameters in diagnosing DPN. Results: This study included 60 participants classified into three groups [20 diabetic cases with DPN, 20 diabetic cases without peripheral neuropathy (PN) and 20 age-/sex-matched healthy control]. All cases underwent full clinical and laboratory investigations. HRUS examination including shear wave elastography (SWE) of the tibial nerve was also performed. Our study revealed statistically significant difference as regard maximum thickness nerve fascicles (MTNF) between DPN and control groups (P = 0.005) with a cutoff value of 0.45 mm yielding 85% sensitivity and 75% specificity. As regard nerve cross-sectional area (CSA), there was significant statistical difference between each of the three studied groups. A cutoff value of 17.5 mm2 was excellent in differentiating DPN group from control group with 80% sensitivity and 95% specificity. The highest mean nerve stiffness was noted among DPN group compared to diabetics without PN and control groups with significant statistical difference between each of the studied groups. The mean nerve stiffness was excellent in differentiating DPN group from control group with 100% sensitivity and 100% specificity. There was significant statistical positive correlation between neuropathy disability score and diabetes duration, HbA1c levels, MTNF, nerve CSA and stiffness. Conclusions: Multi-parametric HRUS using MTNF, CSA and SWE is a promising quantitative technique that has an excellent additive value to the usual qualitative nerve examination. High image quality, real-time examination, non-invasiveness, low cost, wide availability and multi-parametric assessment make HRUS superior to nerve conduction test. It can serve as an accurate novel technique for screening and early diagnosis of DPN even with normal clinical and nerve conduction studies. [ABSTRACT FROM AUTHOR]

The prevalence of chronic polyneuropathy will increase due to the aging population, and therefore, it becomes ever so important to optimize the diagnostic process. However, it is uncertain which blood tests are required and when nerve conduction studies (NCS) should be done in the workup of chronic polyneuropathy. We aimed to investigate the methodology used to develop national polyneuropathy guidelines and to provide an overview and strength of evidence of the recommendations. We searched PubMed and websites of national neurological associations as listed on the website of the World Federation of Neurology to identify national guidelines pertaining to the workup of chronic polyneuropathy by neurologists in an outpatient clinic setting. We identified three national guidelines in the United States and seven national guidelines in Denmark, France, Germany, the Netherlands, Norway, Spain, and Turkey. The methodology used to develop the guidelines differed greatly. All guidelines recommend a series of blood tests. Some guidelines advise to conduct NCS in all patients, while other guidelines advise to conduct NCS when certain symptoms are present. There is variation in recommendations about the extensiveness of NCS, but all mention measuring the sural nerve and the motor peroneal nerve. The evidence for the recommendations is graded as low. Despite some overlap, there are disparities between guidelines regarding the workup that is advised to do in patients with chronic polyneuropathy. It remains unclear which combination of blood tests are to be strongly recommended. Furthermore, it is undetermined whether NCS are always necessary. [ABSTRACT FROM AUTHOR]

Background and Aims: Ultrasound nerve cross‐sectional area (CSA) of patients affected with axonal neuropathy usually shows normal value. Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) seems to represent an exception, showing smaller CSA, but previous reports did not test for biallelic RFC1 gene repeat expansions. Methods: We compared nerve CSA from CANVAS patients (tested positive for biallelic RFC1 gene repeat expansions) with the CSA from a group of patients with chronic idiopathic axonal polyneuropathy (CIAP) who tested negative for RFC1 gene repeat expansions, hereditary axonal neuropathy (Charcot‐Marie‐Tooth type 2, CMT2), and Friedreich ataxia (FRDA). Results: We enrolled 15 CANVAS patients (eight men, mean age 66.3 ± 11.5 years, mean disease duration 9.3 ± 4.1 years), affected with sensory axonal neuronopathy. Controls consisted of 13 CIAP (mean age 68.5 ± 12.8 years, seven men), seven CMT2 (mean age 47.9 ± 18.1 years, four men), 12 FRDA (mean age 33.7 ± 8.8, five men). Nerve ultrasound was performed at median, ulnar, sciatic, sural, and tibial nerves and brachial plexus, bilaterally. The nerve CSA from CANVAS patients was significantly smaller than the one from the other cohorts at several sites with significant and high accuracy at Receiver‐operating characteristic (ROC) curve analyses. RFC1 AAGGG pentanucleotide expansion, disease duration, and disability did not correlate with CSA at any site, after Bonferroni correction. Interpretation: Decreased sonographic nerve sizes, in arms and legs, in patients with sensory neuropathy and normal motor conduction studies could point to CANVAS‐spectrum disease and help guide appropriate genetic testing. [ABSTRACT FROM AUTHOR]

Background and Aims: Charcot-Marie-Tooth (CMT) is a heterogeneous group of genetic neuropathies and is typically characterized by distal muscle weakness, sensory loss, pes cavus and areflexia. Herein we describe a case of CMT2CC presenting with proximal muscle weakness and equivocal electrophysiological features, that was misdiagnosed as chronic inflammatory demyelinating polyneuropathy (CIDP). Case report: A 30-year-old woman complained of proximal muscle weakness with difficulty climbing stairs. Neurological examination showed weakness in lower limb (LL) muscles, that was marked proximally and mild distally, and absence of deep tendon reflexes in the ankles. Nerve conduction studies (NCS) showed sensory-motor neuropathy with non-uniform NC velocity and a partial conduction block (CBs) in peroneal nerve and tibial nerves. Thus, a diagnosis of CIDP was entertained and the patient underwent ineffective treatment with intravenous immunoglobulins. At electrophysiological revaluation CB in peroneal nerve was undetectable as also distal CMAP had decreased whereas the CBs persisted in tibial nerves. Hypothesizing a hereditary neuropathy, we examined the proband's son, who presented mild weakness of distal and proximal muscles at lower limbs. Neurophysiological investigation showed findings consistent with an intermediate-axonal electrophysiological pattern. A targeted-NGS including 136 CMT genes showed the heterozygous frameshift mutation (c.3057dupG; p.K1020fs*43) in the NEFH gene, coding for the neurofilament heavy chain and causing CMT2CC. Interpretation: Diagnosis of a genetic neuropathy may be challenging when clinical features are atypical and/or electrophysiological features are misleading. The most common misdiagnosis is CIDP. Our report suggests that also CMT2CC patients with proximal muscle weakness and equivocal electrophysiological features might be misdiagnosed as CIDP. [ABSTRACT FROM AUTHOR]

