Search results for: spinal accessory nerve

Authors: Asaf Toker

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Matricelf developed a technology that enables the production of autologous engineered tissue composed of matrix and cells derived from patients Omentum biopsy. The platform showed remarkable pre-clinical results for several medical conditions. The company recently licensed the technology that enabled scientist at Tel Aviv university that 3D printed a human heart from human cells and matrix for the first time in human history. The company plans to conduct its first human clinical trial for Acute Spinal Cord Injury (SCI) early in 2023.

Keywords: tissue engineering, regenerative medicine, spinal Cord Injury, autologous implants, iPSC

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Authors: John Yahng, Hansraj Riteesh Bookun

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Popliteal artery aneurysms (PAAs) are the most common arterial aneurysm of the periphery. It is defined as focal dilation of the artery more than 50% of the normal vessel diameter which usually varies between 7 mm to 11 mm. The most common presentation for PAAs is claudication due to luminal stenosis secondary to mural thrombus or acute limb ischaemia due to occlusive thrombosis or distal thromboembolism. It is less common for patients to present with non-ischaemic symptoms secondary to mass effect and compression of adjacent structures, and of these, presentation with common peroneal nerve compression is particularly uncommon. We present a rare case of a 92-year-old female patient presenting with 4-month history of left foot drop with radiological evidence of common peroneal nerve compression secondary to PAA of 22 mm by 21mm in size. To the best of our knowledge, this is the smallest reported popliteal aneurysm presenting with foot drop. We also present the endovascular treatment option taken in our case.

Keywords: aneurysm, foot drop, peroneal nerve, popliteal

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Authors: Betul Taspinar, Eda O. Okur, Ismail Saracoglu, Ismail Okur, Ferruh Taspinar

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Thoracic hyperkyphosis, is a well-known spinal phenomenon, refers to an excessive curvature (> 40 degrees) of the thoracic spine. The aim of this study was to explore the effectiveness of thrust manipulation on thoracic spine alignment. 31 young adults with hyperkyphosis diagnosed with Spinal Mouse® device were randomly assigned either thrust manipulation group (n=16, 11 female, 5 male) or sham manipulation group (n=15, 8 female, 7 male). Thrust and sham manipulations were performed by a blinded physiotherapist who is a certificated expert in musculoskeletal physiotherapy. Thoracic kyphosis degree was measured after the interventions via Spinal Mouse®. Wilcoxon test was used to analyse the data obtained before and after the manipulation for each group, whereas Mann-Whitney U test was used to compare the groups. The mean of baseline thoracic kyphosis degrees in thrust and sham groups were 50.69 o ± 7.73 and 48.27o ± 6.43, respectively. There was no statistically significant difference between groups in terms of initial thoracic kyphosis degrees (p=0.51). After the interventions, the mean of thoracic kyphosis degree in thrust and sham groups were measured as 44.06o ± 6.99 and 48.93o ± 6.57 respectively (p=0.03). There was no statistically significant difference between before and after interventions in sham group (p=0.33), while the mean of thoracic kyphosis degree in thrust group decreased significantly (p=0.00). Thrust manipulation can attenuate thoracic hyperkyphosis immediately in young adults by not using placebo effect. Manipulation might provide accurate proprioceptive (sensory) input to the spine joints and reduce kyphosis by restoring normal segment mobility. Therefore thoracic manipulation might be included in the physiotherapy programs to treat hyperkyphosis.

Keywords: hyperkyphosis, manual therapy, spinal mouse, physiotherapy

Procedia PDF Downloads 342

Authors: S. D. Zalepugin, A. E. Murzich, D. G. Satskevich, A. B. Palivanov

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Introduction. The incidence of spinal injuries in patients under 18 years of age has increased significantly in recent years, which represents a significant economic, social and medical problem. The most common method of surgical stabilization of spinal fractures in pediatric patients is transpedicular posterior spinal fusion, which is widely used by spinal neurosurgeons in adult patients. Purpose of the study: This study evaluates the results of treatment of thoracolumbar spine lesions in children using the transpedicular screw fixation method. Materials and methods. From 2019 to 2024, 35 children with injuries to the thoracic and lumbar spine underwent surgical treatment using the transpedicular screw fixation method. Among the injured, girls prevailed (21 cases, 60%). The age of the victims ranged from 9 to 17 years. The main causes of damage were: catatrauma (19 cases), road accident (5 cases), sports injury (6 cases), and other reasons - 5 cases. In 5 cases, suicidal attempts occurred. Co-injury was observed in most cases (20 patients, or 57%), which is natural for high-energy injury. Vertebral-spinal injury with neurological disorders was observed in 13 patients, the disorders ranged from mild inferior (4 children) to moderate/severe paraparesis (5 patients) and inferior paraplegia (4 children). 6 children had pelvic organ dysfunction in the form of urinary and fecal retention or incontinence. All thirty-five patients, within a period of 1 to 57 days after the injury, underwent several surgical interventions from the posterior surgical access using a screw fixation method (posterior decompression + spinal fusion). In 12 cases, it was necessary to perform the second stage of surgical treatment - anterior decompression of the spinal cord or its roots. Verticalization of patients was carried out within 1 to 5 days after surgery. Results. In all patients, the nearest, up to 1 year, results were evaluated. In children operated in 2019-2021, the results were studied in terms of 3 to 5 years. The procedures used, clinical results and the quality of the fixative installation were assessed. All patients managed to achieve positive results. The use of internal fixation made it possible to carry out early verticalization of children, eliminate pain syndrome and achieve a regression of neurological disorders in most patients (especially in cases when the operation was performed early after injury - from 1 to 3 days). Within the first month, the ability to self-care was fully restored. Bone fusion was observed within 6-12 months after surgery. There were no complications after surgery. The analysis of postoperative radiographs, CT and MRI images revealed the correct standing of the screws in all cases. Conclusion. The posterior spinal fusion using the new method of screw fixation in pediatric patients allows to achieve durable stabilization of damage, begins early rehabilitation of patients and reduces the duration of hospital treatment by 2-3 times. Thus, we recommend the use of a transpedicular fixator in children as a reliable, technically feasible method for restoring spinal stability with a low risk of intra- and postoperative complications.