Background/Objectives: Peripheral nerve conduction velocity (NCV) and nerve cross-sectional area (nCSA) are crucial parameters in neurophysiological assessments, yet their sex-specific differences are not fully understood. This study investigated sex-based variations in NCV and nCSA between upper and lower limbs. Methods: Twenty participants (ten males and ten females) were recruited for this study. The NCV and nCSA of the ulnar and tibial nerves were measured in both the upper and lower limbs. NCV was measured using supramaximal electric stimulation, and nCSA was assessed using peripheral nerve ultrasonography at three regions for each nerve. Supramaximal electric stimulations were applied superficially to the ulnar and tibial nerves at each measurement point. Action potentials were recorded from the abductor digiti minimi and soleus muscles for the ulnar and tibial nerves, respectively. Results: The ulnar nCSA of the upper limbs was significantly greater in males than in females (p < 0.05). However, ulnar NCV was significantly higher in females than in males (p < 0.05). In the lower limbs, no sex differences were observed in tibial NCV or nCSA. Conclusions: These findings reveal sex-specific differences in upper limb peripheral nerve characteristics that may have important implications for clinical assessments and treatment strategies. The contrasting patterns between upper and lower limbs suggest that both developmental and functional factors influence peripheral nerve properties. [ABSTRACT FROM AUTHOR]

To evaluate the continued effectiveness and safety of the eCoin Implantable Tibial Nerve Stimulator system (ITNS) for urgency urinary incontinence (UUI) in patients with overactive bladder (OAB). The 1-year pivotal study was extended through 2 years. The ITNS is a novel and recently FDA-approved therapy. A prospective, multicenter, single-arm trial was conducted on 137 subjects with refractory UUI to evaluate eCoin ITNS therapy. A 3-day voiding diary was collected along with the OAB questionnaire, Patient Global Impression of Improvement, and a custom Likert scale on subject satisfaction. The primary efficacy measure was the proportion of subjects who achieved at least 50% reduction from baseline in number of UUI episodes. The primary safety measure was device-related adverse events (AEs). Seventy-two subjects completed the 96-week evaluation. Around 78% (95% CI: 67%-87%) experienced at least 50% reduction in UUI episodes; 48% (95% CI, 36%-60%) experienced at least 75% reduction, and 22% (95% CI, 13%-33%) were dry on a 3-day diary. Subjects reported a decrease from baseline in their UUI episodes/day of 2.61 (SD 2.97) and 2.97 (SD 2.64) at 48 weeks and 96 weeks, respectively. Around 91.3% did not require additional medications for OAB. No serious or unanticipated AEs were reported in this extension phase. The eCoin ITNS demonstrated consistent continuing effectiveness and safety in treating OAB patients with UUI. The findings support it as an excellent treatment option for refractory patients. [ABSTRACT FROM AUTHOR]

Background: Peripheral nerve injury is a challenging orthopedic issue in clinical management that often leads to limb dysfunction or even disability in severe cases. A thorough exploration of the repair process of peripheral nerve injury and the underlying mechanism contributes to formulate more effective therapeutic strategies. Methods: In the present study, we established a sciatic nerve transection injury model in Sprague-Dawley (SD) rats. A 12-week compensatory repair of sciatic nerve transection injury using a chitin cannula for small gap anastomosis was then performed via sleeve jointing the proximal common peroneal nerve to the distal tibial nerve and common peroneal nerve, with a 2 mm interval. Compensatory repair via small gap amplification was observed via gross observation of nerve specimen, osmic acid staining, and electrophysiological stimulation of sciatic nerve branches of the tibial and common peroneal nerve. Rat limbs were observed, and the functional recovery of effector muscles of the gastrocnemius and tibialis anterior muscles was assessed through weighing the muscle wet weight, Hematoxylin and Eosin (H&E) staining, and muscle strength detection. H&E staining, Masson staining, and toluidine blue staining were performed to observe the morphological changes of the dorsal root ganglion. Positive expressions of key proteins involved in the Phosphatase and tensin homologue deleted on chromosome ten (PTEN)-protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signaling pathway, including PTEN, AKT, mTOR, Toll-like receptor 4 (TLR4), and Caspase9 in the dorsal root ganglion during compensatory repair of sciatic nerve after injury via small gap amplification, were detected by immunohistochemical staining. Results: It is found that the compensatory repair of sciatic nerve transection injury using a chitin cannula for small gap anastomosis via sleeve jointing effectively restored the continuity, number of myelinated nerve fibers, and nerve conduction velocity. It promoted toe abduction recovery, improved muscle fiber morphology and increased the wet weight and muscle strength of the gastrocnemius muscle and tibialis anterior muscle. Moreover, it increased the number of neurons and nerve fibers, and improved their morphology. Downregulated PTEN, TLR4, and Caspase9 in the dorsal root ganglia and upregulated AKT and mTOR were observed after small gap amplification than those of the transection injury group, which were closer to those of the control group. Conclusions: Compensatory repair of sciatic nerve transection injury using a chitin cannula for small gap anastomosis via sleeve jointing can restore the morphology and function of the sciatic nerve, effector muscles, and corresponding dorsal root ganglia by activating the PTEN-AKT/mTOR signaling pathway in the dorsal root ganglia. Our findings provide novel therapeutic targets for peripheral nerve injuries. [ABSTRACT FROM AUTHOR]

Background: Previously, T2-relaxation time (T2app) and proton spin density (ρ) detected nerve injury in a small group of ATTRv amyloidosis. Here, we aim to quantify peripheral nerve impairment in a large cohort of symptomatic and asymptomatic ATTRv amyloidosis and correlate T2-relaxometry markers with clinical parameters and nerve conduction studies (NCS). Methods: Eighty participants with pathologic variants of the transthyretin gene (TTRv) and 40 controls prospectively underwent magnetic resonance neurography. T2-relaxometry was performed, allowing to calculate tibial ρ, T2app and cross-sectional-area (CSA). Detailed clinical examinations and NCS of tibial and peroneal nerves were performed. Results: Forty participants were classified as asymptomatic TTRv-carriers, 40 as symptomatic patients with polyneuropathy. ρ, T2app and CSA were significantly higher in symptomatic ATTRv amyloidosis (484.2 ± 14.8 a.u.; 70.6 ± 1.8 ms; 25.7 ± 0.9 mm2) versus TTRv-carriers (413.1 ± 9.4 a.u., p < 0.0001; 62.3 ± 1.3 ms, p = 0.0002; 19.0 ± 0.8 mm2, p < 0.0001) and versus controls (362.6 ± 7.5 a.u., p < 0.0001; 59.5 ± 1.0 ms, p < 0.0001; 15.4 ± 0.5 mm2, p < 0.0001). Only ρ and CSA differentiated TTRv-carriers from controls. ρ and CSA correlated with NCS in TTRv-carriers, while T2app correlated with NCS in symptomatic ATTRv amyloidosis. Both ρ and T2app correlated with clinical score. Conclusion: ρ and CSA can detect early nerve injury and correlate with electrophysiology in asymptomatic TTRv-carriers. T2app increases only in symptomatic ATTRv amyloidosis in whom it correlates with clinical scores and electrophysiology. Our results suggest that T2-relaxometry can provide biomarkers for disease- and therapy-monitoring in the future. [ABSTRACT FROM AUTHOR]

We herein report a case of traumatic tibial nerve defect involving the ankle joint. A 16-mm-long defect was observed in a 5-mm-diameter tibial nerve. Two 3-mm-inner-diameter PGA-collagen tubes were transferred to the bifurcated tibial nerve. Satisfactory recovery was achieved at 3 year and 9 months postoperatively. [ABSTRACT FROM AUTHOR]

Merkel cell–neurite complexes (MNCs) are enriched in touch-sensitive areas, including whisker hair follicles and the glabrous skin of the rodent’s paws, where tactile stimulation elicits slowly adapting type 1 (SA1) tactile impulses to encode for the sense of touch. Recently, we have shown with rodent whisker hair follicles that SA1 impulses are generated through fast excitatory synaptic transmission at MNCs and driven by acid-sensing ion channels (ASICs). However, it is currently unknown whether, besides whisker hair follicles, ASICs also play an essential role in generating SA1 impulses from MNCs of other body parts in mammals. In the present study, we attempted to address this question by using the skin–nerve preparations made from the hindpaw glabrous skin and tibial nerves of both male and female rodents and applying the pressure-clamped single–fiber recordings. We showed that SA1 impulses elicited by tactile stimulation to the rat hindpaw glabrous skin were largely diminished in the presence of amiloride and diminazene, two ASIC channel blockers. Furthermore, using the hind-paw glabrous skin and tibial nerve preparations made from the mice genetically deleted of ASIC3 channels (ASIC3−/−), we showed that the frequency of SA1 impulses was significantly lower in ASIC3−/− mice than in littermate wild-type ASIC3+/+ mice, a result consistent with the pharmacological experiments with ASIC channel blockers. Our findings suggest that ASIC channels are essential for generating SA1 impulses to underlie the sense of touch in the glabrous skin of rodent hindpaws. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims/Introduction Materials and Methods Results Conclusions This study aims to investigate the association between cross‐sectional area (CSA) imaging findings of nerve ultrasound and conventional nerve conduction studies (NCS) for patients with distal symmetric sensorimotor polyneuropathy (DSPN) due to type 2 diabetes mellitus.We enrolled 103 patients with type 2 diabetes mellitus and collected their demographic data, modified Michigan Neuropathy Screening Instrument (mMNSI) score, NCS, and ultrasonography images of peripheral nerves. The relationship of ultrasound variables for individual nerves and the ultrasound pattern sum score (UPSS) to conventional NCS findings was investigated.A higher grade of DSPN was associated with a notably higher CSA. Multivariate step‐wise regression analysis revealed that the number of abnormal nerves was a positive independent variable for UPSS (β coefficient = 0.4205; P < 0.0001). Of the five nerves studied, abnormalities of the tibial nerve (P ≤ 0.0100) and ulnar nerve (P = 0.052) were the most significant variables.The tibial nerve exhibited the most substantial association with elevated UPSS. In addition, a strong correlation was observed between abnormal NCS findings and UPSS in patients with DSPN. [ABSTRACT FROM AUTHOR]