Keywords: pediatric patients, spinal injuries, transpedicular stabilization, operative treatment

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Authors: Daniela Proca, Yuan Rong, Salvatore Luceno, Jalil Nasibli

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Introduction: Solitary Fibrous Tumors (SFT) have many histologic mimickers and the only way to diagnose it, particularly in an unusual location, such as peripheral nerve trunks, is to use a comprehensive immunohistochemical staining panel. Monoclonal STAT6 immunostain is highly sensitive and specific for SFTs and particularly useful in the diagnosis of difficult SFT cases. Methods: We describe a solitary fibrous tumor (SFT) involving the right branchial plexus in a 66 yo female with 4-year history of slowly growing chest wall mass with recent dysesthesias in fingers 4th and 5th. MRI showed a well-circumscribed heterogenous mass measuring 5.4 x 3.8 x 4.0 cm and encircling peripheral nerves of the branchial plexus; no involvement of the bone or muscle was noted. A biopsy showed a bland spindled and epithelioid proliferation with no significant mitotic activity, no necrosis, and no atypia; peripheral nerve fascicles were encircled by the lesion. The main clinical and pathologic differential diagnosis included peripheral nerve sheath tumor, particularly schwannoma; HE microscopy didn’t show the classic Antoni A and B areas but showed focal subtle nuclear palisading, as well as prominent vessels with hyalinization. Immunohistochemical stains showed focal, weak cytoplasmic S100 positivity in the lesion; CD 34 and Vimentin were strongly and diffusely positive; the neoplastic cells were negative with AE1/AE3, EMA, CD31, SMA, Desmin, Calretinin, HMB-45, Melan A, PAX-8, NSE. The immunohistochemical and histologic pattern was not typical of peripheral nerve sheath tumor. On additional stains, the tumor was positive with STAT-6 and bcl-2 and focally positive with CD99. Given this profile, the final diagnosis was that of a solitary fibrous tumor. Results: NA Conclusion: Very few SFTs involving peripheral nerves and mimicking a peripheral nerve sheath tumor are described in the literature. Although histologically benign on this biopsy, long-term follow-up is required because of the risk of recurrence of these tumors and their uncertain biological behavior.

Keywords: solitary fibrous tumor, pathology, diagnosis, immunohistochemistry

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Authors: Walid Abouzeid, Mohamed Shadad, Mostafa Farid, Magdy El Hawary

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The most frequent treatable vascular abnormality of the spinal canal is spinal dural arteriovenous fistulae (SDAVFs), which cause progressive para- or quadriplegia mostly affecting elderly males. SDAVFs are present in the thoracolumbar region. The main goal of treatment must be to obliterate the shunting zone via superselective embolization with the usage of a liquid embolic agent. This study aims to evaluate endovascular technique as a safe and efficient approach for the treatment SDAVFs, especially with long-term follow-up clinical outcomes. Study Design: A retrospective clinical case study. From May 2010 to May 2017, 15 patients who had symptoms attributed to SDAVFs underwent the operation in the Departments of Neurosurgery in Suhag, Tanta, and Al-Azhar Universities and Interventional Radiology, Ain Shams University. All the patients had varying degrees of progressive spastic paraparesis with and without sphincteric disturbances. Endovascular embolization was used in all cases. Fourteen were males, with ages ranging from 45 to 74 years old. After the treatment, good outcome was found in five patients (33.3%), a moderate outcome was delineated in six patients (40 %), and four patients revealed a poor outcome (26.7%). Spinal AVF could be treated safely and effectively by the endovascular approach. Generally, there is no correlation between the disappearance of MRI abnormalities and significant clinical improvement. The preclinical state of the patient is directly proportional to the clinical outcome. Due to unexpected responses, embolization should be attempted even the patient is in a bad clinical condition.

Keywords: spine, arteriovenous, fistula, endovascular, embolization

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Authors: Jihoon Yang, Jeong II Choi

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Mincle is expressed in macrophages and is members of immunoreceptors induced after exposure to various stimuli and stresses. Mincle receptor activation promotes the production of these substances by increasing the transcription of inflammatory cytokines and chemokines. Cytokines, which play an important role in the initiation and maintenance of such inflammatory pain diseases, have a significant effect on sensory neurons in addition to their enhancement and inhibitory effects on immune and inflammatory cells as mediators of cell interaction. Glial cells in the central nervous system play a critical role in development and maintenance of chronic pain states. Microglia are tissue-resident macrophages in the central nervous system, and belong to a group of mononuclear phagocytes. In the central nervous system, mincle receptor is present in neurons and glial cells of the brain.This study was performed to identify the Mincle receptor in the spinal cord and to investigate the effect of Mincle receptor activation on nociception and the changes of microglia. Materials and Methods: C-type lectins(Mincle) was identified in spinal cord of Male Sprague–Dawley rats. Then, mincle receptor ligand (TDB), via an intrathecal catheter. Mechanical allodynia was measured using von Frey test to evaluate the effect of intrathecal injection of TDB. Result: The present investigation shows that the intrathecal administration of TDB in the rat produces a reliable and quantifiable mechanical hyperalgesia. In addition, The mechanical hyperalgesia after TDB injection gradually developed over time and remained until 10 days. Mincle receptor is identified in the spinal cord, mainly expressed in neuronal cells, but not in microglia or astrocyte. These results suggest that activation of mincle receptor pathway in neurons plays an important role in inducing activation of microglia and inducing mechanical allodynia.

Keywords: mincle, spinal cord, pain, microglia

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Authors: Kaushikk Iyer, Richard M Hall, David Keeling