Background: The efficacy and acupoint selection of acupuncture in treating chemotherapy-induced peripheral neuropathy (CIPN) remain controversial. This study aims to explore the specific efficacy and acupoint selection of acupuncture in treating CIPN through a meta-analysis and data mining. Methods: Searching for clinical trials on acupuncture treatment for CIPN in 8 databases, evaluating its efficacy and safety through a meta-analysis, and exploring its acupoint selection through data mining. Results: The meta-analysis included 21 studies and 2,121 patients, showing that compared with the control group, the acupuncture group could significantly improve neuropathic pain intensity (SMD = −0.66, 95% CI [−1.07, −0.25], p = 0.002), significantly reduce the NCI-CTCAE (MD = −0.29, 95%CI [−0.50, −0.08], p < 0.01), significantly reduce the FACT-NXT score (MD = 2.09, 95% CI [0.73,3.45], p < 0.05), significantly increase the motor conduction velocities (MCV) of median nerve (MD = 2.38, 95% CI [2.10, 2.67], p < 0.001), the sensory conduction velocities (SCV) of the median nerve (MD = 0.56, 95 %CI [−1.45, 2.57], p = 0.58), the SCV of the tibial nerve (MD = 1.78, 95% CI [0.50, 3.05], p < 0.01), and the SCV of sural nerves (MD = 4.60, 95% CI [0.17, 9.02], p < 0.05), as well as improving the quality of life score (MD =7.35, 95% CI [1.53, 13.18], p = 0.01). Data mining showed that the core acupoints for acupuncture treatment of CIPN were LI4, ST36, LI11, LR3, and SP6. Conclusion: Acupuncture can improve the neuropathic pain intensity, the intensity of the CIPN, MCV of the median nerve, SCV of the tibial nerve and peroneal nerve, quality of life, and has good safety in CIPN patients. LI4 (Hegu), ST36 (Zusanli), LI11 (Quchi), LR3 (Taichong), and SP6 (Sanyinjiao) are the core acupuncture points for treating CIPN, and this protocol has the potential to become a supplementary treatment for CIPN. Systematic review registration: https://www.crd.york.ac.uk/prospero, identifier CRD42024551137. [ABSTRACT FROM AUTHOR]

Background: Popliteal pterygium syndrome (PPS) is a rare congenital disorder characterized by orofacial, cutaneous, musculoskeletal, and genital anomalies. Surgical interventions are necessary to address the severe knee flexion contracture and equinovarus deformity, but there are no established treatment guidelines. Methods: We present the case of a one-year-old patient with PPS and discuss the challenges in managing the knee deformity. The surgical option chosen for the unilateral knee contracture of 80° consisted of skin management by a large Z-plasty, lengthening of popliteal vessels by grafts, lengthening of the tibial and peroneal nerves by autografts and allografts, capsular releases, and tendon releases to improve mobility and preserve foot sensibility. Results: With a three-year follow-up, the surgical interventions resulted in proper ability to walk freely. Wearing of a foot orthesis was necessary to balance the leg length differences and support the midfoot deformity. Furthermore, sensation of the foot could be restored in terms of touch sensibility and perfusion was always stable during growth. Discussion: The treatment of PPS requires a multidisciplinary approach, considering the rarity and complexity of the syndrome. Surgical interventions aim to release contractures, correct deformities, and preserve foot sensibility. Each treatment option has its advantages and disadvantages, highlighting the need for individualized care. [ABSTRACT FROM AUTHOR]

Diabetic peripheral neuropathy (DPN) affects ∼50% of the 500 million people with type 2 diabetes worldwide and is considered disabling and irreversible. The current study was undertaken to assess the effect of metformin on peripheral neuropathy outcomes in type 2 diabetes. Participants with type 2 diabetes (n = 69) receiving metformin were recruited and underwent clinical assessment, peripheral nerve ultrasonography, nerve conduction studies, and axonal excitability studies. Also concurrently screened were 318 participants who were not on metformin, and 69 were selected as disease control subjects and matched to the metformin participants for age, sex, diabetes duration, BMI, HbA1c, and use of other diabetes therapies. Medical record data over the previous 20 years were analyzed for previous metformin use. Mean tibial nerve cross-sectional area was lower in the metformin group (metformin 14.1 ± 0.7 mm2, nonmetformin 16.2 ± 0.9 mm2, P = 0.038), accompanied by reduction in neuropathy symptom severity (P = 0.021). Axonal excitability studies demonstrated superior axonal function in the metformin group, and mathematical modeling demonstrated that these improvements were mediated by changes in nodal Na+and K+conductances. Metformin treatment is associated with superior nerve structure and clinical and neurophysiological measures. Treatment with metformin may be neuroprotective in DPN. Article Highlights: We aimed to assess whether peripheral neuropathy outcomes for patients with type 2 diabetes were better on metformin treatment. Metformin and nonmetformin groups with type 2 diabetes were matched for demographic and metabolic factors. Clinical neuropathy scores, peripheral nerve ultrasonography, nerve conduction studies, axonal excitability, and mathematical modeling findings were all superior in the metformin group. Mathematical modeling suggested this was due to superior nodal Na+and K+conductances. Treatment with metformin may be neuroprotective in diabetic peripheral neuropathy. [ABSTRACT FROM AUTHOR]

Background: It has been reported that 43.6% of ankle fractures are accompanied by posterior malleolus fractures. The aim of this study is to define a safe zone for posterior malleolus fractures by determining the locations of the important anatomical structures in this region. Additionally, it aims to identify the trans-Achilles passage line for Kirschner wire insertion through a posteroanterior approach for posterior malleolus fragments. Methods: Six below-knee amputee fresh-frozen leg cadavers were used in this study. A trans-Achilles Kirschner wire was applied to the cadavers in the posteroanterior direction under the guidance of fluoroscopy. The areas where the Kirschner wire passed were dissected, and their proximity to vital anatomical structures was measured. Results: In all cadavers, the transverse thickness of the Achilles tendon at the level of the trans-Achilles Kirschner wire was 15.5 mm and the trans-Achilles Kirschner wire application was 18.6 mm from the sural nerve, 16 mm from the posterior tibial tendon, and 12.16 mm from the flexor digitorum longus muscle. It was performed 15.16 and 14.6 mm from the posterior tibial artery and vein, 12.3 mm from the tibial nerve, 13.6 mm from the tibiofibular joint, and 55.5 mm from the insertion site of the Achilles tendon to the calcaneus and at a sufficient distance from vital anatomical structures. Conclusions: The proposed trans-Achilles percutaneous surgical technique is safe from neurovascular structures for fixing posterior malleolar fractures. However, the long-term clinical outcomes of this technique need to be explored. Level of evidence: Level III, A cadaveric study. [ABSTRACT FROM AUTHOR]