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Hardware-in-the-loop (HIL) simulation is an advanced technique for developing and testing complex real-time control systems. This paper presents the benefits of HIL simulation and how it can be implemented and used effectively to develop, test, and validate advanced control algorithms used in a spinal joint Wear simulator for the Tribological testing of spinal disc prostheses. spinal wear simulator is technologically the most advanced machine currently employed For the in-vitro testing of newly developed spinal Discimplants. However, the existing control techniques, such as a simple position control Does not allow the simulator to test non-sinusoidal waveforms. Thus, there is a need for better and advanced control methods that can be developed and tested Rigorouslybut safely before deploying it into the real simulator. A benchtop HILsetupis was created for experimentation, controller verification, and validation purposes, allowing different control strategies to be tested rapidly in a safe environment. The HIL simulation aspect in this setup attempts to replicate similar spinal motion and loading conditions. The spinal joint wear simulator containsa four-Barlinkpowered by electromechanical actuators. LabVIEW software is used to design a kinematic model of the spinal wear Simulator to Validatehow each link contributes towards the final motion of the implant under test. As a result, the implant articulates with an angular motion specified in the international standards, ISO-18192-1, that define fixed, simplified, and sinusoid motion and load profiles for wear testing of cervical disc implants. Using a PID controller, a velocity-based position control algorithm was developed to interface with the benchtop setup that performs HIL simulation. In addition to PID, a fuzzy logic controller (FLC) was also developed that acts as a supervisory controller. FLC provides intelligence to the PID controller by By automatically tuning the controller for profiles that vary in amplitude, shape, and frequency. This combination of the fuzzy-PID controller is novel to the wear testing application for spinal simulators and demonstrated superior performance against PIDwhen tested for a spectrum of frequency. Kaushikk Iyer is a Ph.D. Student at the University of Leeds and an employee at Key Engineering Solutions, Leeds, United Kingdom, (e-mail: [email protected], phone: +44 740 541 5502). Richard M Hall is with the University of Leeds, the United Kingdom as a professor in the Mechanical Engineering Department (e-mail: [email protected]). David Keeling is the managing director of Key Engineering Solutions, Leeds, United Kingdom (e-mail: [email protected]). Results obtained are successfully validated against the load and motion tolerances specified by the ISO18192-1 standard and fall within limits, that is, ±0.5° at the maxima and minima of the motion and ±2 % of the complete cycle for phasing. The simulation results prove the efficacy of the test setup using HIL simulation to verify and validate the accuracy and robustness of the prospective controller before its deployment into the spinal wear simulator. This method of testing controllers enables a wide range of possibilities to test advanced control algorithms that can potentially test even profiles of patients performing various dailyliving activities.

Keywords: Fuzzy-PID controller, hardware-in-the-loop (HIL), real-time simulation, spinal wear simulator

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Authors: Jeounghee Kim

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Objective: To describe the incidence of complication, according to the stage of Traumatic Spinal Cord Injury (TSCI) which was treated at Asan Medical Center (AMC), Korea. Hereafter, it should be developed in nursing management protocol of traumatic SCI. Methods. Retrospectively reviewed hospital records about the patients who were admitted AMC Patients with traumatic spinal cord injury until January 2005 and December 2016 were analyzed (n=97). AMC is a single institution of 2,700 beds where patients with trauma and severe trauma can be treated. Patients who were admitted to the emergency room due to spinal cord injury and who underwent intensive care unit, general ward, and rehabilitation ward. To identify long-term complications, we excluded patients who were operated on to other hospitals after surgery. Complications such as respiratory(pneumonia, atelectasis, pulmonary embolism, and others), cardiovascular (hypotension), urinary (autonomic dysreflexia, urinary tract infection (UTI), neurogenic bladder, and others), and skin systems (pressure ulcers) from the time of admission were examined through medical records and images. Results: SCI was graded according to ASIA scale. The initial grade was checked at admission. (grade A 55(56.7%), grade B 14(14.4)%, grade C 11(11.3%), grade D 15(15.5%), and grade E 2(2.1%). The grade was rechecked when the patient was discharged after treatment. (grade A 43(44.3%), grade B 15(15.5%), grade C 12(12.4%), grade D 21(21.6%), and grade E 6(6.2%). The most common complication after SCI was UTI 24cases (mean 36.5day), sore 24cases (40.5day), and Pneumonia which was 23 cases after 10days averagely. The other complications after SCI were neuropathic pain 19 cases, surgical site infection 4 cases. 53.6% of patient who had SCI were educated about intermittent catheterization at discharge from hospital. The mean hospital stay of all SCI patients was 61days. Conclusion: The Complications after traumatic SCI were developed at various stages from acute phase to chronic phase. Nurses need to understand fully the time-course of complication in traumatic SCI to provide evidence-based practice.

Keywords: spinal cord injury, complication, nursing, rehabilitation

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Authors: Obulesh Avuku, Satwik Sunnam, Sri Charan Mohan Janthuka, Keerthi Yalamaddi

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In the United States alone, there are over 1.5 million spine fractures per year, resulting in about 17,730 spinal cord injuries. The cervical spine is where fractures in the spine most frequently occur. The prevalence of spinal fractures in the elderly has increased, and in this population, fractures may be harder to see on imaging because of coexisting degenerative illness and osteoporosis. Nowadays, computed tomography (CT) is almost completely used instead of radiography for the imaging diagnosis of adult spine fractures (x-rays). To stop neurologic degeneration and paralysis following trauma, it is vital to trace any vertebral fractures at the earliest. Many approaches have been proposed for the classification of the cervical spine [2d models]. We are here in this paper trying to break the bounds and use the vision transformers, a State-Of-The-Art- Model in image classification, by making minimal changes possible to the architecture of ViT and making it 3D-enabled architecture and this is evaluated using a weighted multi-label logarithmic loss. We have taken this problem statement from a previously held Kaggle competition, i.e., RSNA 2022 Cervical Spine Fracture Detection.

Keywords: cervical spine, spinal fractures, osteoporosis, computed tomography, 2d-models, ViT, multi-label logarithmic loss, Kaggle, public score, private score

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Authors: Ghoul Rachid Brahim

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Introduction: Tuberculous spondylodiscitis is an infection of the spine by Mycobacterium tuberculosis. Tuberculous spondylodiscitis still remains a topical disease in developing countries and continues to pose a public health problem in endemic countries. Materials and methods: Clinical case: This is a 12-year-old child followed in pediatrics for weight loss and progressively worsening low back pain. The neurological examination found an irritative pyramidal syndrome in both lower limbs with a severe lumbar spinal syndrome. The radiological assessment: (Rx of the spine supplemented by CT and MRI) shows L1L2 spondylodiscitis. Treatment: The child is put on anti-tuberculosis treatment, and the spine is restrained with a corset. Control MRI shows a worsening of the dorsal kyphosis with a backward movement of the posterior wall and spinal cord compression. The child is operated on via the posterior approach (the operative procedure consists of an L1 laminectomy and D11 L3 osteosynthesis). Results: Spinal cord décompression and stabilization of the spine. Conclusion: Tuberculous spondylodiscitis in children remains a rare, aggressive, and progressive condition. The prognosis depends on the diagnosis's precocity and the therapeutic management quality.