Background: Primary dysmenorrhea is a leading cause of chronic cyclic pelvic pain, contributing to a reduced quality of life and sleep disturbances in women. The objective of this study was to assess the effectiveness of transcutaneous tibial nerve stimulation (TTNS) in improving the quality of life, sleep, and overall health perceptions of participants compared to a control group of women with dysmenorrhea over short-term, medium-term, and long-term periods. Methods: A single-blind, controlled clinical trial was conducted, with participants randomly assigned to an experimental group (receiving TTNS) or a control group (receiving sham TTNS). Both groups underwent 12, weekly 30 min sessions using the NeuroTrac™ PelviTone electrostimulation device. Outcomes related to quality of life, sleep deficiency, and overall improvement were evaluated at three time points: short-term (post-treatment), medium-term (1–3 months), and long-term (6 months). Results: Of the 61 participants initially randomized (31 in the experimental group and 30 in the control group), 55 completed the study and were included in the final analysis. A statistically significant improvement was observed in the experimental group in both physical and mental health components, as measured by the SF-36v2® questionnaire, following 12 weeks of intervention, compared to the control group, persisting 6 months after the intervention. Additionally, statistically significant differences in overall improvement were noted between the two groups, as measured by the PGIC questionnaire at the end of treatment (p = 0.0103) and 6 months post-treatment (p = 0.0432). Conclusions: TTNS appears to be a safe and effective strategy for enhancing quality of life and overall health in women with PD, potentially reducing the reliance on pharmacological treatments or more invasive methods. [ABSTRACT FROM AUTHOR]

Background/Objectives: Multiple sclerosis (MS) frequently results in both urinary and sexual dysfunction, which significantly impairs quality of life. Conventional treatments for bladder dysfunction often prove insufficient, leading to the exploration of alternative therapies such as percutaneous tibial nerve stimulation (PTNS). This study aimed to assess the impact of PTNS on sexual function and bladder symptoms in female MS patients with neurogenic detrusor overactivity (NDO) and female sexual dysfunction (FSD). Methods: A total of 65 female MS patients with NDO were evaluated and underwent 12 weeks of standardized PTNS treatment. Sexual function was assessed using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R), while bladder symptoms were evaluated using the OAB-v8 questionnaire. Participants were grouped based on the presence of sexual dysfunction and distress and compared to a control group of 20 patients who declined PTNS. Results: Significant improvements were observed in FSFI scores across multiple domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) in the treatment groups (p < 0.05). Additionally, 58.46% of patients showed positive responses to PTNS regarding overactive bladder symptoms (OAB-v8 score), while the control group showed no significant changes. Conclusions: PTNS appears to be an effective therapeutic option for improving sexual function and urinary symptoms in female MS patients with NDO and FSD, offering a promising non-invasive alternative for managing these conditions. [ABSTRACT FROM AUTHOR]

Background/ Aim: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease affecting upper and lower motor neurons, causing progressive atrophy of muscles, hypertonia, and paralysis. This study aimed to evaluate the current evidence and effectiveness of ultrasound in investigating nerve cross-sectional area (CSA) of peripheral nerves, vagus and cervical roots in those with ALS compared with healthy controls and to pool the CSA measurements. Methods: A systematic search was conducted on Cochrane, Clarivate Web of Science, PubMed, Scopus, and Embase for the mesh terms nerve, ultrasonography, and amyotrophic lateral sclerosis. A quality assessment was performed using the New-Ottawa scale. In addition, a double-arm meta-analysis using Review Manager 5 software version 5.4 was performed. Results: From the seventeen studies included in this review, the overall mean difference showed that individuals with ALS had a significantly smaller CSA in comparison to healthy controls for median, ulnar, C6 root, and phrenic nerves. However, no significant difference in the CSA was found in radial, vagal, sural, and tibial nerves. Discussion: This study confirmed results of some of the included studies regards the anatomic sites, where nerve atrophy in ALS could be detected to potentially support the diagnosis of ALS. However, we recommend further large, prospective studies to assess the diagnostic value of these anatomical sites for the diagnosis of ALS. Conclusions: Our findings confirmed specific anatomic sites to differentiate ALS patients from healthy controls through ultrasound. However, these findings cannot be used to confirm the ALS diagnosis, but rather assist in differentiating it from other diagnoses. Trial registration: Retrospectively registered on July 30th 2024 in PROSPERO (PROSPERO (york.ac.uk)) with ID574702. [ABSTRACT FROM AUTHOR]

Background/Objectives: The tibial nerve, commonly misnamed the "posterior tibial nerve", branches into four key nerves: the medial plantar, lateral plantar, inferior calcaneal (Baxter's nerve), and medial calcaneal branches. These nerves are integral to both the sensory and motor functions of the foot. Approximately 15% of adults with foot issues experience heel pain, frequently stemming from neural origins, such as tarsal tunnel syndrome (TTS). TTS diagnosis remains challenging due to a high false negative rate in neurophysiological studies. This study aims to improve the understanding and diagnosis of distal tarsal tunnel pathology to enable more effective treatments, including platelet-rich plasma, hydrodissections, radiofrequencies, and prolotherapy. Methods: Ultrasound-guided techniques were employed to examine the distal tarsal tunnel using the Heimkes triangle for optimal probe placement. Results: The results indicate that the tunnel consists of two chambers separated by the interfascicular septum, housing the medial, lateral plantar, and inferior calcaneal nerves. Successful interventions depend on precise visualization and patient positioning. This study emphasizes the importance of avoiding the calcaneus periosteum to reduce discomfort. Conclusions: Standardizing nerve involvement classification in TTS is difficult without robust neurophysiological studies. The accurate targeting of nerve branches is essential for effective treatment. [ABSTRACT FROM AUTHOR]