Keywords: tuberculous spondylodiscitis, mycobacterium tuberculosis, laminectomy, MRI

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Authors: Chih-Hsien Chen, Yi-Hung Ho, Chih-Wei Wang, Chih-Wei Chang, Yen-Nien Chen, Chih-Han Chang, Chun-Ting Li

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Laminotomy is a spinal decompression surgery compatible with a minimally invasive approach. However, the unilateral laminotomy for bilateral side decompression leads to more perioperative complications than the bilateral laminotomy. Although the unilateral laminotomy removes the least bone tissue among the spinal decompression surgeries, the difference of spinal stability between unilateral and bilateral laminotomy and laminectomy is rarely investigated. This study aims to compare the biomechanical effects of unilateral and bilateral laminotomy and laminectomy on the lumbar spine by finite element (FE) simulation. A three-dimensional FE model of the lumbar spine (L1–L5) was constructed with the vertebral body, discs, and ligaments, as well as the sacrum was constructed. Three different surgical methods, namely unilateral laminotomy, bilateral laminotomy and laminectomy, at L3–L4 and L4–L5 were considered. Partial pedicle and entire ligamentum flavum were removed to simulate bilateral decompression in laminotomy. The entire lamina and spinal processes from the lower L3 to upper L5 were detached in the laminectomy model. Then, four kinds of loadings, namely flexion, extension, lateral bending and rotation, were applied on the lumbar with various decompression conditions. The results indicated that the bilateral and unilateral laminotomy both increased the range of motion (ROM) compared with intact lumbar, while the laminectomy increased more ROM than both laminotomy did. The difference of ROM between the bilateral and unilateral laminotomy was very minor. Furthermore, bilateral laminotomy demonstrated similar poster element stress with unilateral laminotomy. Unilateral and bilateral laminotomy are equally suggested to bilateral decompression of lumbar spine with minimally invasive technique because limited effect was aroused due to more bone remove in the bilateral laminotomy on the lumbar stability. Furthermore, laminectomy is the last option for lumbar decompression.

Keywords: minimally invasive technique, lumbar decompression, laminotomy, laminectomy, finite element method

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Authors: Afshin Zahedi, Keivan Jamshidi

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This study was conducted to determine the neurotoxic effects of different doses of ACR on the thoracic axons of the spinal cord of rat. To evaluate this hypothesis in the thoracic axons, amino-cupric silver staining technique of the de Olmos was conducted to define the histopathologic characteristic (argyrophilia) of axonal damage following ACR exposure. For this purpose 60 adult male rats (Wistar, approximately 250 g) were selected. Rats were hosed in polycarbonate boxes as two per each. Randomly assigned groups of rats (10 rats per exposure group, total 5 exposure groups as A, B, C, D and E) were exposed to 0.5, 5, 50, 100 and 500 mg/kg per day×11days intraperitoneal injection (IP injection) respectively. The remaining 10 rats were housed in group (F) as control group. Control rats received daily injections of 0.9% saline (3ml/kg). As indices of developing neurotoxicity, weight gain, gait scores and landing hindlimb foot splay (LHF) were determined. Weight gains were measured daily prior to injection. Gait scoring involved observation of spontaneous open field locomotion, included evaluations of ataxia, hopping, rearing and hind foot placement, and hindlimb foot splay were determined 3-4 times per week. Gait score was assigned from 1-4. After 11 days, two rats for silver stain, were randomly selected, dissected and proper samples were collected from thoracic portion of the spinal cord of rat. Results did show no neurological behavior in groups A, B and F, whereas severe neurotoxicity was observed in groups C and D. Rats in groups E died within 1-2 hours due to severe toxemia. In histopathological studies based on the de Olmos technique no argyrophilic neurons or processes were observed in stained sections obtained from the thoracic portion of the spinal cord of rats belong to groups A, B and F, while moderate to severe argyrophilic changes were observed in different stained sections obtained from the thoracic portion of the spinal cord of rats belong to groups C and D.

Keywords: acrylamide, rat, axonopathy, argyrophily, de Olmos

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Authors: Anna Demian, Levi Howard, L. Ng, Leslie Simon, Mark Dragon, A. Desai, Timothy Devlantes, W. David Freeman

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Introduction: Out-of-hospital cardiac arrest (OHCA) can carry a high mortality. For survivors, the most common complication is hypoxic-ischemic brain injury (HIBI). Rarely, lumbosacral spinal cord and/or other spinal cord artery ischemia can occur due to anatomic variation and variable mean arterial pressure after the return of spontaneous circulation. We present a case of an OHCA survivor who later woke up with bilateral leg weakness with preserved sensation (ASIA grade B, L2 level). Methods: We describe a clinical, radiographic, and laboratory presentation, as well as a National Library of Medicine (NLM) search engine methodology, characterizing incidence/prevalence of this entity is discussed. A 70-year-old male, a longtime smoker, and alcohol user, suddenly collapsed at a bar surrounded by friends. He had complained of chest pain before collapsing. 911 was called. EMS arrived, and the patient was in pulseless electrical activity (PEA), cardiopulmonary resuscitation (CPR) was initiated, and the patient was intubated, and a LUCAS device was applied for continuous, high-quality CPR in the field by EMS. In the ED, central lines were placed, and thrombolysis was administered for a suspected Pulmonary Embolism (PE). It was a prolonged code that lasted 90 minutes. The code continued with the eventual return of spontaneous circulation. The patient was placed on an epinephrine and norepinephrine drip to maintain blood pressure. ECHO was performed and showed a “D-shaped” ventricle worrisome for PE as well as an ejection fraction around 30%. A CT with PE protocol was performed and confirmed bilateral PE. Results: The patient woke up 24 hours later, following commands, and was extubated. He was found paraplegic below L2 with preserved sensation, with hypotonia and areflexia consistent with “spinal shock” or anterior spinal cord syndrome. MRI thoracic and lumbar spine showed a conus medullaris level spinal cord infarction. The patient was given IV steroids upon initial discovery of cord infarct. NLM search using “cardiac arrest” and “spinal cord infarction” revealed 57 results, with only 8 review articles. Risk factors include age, atherosclerotic disease, and intraaortic balloon pump placement. AoA (Artery of Adamkiewicz) anatomic variation along with existing atherosclerotic factors and low perfusion were also known risk factors. Conclusion: Acute paraplegia from anterior spinal cord infarction of the AoA territory after cardiac arrest is rare. Larger prospective, multicenter trials are needed to examine potential interventions of hypothermia, lumbar drains, which are sometimes used in aortic surgery to reduce ischemia and/or other neuroprotectants.

Keywords: cardiac arrest, spinal cord infarction, artery of Adamkiewicz, paraplegia

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Authors: Simon Grossemy, Peggy P. Y. Chan, Pauline M. Doran

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Nerve tissue engineering is the main field of research aimed at finding an alternative to autografts as a treatment for nerve injuries. Scaffolds are used as a support to enhance nerve regeneration. In order to successfully design novel scaffolds and in vitro cell culture systems, a deep understanding of the factors affecting nerve regeneration processes is needed. Physical and biological parameters associated with the culture environment have been identified as potentially influential in nerve cell differentiation, including electrical stimulation, exposure to extracellular-matrix (ECM) proteins, dynamic medium conditions and co-culture with glial cells. The mechanisms involved in driving the cell to differentiation in the presence of these factors are poorly understood; the complexity of each of them raises the possibility that they may strongly influence each other. Some questions that arise in investigating nerve regeneration include: What are the best protein coatings to promote neural cell attachment? Is the scaffold design suitable for providing all the required factors combined? What is the influence of dynamic stimulation on cell viability and differentiation? In order to study these effects, scaffolds adaptable to bioreactor culture conditions were designed to allow electrical stimulation of cells exposed to ECM proteins, all within a dynamic medium environment. Gold coatings were used to make the surface of viscose rayon microfiber scaffolds (VRMS) conductive, and poly-L-lysine (PLL) and laminin (LN) surface coatings were used to mimic the ECM environment and allow the attachment of rat PC12 neural cells. The robustness of the coatings was analyzed by surface resistivity measurements, scanning electron microscope (SEM) observation and immunocytochemistry. Cell attachment to protein coatings of PLL, LN and PLL+LN was studied using DNA quantification with Hoechst. The double coating of PLL+LN was selected based on high levels of PC12 cell attachment and the reported advantages of laminin for neural differentiation. The underlying gold coatings were shown to be biocompatible using cell proliferation and live/dead staining assays. Coatings exhibiting stable properties over time under dynamic fluid conditions were developed; indeed, cell attachment and the conductive power of the scaffolds were maintained over 2 weeks of bioreactor operation. These scaffolds are promising research tools for understanding complex neural cell behavior. They have been used to investigate major factors in the physical culture environment that affect nerve cell viability and differentiation, including electrical stimulation, bioreactor hydrodynamic conditions, and combinations of these parameters. The cell and tissue differentiation response was evaluated using DNA quantification, immunocytochemistry, RT-qPCR and functional analyses.

Keywords: bioreactor, electrical stimulation, nerve differentiation, PC12 cells, scaffold

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Authors: Subhankar Karmakar, Madhan Kumar Vasudevan, Manivannan Muniyandi

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Thermal Grill Illusion (TGI) elicits a strong and often painful sensation of burn when interlacing warm and cold stimuli that are individually non-painful, excites thermoreceptors beneath the skin. Among several theories of TGI, the “disinhibition” theory is the most widely accepted in the literature. According to this theory, TGI is the result of the disinhibition or unmasking of the pain-sensitive HPC (Heat-Pinch-Cold) nerve fibers due to the inhibition of cold-sensitive nerve fibers that are responsible for masking HPC nerve fibers. Although researchers focused on understanding TGI throughexperiments and models, none of them investigated the prediction of TGI pain intensity through a computational model. Furthermore, the comparison of psychophysically perceived TGI intensity with neurophysiological models has not yet been studied. The prediction of pain intensity through a computational model of TGI can help inoptimizing thermal displays and understanding pathological conditions related to temperature perception. The current studyfocuses on developing a computational model to predict the intensity of TGI pain and experimentally observe the perceived TGI pain. The computational model is developed based on the disinhibition theory and by utilizing the existing popular models of warm and cold receptors in the skin. The model aims to predict the neuronal activity of the HPC nerve fibers. With a temperature-controlled thermal grill setup, fifteen participants (ten males and five females) were presented with five temperature differences between warm and cold grills (each repeated three times). All the participants rated the perceived TGI pain sensation on a scale of one to ten. For the range of temperature differences, the experimentally observed perceived intensity of TGI is compared with the neuronal activity of pain-sensitive HPC nerve fibers. The simulation results show a monotonically increasing relationship between the temperature differences and the neuronal activity of the HPC nerve fibers. Moreover, a similar monotonically increasing relationship is experimentally observed between temperature differences and the perceived TGI intensity. This shows the potential comparison of TGI pain intensity observed through the experimental study with the neuronal activity predicted through the model. The proposed model intends to bridge the theoretical understanding of the TGI and the experimental results obtained through psychophysics. Further studies in pain perception are needed to develop a more accurate version of the current model.

Keywords: thermal grill Illusion, computational modelling, simulation, psychophysics, haptics

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Authors: Ghoul Rachid Brahim, Trad Khodja Rafik

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Vertebral localization of the hydatid cyst is a severe form of bone hydatidosis, is a parasitic infection caused by the larval forms of the tapeworms Echinococcus granulosus, The disease is slowly remaining silent (a long incubation period) which may explain why this pathology is often discovered at the stage of neurological complications. The objective of this study is to recall the clinical and radiological aspects of this condition and the importance of early diagnosis and appropriate management. We report a study of 5 patients with vertebral hydatidosis, four men and one woman, four (04) patients operated in the emergency setting for spinal cord compression (decompression by wide laminectomy with evacuation of intra and extra canal vesicles).Albendazole-based medical treatment is instituted in all patients. Results: The evolution was favorable for three patients, the other two patients reoperated for a local recurrence. Conclusion: Vertebral hydatidosis is a rare condition with a poor prognosis due to the risk of neurological damage, the infiltrating nature of bone lesions, the frequency of relapses and therapeutic difficulties. The only curative method remains surgery, which must aim for complete and large excision of the lesions as if it were a “malignant tumour”.

Keywords: hydatidosis, Echinococcosis granulosus, hydatid cyst, spinal cord compression, laminectomy

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Authors: Ilma Robo, Manola Kelmendi, Kleves Elezi, Nevila Alliu

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The most important stage in deciding whether to re-treat or not endodontically is to find the reason for the clinical in-success. Therefore, endodontic re-treatment aims to eliminate the etiology of the pathology, where the main ones are the bacteria remaining in the inter-radicular spaces or the presence of other irritants that can be not only bacterial toxins but also the elements that keep the batteries fixed or extra-canal toxins such as extraction outside the apex of the canal filling. Shortcomings of endodontic treatment can be corrected, if possible, only with endodontic re-treatment that is initially attempted orthograde, and if clinical endodontic success is not achieved again, it can be performed retrograde or surgically. The elements that do not help in this direction are the anatomical deformations in the canal network of the tooth roots, in the presence of the delta at the apex of the tooth root, in the isthmuses present, all of which can be explained by the endodontic canal anatomical morphology. Actually, even if the causative endodontic bacteria remains isolated and without an exit in the healthy periodontal tissues, then this can also be a clinical endodontic success, regardless of the fact that the endodontic isolation occurred only in the exits such as the apex or the accessory canals. Clinical endodontic in-success occurs only when bacterial residues emerge or provide an exit in the healthy periradicular tissues or along the entire length of the canal where the accessory canals exit.