This trial examined the effectiveness of the popliteal plexus block (PPB) and tibial nerve block (TNB) for early rehabilitation after total knee arthroplasty (TKA). We allocated 136 participants to receive PPB or TNB with 0.25% levobupivacaine 10 mL in a randomized, double-masked manner. The primary outcome was achieving rehabilitation goals with a non-inferiority 9-hour margin, including adequate pain relief, knee flexion angles over 90 degrees, and enabling ambulatory rehabilitation. The time to reach rehabilitation goals showed non-inferiority with 49.7 ± 10.5 h for TNB and 47.4 ± 9.7 h for PPB, whose mean difference (PPB - TNB) was − 2.3 h (95% CI -5.8 to 1.2 h; P < 0.001). PPB showed higher dorsal and plantar percentage of maximum voluntary isometric contraction (dorsal, PPB 87.7% ± 11.4% vs. TNB 74.0% ± 16.5%: P < 0.001; plantar, PPB 90.9% ± 10.3% vs. TNB 72.1% ± 16.0%; P < 0.001) at six hours after nerve block. No significant differences between the two groups emerged in pain scores, knee range of motion, additional analgesic requirements, success in the straight leg raise, and adverse events. PPB exhibited non-inferiority to TNB in achieving postoperative rehabilitation goals and had superiority in preserving foot motor strength after TKA. (200) [ABSTRACT FROM AUTHOR]

Aims: We hypothesise that PTNS is a safe and effective treatment for OAB. Overactive bladder (OAB) is estimated to affect 11.8% of women worldwide, causing diminished quality of life. Lifestyle modifications, muscarinic receptor antagonist and beta‐adrenoreceptor agonist remain the mainstay of treatment but are limited by their efficacy and adverse effects. Access to third‐line therapies of intravesical botulinum toxin type A or sacral neuromodulation is limited by their invasive nature. Percutaneous tibial nerve stimulation (PTNS) has emerged as a non‐invasive treatment option for OAB. Methods: This study was a single‐arm trial of women requesting third‐line treatment for OAB. The primary treatment outcome was patient‐reported visual analogue score (VAS) improvement of at least 50%. Secondary outcome measures were Urinary Distress Inventory Short Form (UDI‐6) score and two‐day bladder diary. Patients also provided feedback on adverse effects encountered. Results: In the 84 women recruited, initial treatment protocol showed a success rate of 77.2% among those who completed treatment based on VAS, with a statistically significant improvement in mean UDI‐6 score of 20.13 (P < 0.01, standard deviation: 12.52). Continued success following tapering protocol of 60.8% and a mean maintenance protocol of 14.2 months was achieved. No adverse effects were reported. Conclusion: The results from this study are in concordance with previously published literature on the effectiveness and safety of PTNS as a treatment modality for OAB. Further randomised controlled trials to evaluate the optimal treatment protocol are warranted to establish a standardised regime. [ABSTRACT FROM AUTHOR]

Neuromuscular ultrasound has emerged as a beneficial, complementary tool to electromyography (EMG) in the diagnosis of neuromuscular diseases as it provides high-resolution anatomic imaging of peripheral nerves and muscles. It has been used previously as an adjunct to EMG to diagnose Charcot-Marie-Tooth disease. Here, we present a case of a 64-yr-old man with bilateral sensorineural hearing loss of 14 yrs who presented to an outpatient neuromuscular clinic at a tertiary medical center with very slow progressive paresthesias. This case highlights the application of neuromuscular ultrasound to help confirm the presence of a likely Charcot-Marie-Tooth disease type 4C despite indeterminate genetic testing results and challenging EMG results. He had genetic testing which revealed a normal PMP22 gene; however, he had a variant of uncertain significance in the SH3TC2 gene which has shown associations with autosomal recessive CMT4C. Neuromuscular ultrasound revealed mild median and significant tibial nerve uniform enlargement throughout their course. There may also be utility in performing neuromuscular ultrasound on similarly affected family members if the same variant of uncertain significance returns for SH3TC2, with consideration of both peripheral nerve and nerve root assessment. [ABSTRACT FROM AUTHOR]

Context: Inflamed nerve root leads to mechano-sensitization and upregulation of sodium channels in nerve endings far distal to the site of inflammation, leading to tenderness of these nerve endings. Due to pseudounipolar nature, the blockade of sodium channels at peripheral nerve endings leads to relief in radicular pain. Aims: The aim of this study was to assess the efficacy of bupivacaine in improving pain and straight leg raising test (SLRT), 30 min after injection around tender nerves near the ankle, in patients with unilateral radicular pain. Design: This was a randomized placebo-controlled triple-blinded study. Methods: One hundred patients of single-level lumbar disc prolapse and unilateral radicular pain were randomized into two equal groups. Three nerves (sural nerve, lateral branch of deep peroneal nerve and posterior tibial nerve) were assessed for tenderness around the ankle. Bupivacaine (0.5%) was injected around each tender nerve in the case group whereas equal volume of normal saline was injected in the control group around each tender nerve. Pain Numerical Rating Scale (NRS) and SLRT were checked before and 30 min postinjection. A proportion of patients achieving minimum clinically important difference (MCID) of NRS ≤4 and MCID of SLRT ≥30° were compared. Results: A mean decrease in NRS among cases was from 8.06 ± 1.236 to 3.90 ± 2.013 (P < 0.001) with 78% achieving MCID. A mean decrease in NRS in the control group was from 7.88 ± 1.023 to 7.66 ± 1.171 (P = 0.084), and only 2% of patients achieved MCID. There was a statistically significant improvement in SLR in the case group (40.90°–60.90°, P < 0.001), and 54% showed a clinically significant improvement by crossing MCID threshold. The control group showed nonsignificant improvement in SLRT (38.10°–39.10°, P = 0.351), and only 2% achieved MCID. Conclusions: In single-level lumbar disc prolapse with unilateral radicular pain, injection of bupivacaine 0.5% (a sodium channel blocker) around tender nerves near the ankle provides clinically significant relief in pain and SLRT at 30 min when compared to placebo. [ABSTRACT FROM AUTHOR]