Keywords: endodontic success, E. foecalis, nanoparticles, laser diode, antibacterial, antiseptic

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Authors: Amlan Datta

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Dengue is an arboviral, vector borne infection, quite prevalent in tropical countries such as India. Approximately, 1 to 25% of cases may give rise to neurological complication, such as, seizure, delirium, Guillian-Barre syndrome (GBS), multiple cranial nerve palsies, intracranial thrombosis, stroke-like presentations, to name a few. Dengue fever, as an antecedent to GBS is uncommon, especially in adults.Here, we report a case about a middle aged lady who presented with an acute onset areflexic ascending type of polyradiculoneuropathy along with bilateral lower motor neuron type of facial nerve palsy, as well as abducens and motor component of trigeminal (V3) weakness. Her respiratory and neck muscles were spared. She had an established episode of dengue fever (NS1 and dengue IgM positive) 7 days prior to the weakness. Nerve conduction study revealed a demyelinating polyradiculopathy of both lower limbs and cerebrospinal fluid examination showed albuminocytological dissociation. She was treated with 5 days of intravenous immunoglobulin (IVIg), following which her limb weakness improved considerably. This case highlights GBS as a potential complication following dengue fever.

Keywords: areflexic, demyelinating, dengue, polyradiculoneuropathy

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Authors: Jiahui Song

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There have been decades of research into the action potential block in nerves. To our best knowledge electrical voltages can reversibly block the conduction of action potentials across whole animal nerves. Blocking biological electrical signaling pathways can have a variety of applications in muscular and sensory incapacitation and clinical research, including urethral pressure reduction and relieving chronic pain relief from a peripheral nerve injury. The cessation ability has been used in muscle activation and fatigue reduction. Ultrashort, high-intensity electric pulses modulate the membrane conductivity to block nerve conduction through the electroporation process. Nanopore formation on the membrane surface would increase the local membrane conductivity and effectively "short-out" the trans-membrane potential of a nerve that inhibits action potential propagation. This block would be similar in concept to stopping the propagation of an air-pressure wave down a "leaky" pipe. This research focuses on a distributed electrical model with an additional time-dependent membrane conductance to calculate the poration induced by the ultrashort, high-intensity electric pulses. The changes in membrane conductivity are used to predict changes in action potential transmission. A "strength-duration (SD)" curve is generated for action potential blockage and would be used as a design guide for benchmarking safety thresholds or setting the pulse voltage and/or durations necessary for neuro-muscular incapacitation.

Keywords: action potential, ultrashort, high-intensity, nerve, strength-duration

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Authors: Fendouli Ines, Zaafrane Nesrine, Mhamdi Hana, Knani Leila, Ghorbel Mohamed

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Introduction: Ocular infiltration of leukemia can involve orbit, uveal tract, retina and optic nerve. It may result from direct ocular infiltration by leukemic cells or indirect ocular involvement resulting from secondary hematologic changes, opportunistic infections and complications of various modalities of therapy. We here in report a case of central venous retinal occlusion associated to optic nerve infiltration as presenting signs of a relapse of acute lymphoblastic leukemia. Case Report: A twelve-year-old male -patient of acute B lymphoblastic leukemia presented with headaches and bilateral blurred vision in the left ee. Ophthalmic examination showed a visual acuity reduced to counting fingers in the right eye and no light perception in the left eye. Funduscopy revealed a voluminous disc edema surrounded by retinal haemorrhages in the right eye, and venous tortusities, papillary edema, and hemorrages suggesting central retinal venous occlusion in the LE. Swept source optical coherence tomography revealed a serous retinal detachment in the RE and .hyperreflective inner layers with macular edema in the left eye. Cerebro-orbital MRI showed bilateral thickened left optic nerve. There were no radiological signs of true papillary edema due to intracranial hypertension secondary to central nervous system involvement. Myelogram and lumbar punction demonstrated blast infiltration and confirmed ocular relapse of the leukemia. Conclusion: Ocular involvement lymphoblastic acute leukemias decreased since the introduction of a systematic prophylactic treatment of central nervous system. Periodic ophthalmic examination is necessary to allow early diagnosis and treatment.

Keywords: acute leukemia, optic nerve, infiltration, relapse

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Authors: Oya Umit Yemisci, Nur Saracgil Cosar, Tubanur Ozturk Sisman, Selin Ozen

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Chronic autoimmune thyroiditis (AIT) may result in a wide spectrum of reversible abnormalities in the neuromuscular function. Usually, proximal muscle-related symptoms and neuropathic findings such as mild axonal peripheral neuropathy have been reported. Sympathetic skin responses are useful in evaluating sudomotor activity of the unmyelinated sympathetic fibers of the autonomic nervous system. Neurocognitive impairment may also be a prominent feature of hypothyroidism, particularly in elderly patients. Electromyographic reaction times as a highly sensitive parameter provides. Objective data concerning cognitive and motor functions. The aim of this study was to evaluate peripheral nerve functions, sympathetic skin response and electroneuromyographic (ENMG) reaction times in euthyroid and subclinically hypothyroid patients with a diagnosis of AIT and compare to those of a control group. Thirty-five euthyroid, 19 patients with subclinical hypothyroidism and 35 age and sex-matched healthy subjects were included in the study. Motor and sensory nerve conduction studies, sympathetic skin responses recorded from hand and foot by stimulating contralateral median nerve and simple reaction times by stimulating tibial nerve and recording from extensor indicis proprius muscle were performed to all patients and control group. Only median nerve sensory conduction velocities of the forearm were slower in patients with AIT compared to the control group (p=0.019). Otherwise, nerve conduction studies and sympathetic skin responses showed no significant difference between the patients and the control group. However, reaction times were shorter in the healthy subjects compared to AIT patients. Prolongation in the reaction times may be considered as a parameter reflecting the alterations in the cognitive functions related to the primary disease process in AIT. Combining sympathetic skin responses with more quantitative tests such as cardiovascular tests and sudomotor axon reflex testing may allow us to determine higher rates of involvement of the autonomic nervous system in AIT.

Keywords: sympathetic skin response, simple reaction time, chronic autoimmune thyroiditis

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Authors: Yves Monette, Brad Loewen, Louise Pothier

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This study explores the first bog iron ore extraction activities which took place in colonial New France. Archaeological excavations carried on the founding site of Montreal in the last ten years have revealed the remains of Fort Ville-Marie erected in 1642. In a level related to the fort occupation between 1660 and 1680, kilos of scories, a dozen of half-finished iron artefacts and a light yellow clayey ore material have recovered that point to extractive metallurgy activities at the fort. Examples of scories, artefacts and of a possible bog iron ore were submitted to SEM-EDS analysis. The results clearly indicate that iron was extracted from local limonite ores in a bloomery. We discovered that the gangue material could be traced from the ore to the scories. However, some lime silicates and some accessory minerals found in the scories, like barite and celestine for example, were absent from the ore but present in dolomite fragments found in the same archaeological context. The tracing of accessory minerals suggests that the ironmaster introduced a lime flux in the bloomery charge to maximize the separation of the iron ore. Before the introduction of the blast furnace in Western Europe during the first half of the 18th Century, the use of fluxes in iron bloomery was not a common practice.

Keywords: bog iron ore, extractive metallurgy, French colonial America, Montreal, scanning electron microscopy (SEM)

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Authors: Sweta Das

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This case report is a 15-year-old male who presented with painless unilateral vision loss from left optic nerve compression due to juvenile nasopharyngeal angiofibroma. JNA is a rare, benign neoplasm that causes intracranial and intraorbital bone destruction and extends aggressively into surrounding soft tissues. It accounts for <1% of all head and neck tumors, is predominantly found in pediatric males and tends to affect indigenous population disproportionately. The most common presenting symptom for JNA is epistaxis and nasal obstruction. However, it can invade orbit, chiasm and pituitary gland, causing loss of vision and field. Visual acuity and function near normalized following surgical excision. Optometry plays an important role in the diagnosis and co-management of JNA with optic nerve compression by closely monitoring afferent optic nerve function and structure, and extraocular motility. Visual function and acuity in patients with short-term compressive neuropathy may drastically improve following surgical resection as this case demonstrates.

Keywords: orbital mass, painless monocular vision loss, compressive optic neuropathy, pediatric tumor

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Authors: H. Merhni, A. Sbiti, I. Ratbi, A. Sefiani

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The proximal spinal muscular atrophy (SMA) is a group of neuromuscular disorders characterized by progressive muscle weakness due to the degeneration and loss of anterior motor neurons of the spinal cord. Depending on the age of onset of symptoms and their evolution, four types of SMA, varying in severity, result in a mutations of the SMN gene (survival of Motor neuron). We have analyzed the DNA of 295 patients referred to our genetic counseling; since January 1996 until October 2014; for suspected SMA. The homozygous deletion of exon 7 of the SMN gene was found in 133 patients; of which, 40.6% were born to consanguineous parents. In countries like Morocco, where the frequency of heterozygotes for SMA is high, genetic testing should be offered as first-line and, after careful clinical assessment, especially in newborns and infants with congenital hypotonia unexplained and prognosis compromise. The molecular diagnosis of SMA allows a quick and certainly diagnosis, provide adequate genetic counseling for families at risk and suggest, for couples who want prenatal diagnosis. The analysis of the SMN gene is a perfect example of genetic testing with an excellent cost/benefit ratio that can be of great interest in public health, especially in low-income countries. We emphasize in this work for the benefit of the generalization of molecular diagnosis of SMA by the technique of PCR-enzymatic digestion in other centers in Morocco.

Keywords: Exon7, PCR-digestion, SMA, SMN gene

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Authors: Wenjie Wu, Peng Cheng, Zehua Zhang, Fei Luo, Feng Wu, Min Zhong, Jianzhong Xu

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Background: There has been limited research into the therapeutic efficacy of rapid diagnosis of spinal tuberculosis complicated with pulmonary tuberculosis. We attempted to discover whether the utilization of a DNA microarray assay to detect multidrug-resistant spinal tuberculosis complicated with pulmonary tuberculosis can improve clinical outcomes. Methods: A prospective study was conducted from February 2006 to September 2015. One hundred and forty-three consecutive culture–confirmed, clinically and imaging diagnosed MDR-TB patients with spinal tuberculosis complicated by pulmonary tuberculosis were enrolled into the study. The initial time to treatment for MDR-TB, the method of infection control, radiological indicators of spinal tubercular infectious foci, culture conversion, and adverse drug reactions were compared with the standard culture methods. Results: Of the total of 143 MDR-TB patients, 68 (47.6%) were diagnosed by conventional culture methods and 75 (52.4%) following the implementation of detection using the DNA microarray. Patients in the microarray group began rational use of the second-line drugs schedule more speedily than sufferers in the culture group (17.3 vs. 74.1 days). Among patients were admitted to a general tuberculosis ward, those from the microarray group spent less time in the ward than those from the culture group (7.8 vs. 49.2 days). In those patients with six months follow-up (n=134), patients in the microarray group had a higher rate of sputum negativity conversion at six months (89% vs. 73%). In the microarray group, the rate of drug adverse reactions was significantly lower (22.2% vs. 67.7%). At the same time, they had a more obvious reduction of the area with spinal tuberculous lesions in radiological examinations (77% vs. 108%). Conclusions: The application of the CapitalBio™ DNA Microarray assay caused noteworthy clinical advances including an earlier time to begin MDR-TB treatment, increased sputum culture conversion, improved infection control measures and better radiographical results

Keywords: tuberculosis, multidrug-resistant, tuberculous spondylitis, DNA microarray, clinical outcomes

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Authors: H. Pegram, R. Stevens, L. De Girolamo