Introduction: Postpartum constipation is a frequent occurrence of Cesarean section delivery. Although medications such as laxatives are effective treatments, they have widely-documented side effects and their benefits cease upon discontinuation. This study sought to examine whether bilateral transcutaneous tibial nerve stimulation (TTNS) could be more beneficial in treating postpartum constipation. Material and methods: The study included 56 women, aged 20 to 35 years with a Body Mass Index (BMI) from 25 to 33 kg/m², who complained of constipation after giving birth. The participants were randomly allocated into two equal groups and received 12 sessions of treatment. The TTNS group received bilateral TTNS, diaphragmatic breathing, abdominal muscle training, and behavioral therapy advice. The control group received the same therapy as the TTNS group but without the TTNS program. All participants were assessed at baseline and after 12 weeks through the Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QOL), the Patient Assessment of Constipation Symptom Questionnaire (PAC-SYM), and the Bristol Stool Form Scale (BSFS). Results: All outcome variables in both groups demonstrated a significant improvement after therapy compared to before (p < 0.05). However, the final PAC-SYM and PAC-QOL scores were significantly more favorable (p < 0.05) in the TTNS group. Conclusions: When treating constipation in postpartum women, adding bilateral TTNS to traditional physiotherapy treatment might be better than using traditional therapy alone. [ABSTRACT FROM AUTHOR]

Aim: Neuromuscular Taping (NMT) is the application of elastic adhesive tape to the skin without any tension in it. NMT creates wrinkles on the surface of the skin to help stretch the skin passively and this elongation force assists in muscle contraction and relaxation. Therefore, this study aimed to assess the effectiveness of NMT in the improvement of sensorimotor complications following diabetic peripheral neuropathy (DPN). Setting and Design: A randomized controlled trial performed at a tertiary health care center. Materials and Methods: A total of 20 participants were recruited and were divided into two groups: The experimental group (EG; N = 10) and the control group (CG; N = 10). Eight weeks of physiotherapy intervention including NMT on bilateral tibialis anterior, tibialis posterior, peroneus longus muscles, transverse arch of the foot, and transcutaneous electrical nerve stimulation (TENS) on the course of bilateral tibial and peroneal nerves for EG. CG received sham taping and TENS as an EG group. The patients were assessed for pre- and post-intervention using the outcomes: Leeds Assessment of Neuropathic Signs and Symptoms and nerve conduction velocity of tibial, peroneal, and sural nerves and H-reflex, Berg Balance Scale, and Pedalo-Sensamove Mini Board. Results: The results revealed that both the groups showed significant improvements in all variables except for the H-reflex of the right and left sides at P > 0.05. EG showed more clinical and symptomatic improvement compared with CG. In EG, most of the variables showed moderate to large effect sizes ranging from 0.66 to 0.97 except for bilateral H-reflex; ranging from 0.15 to 0.33. Conclusion: This study concludes that NMT can be a trustworthy approach to treating DPN. [ABSTRACT FROM AUTHOR]

IntroductionWhile it is well known that the sensory arm of the micturition reflex is mediated by A-δ afferents in the pelvic nerve, the urinary bladder is also innervated by afferents in the hypogastric nerve (HGN), whose role in micturition is less well understood. We have recently determined that stimulation of HGN afferents can facilitate nociceptive bladder activity in the cat induced by intravesical instillation of acetic acid. The aim of the present study, then, was to determine if activation of HGN afferents could similarly facilitate normal bladder activity in the cat, evoked by saline distension. Additional experiments examined if HGN stimulation could modulate the inhibitory effects of tibial or pudendal neuromodulation on bladder capacity.MethodsContinuous infusion cystometry was performed in 9 (4 male, 5 female) α-chloralose anesthetized cats in which the HGNs were transected bilaterally. Bipolar electrodes were used to stimulate the central end of the cut HGNs at varying intensities (1-15 V) and frequencies (1-40 Hz) during bladder filling with saline (1-2 ml/min) until a micturition contraction occurred. Tripolar cuff electrodes were also placed on the left pudendal and left tibial nerve to examine the effect of neuromodulation on bladder capacity during cystometry.ResultsHypogastric nerve stimulation (HGNS) at 30 Hz and 15 V significantly reduced bladder capacity to 80.01 ± 3.86% of control. Tibial or pudendal nerve stimulation (5 Hz, 2 T) significantly increased bladder capacity to 187.6 ± 20.2% or 193.8 ± 19.0% of control, respectively. Simultaneous HGNS significantly reduced the efficacy of tibial nerve neuromodulation (reduced to 158.7 ± 18.7% of control) and but only partially suppressed the bladder inhibition induced by pudendal neuromodulation (reduced to 161.9 ± 18.0% of control).ConclusionThese results suggest that HGN afferents (possibly C-fiber nociceptors) from the bladder or other pelvic organs may facilitate normal bladder activity to cause bladder overactivity. Additionally, HGN afferents may influence the efficacy of tibial or pudendal neuromodulation therapy in treating OAB.