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Aligned electrospun nanofibres act as effective neuronal and glial cell scaffolds that can be layered to contain multiple sheets harboring different cell populations. This allows personalised biofunctional prostheses to be manufactured with both acellular and cellularised layers for the treatment of spinal cord injury. Additionally, the manufacturing route may be configured to produce in-vitro 3D cell based model of spinal cord injury to aid drug development and enhance prosthesis performance. The goal of this investigation was to optimise the multi-layer scaffold design parameters for prosthesis manufacture, to enable the development of multi-layer patient specific implant therapies. The work has also focused on the fabricating aligned nanofibre scaffolds that promote in-vitro neuronal and glial cell population growth, cell-to-cell interaction and long-term survival following trauma to mimic an in-vivo spinal cord lesion. The approach has established reproducible lesions and has identified markers of trauma and regeneration marked by effective neuronal migration across the lesion with glial support. The investigation has advanced the development of an in-vitro model of traumatic spinal cord injury and has identified a route to manufacture prostheses which target the repair spinal cord injury. Evidence collated to investigate the multi-layer concept suggests that physical cues provided by nanofibres provide both a natural extra-cellular matrix (ECM) like environment and controls cell proliferation and migration. Specifically, aligned nanofibre layers act as a guidance system for migrating and elongating neurons. On a larger scale, material type in multi-layer systems also has an influence in inter-layer migration as cell types favour different material types. Results have shown that layering nanofibre membranes create a multi-level scaffold system which can enhance or prohibit cell migration between layers. It is hypothesised that modifying nanofibre layer material permits control over neuronal/glial cell migration. Using this concept, layering of neuronal and glial cells has become possible, in the context of tissue engineering and also modelling in-vitro induced lesions.

Keywords: electrospinning, layering, lesion, modeling, nanofibre

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Authors: Yori Gidron, Laura Caton, Irit Ben-Aharon

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Background: Many patients and even certain clinicians attribute cancer development to psychosocial factors. Yet, empirical data supports more the prognostic role, rather than the etiological role, of psychosocial factors in cancer. Part of the inconsistency may result from not considering possible moderating factors in the etiological role of psychosocial factors. One important candidate moderating factor is the vagal nerve, whose activity is indexed by heart-rate variability (HRV). The vagal nerve may prevent cancer since it reduces inflammation on the one hand, and since it increases anti-tumor immunity on the other hand. This study examined the moderating role of the vagus in the relation between life threatening events (LTE) and cancer development. Method: We re-analyzed data from the Lifelines Dutch longitudinal cohort study of over 150,000 people. The present study included 82,751 adults, who initially were cancer-free. We extracted information on background factors (e.g., age, gender, fat consumption), whether they ever experienced LTE, HRV and cancer diagnosis as reported by patients in annual clinic visits. HRV was derived from brief ECGs. Results: Of the full sample, 1011 people developed cancer during a follow-up. In the full sample, LTE significantly predicted cancer development (R.R = 1.063 p < .01) and HRV significantly predicted a reduced risk of cancer development (R.R = .506 p <.001). Importantly, LTE significantly predicted cancer only when HRV was low (R.R = 1.056, 95% CI: 1.007 - 1.108, p < .05) but not when HRV was high (R.R = 1.014; 95% CI: 0.916 - 1.122, p > 0.05), independent of confounders. Conclusions: To the best of our knowledge, this is the first study showing in a large sample that LTE predict cancer development, and that this occurs only when vagal nerve activity (HRV) is relatively low. These results could result from lack of vagal modulation of inflammation and also from lack of vagal modulation of stress responses. Results are in line with the cancer-protective role of the vagus. HRV needs to be routinely monitored in the population and future intervention trials need to examine whether vagal nerve activation can prevent cancer in people with LTE and with other cancer risk factors.

Keywords: cancer development, life-events, moderation, vagal nerve

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Authors: R. Srinivas, K. V. Ramana

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This paper presents a novel method called VESTAL to label vertebrae and inter vertebral discs. Each vertebra has certain statistical features properties. To label vertebrae and discs, a new equation to model the path of spinal cord is derived using statistical properties of the spinal canal. VESTAL uses this equation for labeling vertebrae and discs. For each vertebrae and inter vertebral discs both posterior, interior width, height are measured. The calculated values are compared with real values which are measured using venires calipers and the comparison produced 95% efficiency and accurate results. The VESTAL is applied on 50 patients 350 MR images and obtained 100% accuracy in labeling.

Keywords: spine, vertebrae, inter vertebral disc, labeling, statistics, texture, disc

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Authors: Yori Gidron, Maartje Mol, Norbert Foudraine, Frits Van Osch, Joop Van Den Bergh, Moshe Farchi, Maud Straus

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Background: The worldwide pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-COV2), which began in 2019, also known as Covid-19, has infected over 136 million people and tragically took the lives of over 2.9 million people worldwide. Many of the complications and deaths are predicted by the inflammatory “cytokine storm.” One way to progress in the prevention of death is by finding a predictive and protective factor that inhibits inflammation, on the one hand, and which also increases anti-viral immunity on the other hand. The vagal nerve does precisely both actions. This study examined whether vagal nerve activity, indexed by heart-rate variability (HRV), predicts survival in patients with Covid-19. Method: We performed a pseudo-prospective study, where we retroactively obtained ECGs of 271 Covid-19 patients arriving at a large regional hospital in The Netherlands. HRV was indexed by the standard deviation of the intervals between normal heartbeats (SDNN). We examined patients’ survival at 3 weeks and took into account multiple confounders and known prognostic factors (e.g., age, heart disease, diabetes, hypertension). Results: Patients’ mean age was 68 (range: 25-95) and nearly 22% of the patients had died by 3 weeks. Their mean SDNN (17.47msec) was far below the norm (50msec). Importantly, relatively higher HRV significantly predicted a higher chance of survival, after statistically controlling for patients’ age, cardiac diseases, hypertension and diabetes (relative risk, H.R, and 95% confidence interval (95%CI): H.R = 0.49, 95%CI: 0.26 – 0.95, p < 0.05). However, since HRV declines rapidly with age and since age is a profound predictor in Covid-19, we split the sample by median age (40). Subsequently, we found that higher HRV significantly predicted greater survival in patients older than 70 (H.R = 0.35, 95%CI: 0.16 – 0.78, p = 0.01), but HRV did not predict survival in patients below age 70 years (H.R = 1.11, 95%CI: 0.37 – 3.28, p > 0.05). Conclusions: To the best of our knowledge, this is the first study showing that higher vagal nerve activity, as indexed by HRV, is an independent predictor of higher chances for survival in Covid-19. The results are in line with the protective role of the vagal nerve in diseases and extend this to a severe infectious illness. Studies should replicate these findings and then test in controlled trials whether activating the vagus nerve may prevent mortality in Covid-19.

Keywords: Covid-19, heart-rate Variability, prognosis, survival, vagal nerve

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