An antisense oligonucleotide drug nusinersen can improve motor function of spinal muscular atrophy (SMA) patients. The Hybrid Assistive Limb (HAL) is a wearable robot assisting the wearers' movements in real time. Gait rehabilitation using HAL is useful for SMA. However, the efficacy of combined treatment has never been reported before. We have investigated the efficacy of combining both therapies. A 21‐year‐old man, genetically diagnosed with type 3 SMA, was treated by combining nusinersen and five sessions of gait rehabilitation using HAL over 2 years. Hammersmith Functional Motor Scale‐Expanded (HFMSE) score improved by 12 points after treatment. Electrophysiological parameters of the tibial nerves improved. Muscle volume also increased by 8% at 39 months. The combined therapy resulted in a good clinical outcome. This may be due to promotion of nerve regeneration and recovery of muscle volume by a synergy of nusinersen and motor learning correctly guided by HAL. [ABSTRACT FROM AUTHOR]

INTRODUCTION AND HYPOTHESIS: In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial. METHODS: This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Marks score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p

Cutaneous feedback from feet is involved in regulation of muscle activity during locomotion, and the lack of this feedback results in motor deficits. We tested the hypothesis that locomotor changes caused by local unilateral anesthesia of paw pads in the cat could be reduced/reversed by electrical stimulation of cutaneous and proprioceptive afferents in the distal tibial nerve during stance. Several split-belt conditions were investigated in four adult female cats. In addition, we investigated the effects of similar distal tibial nerve stimulation on overground walking of one male cat that had a transtibial, bone-anchored prosthesis for 29 months and, thus, had no cutaneous/proprioceptive feedback from the foot. In all treadmill conditions, cats walked with intact cutaneous feedback (control), with right fore- and hindpaw pads anesthetized by lidocaine injections, and with a combination of anesthesia and electrical stimulation of the ipsilateral distal tibial nerve during the stance phase at 1.2× threshold of afferent activation. Electrical stimulation of the distal tibial nerve during the stance phase of walking with anesthetized ipsilateral paw pads reversed or significantly reduced the effects of paw pad anesthesia on several kinematic variables, including lateral center of mass shift, cycle and swing durations, and duty factor. We also found that stimulation of the residual distal tibial nerve in the prosthetic hindlimb often had different effects on kinematics compared with stimulation of the intact hindlimb with paw anesthetized. We suggest that stimulation of cutaneous and proprioceptive afferents in the distal tibial nerve provides functionally meaningful motion-dependent sensory feedback, and stimulation responses depend on limb conditions. [ABSTRACT FROM AUTHOR]

Introduction Approximately 89% of all service members with amputations do not return to duty. Restoring intuitive neural control with somatosensory sensation is a key to improving the safety and efficacy of prosthetic locomotion. However, natural somatosensory feedback from lower-limb prostheses has not yet been incorporated into any commercial prostheses Materials and Methods We developed a neuroprosthesis with intuitive bidirectional control and somatosensation and evoking phase-dependent locomotor reflexes, we aspire to significantly improve the prosthetic rehabilitation and long-term functional outcomes of U.S. amputees. We implanted the skin and bone integrated pylon with peripheral neural interface pylon into the cat distal tibia, electromyographic electrodes into the residual gastrocnemius muscle, and nerve cuff electrodes on the distal tibial and sciatic nerves. Results. The bidirectional neural interface that was developed was integrated into the existing passive Free-Flow Foot and Ankle prosthesis, WillowWood, Mount Sterling, OH. The Free-Flow Foot was chosen because it had the highest Index of Anthropomorphicity among lower-limb prostheses and was the first anthropomorphic prosthesis brought to market. Conclusion. The cats walked on a treadmill with no cutaneous feedback from the foot in the control condition and with their residual distal tibial nerve stimulated during the stance phase of walking [ABSTRACT FROM AUTHOR]

Background and Aims: Histopathological diagnosis is the gold standard in many acquired inflammatory, infiltrative and amyloid based peripheral nerve diseases and a sensory nerve biopsy of sural or superficial peroneal nerve is favoured where a biopsy is deemed necessary. The ability to determine nerve pathology by high‐resolution imaging techniques resolving anatomy and imaging characteristics might improve diagnosis and obviate the need for biopsy in some. The sural nerve is anatomically variable and occasionally adjacent vessels can be sent for analysis in error. Knowing the exact position and relationships of the nerve prior to surgery could be clinically useful and thus reliably resolving nerve position has some utility. Methods: 7T images of eight healthy volunteers' (HV) right ankle were acquired in a pilot study using a double‐echo in steady‐state sequence for high‐resolution anatomy images. Magnetic Transfer Ratio images were acquired of the same area. Systematic scoring of the sural, tibial and deep peroneal nerve around the surgical landmark 7 cm from the lateral malleolus was performed (number of fascicles, area in voxels and mm2, diameter and location relative to nearby vessels and muscles). Results: The sural and tibial nerves were visualised in the high‐resolution double‐echo in steady‐state (DESS) image in all HV. The deep peroneal nerve was not always visualised at level of interest. The MTR values were tightly grouped except in the sural nerve where the nerve was not visualised in two HV. The sural nerve location was found to be variable (e.g., lateral or medial to, or crossing behind, or found positioned directly posterior to the saphenous vein). Interpretation: High‐resolution high‐field images have excellent visualisation of the sural nerve and would give surgeons prior knowledge of the position before surgery. Basic imaging characteristics of the sural nerve can be acquired, but more detailed imaging characteristics are not easily evaluable in the very small sural and further developments and specific studies are required for any diagnostic utility at 7T. [ABSTRACT FROM AUTHOR]