Search results for: recurrent nerve palsy

Authors: Krupali Mukeshkumar, Jinesh Shah

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Background: Bilateral Sagittal Split Osteotomy (BSSO), used for the correction of mandibular deformities, is a common oral and maxillofacial surgical procedure. Inferior alveolar nerve dysfunction is commonly reported post-operatively by patients as paresthesia or anesthesia. The current literature lacks a consensus on the incidence of inferior alveolar nerve dysfunction as patients are not routinely assessed pre and post-operatively with an objective assessment. The range of incidence varies from 9% to 85% of patients, with some authors arguing that 100% of patients experience nerve dysfunction immediately post-surgery. Systematic reviews have shown a difference between incidence rates at different follow-up periods using objective and subjective methods. Aim: To identify the incidence of inferior alveolar nerve dysfunction following BSSO. Gold standard: Nerve dysfunction incidence rates similar or lower than current literature of 83% day one post-operatively and 18.4% at one year follow up. Setting: A retrospective cross-sectional audit of patients treated between 2017-2019 at the Royal Stoke University Hospital, Maxillofacial and Orthodontic departments. Sample: All patients who underwent a BSSO (with or without le fort one osteotomy) between 2017–2019 were identified from the database. Patients with pre-existing neurosensory disturbance, those who had a genioplasty at the same time and those with no follow-up were excluded. The sample consisted of 121 patients, 37 males and 84 females between the ages of 17-50 years at the time of surgery. Methods: Clinical records of 121 cases were reviewed to assess the age, sex, type of mandibular osteotomy, status of the nerve during the surgical procedure, type of bony split and incidence of nerve dysfunction at follow-up appointments. The surgical procedure was carried out by three Maxillo-facial surgeons and follow-up appointments were carried out in the Orthodontic and Oral and Maxillo-facial departments. Results: 120 patients were treated to correct the mandibular facial deformity and 1 patient was treated for sleep apnoea. Seventeen patients had a mandibular setback and 104 patients had mandibular advancement. 68 patients reported inferior alveolar nerve dysfunction at one week following their surgery. Seventy-six patients had temporary paresthesia present between 2 weeks and 12 months post-surgery. 13 patients had persistent nerve dysfunction at 12 months, of which 1 had a bad bony split during the BSSO. The incidence of nerve dysfunction postoperatively was 6.6% after 1 day, 56.1% at 1 week, 62.8% at 2 weeks, 59.5% between 3-6 weeks, 43.0% between 8-16 weeks and 10.7% at 1 year. Conclusions: The results of this audit show a similar incidence rate to the research gold standard at the one-year follow-up. Future Recommendations: No changes to surgical procedure or technique are indicated, but a need for improved documentation and a standardized approach for assessment of post-operative nerve dysfunction would be beneficial.

Keywords: bilateral sagittal split osteotomy, inferior alveolar nerve, mandible, nerve dysfunction

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Authors: Rami El-Hajj Mohamad, Mahmoud Skafi, Ali Massoud Haidar

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Several meteorological parameters were used for the prediction of monthly average daily global solar radiation on horizontal using recurrent neural networks (RNNs). Climatological data and measures, mainly air temperature, humidity, sunshine duration, and wind speed between 1995 and 2007 were used to design and validate a feed forward and recurrent neural network based prediction systems. In this paper we present our reference system based on a feed-forward multilayer perceptron (MLP) as well as the proposed approach based on an RNN model. The obtained results were promising and comparable to those obtained by other existing empirical and neural models. The experimental results showed the advantage of RNNs over simple MLPs when we deal with time series solar radiation predictions based on daily climatological data.

Keywords: recurrent neural networks, global solar radiation, multi-layer perceptron, gradient, root mean square error

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Authors: Kayla Belanger, Pascale Vigneron, Guy Schlatter, Bernard Devauchelle, Christophe Egles

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A severe injury to a peripheral nerve leads to its degeneration and the loss of sensory and motor function. To this day, there still lacks a more effective alternative to the autograft which has long been considered the gold standard for nerve repair. In order to overcome the numerous drawbacks of the autograft, tissue engineered biomaterials may be effective alternatives. Silk fibroin is a favorable biomaterial due to its many advantageous properties such as its biocompatibility, its biodegradability, and its robust mechanical properties. In this study, bio-mimicking multi-channeled nerve guidance conduits made of aligned nanofibers achieved by electrospinning were functionalized with signaling biomolecules and were tested in vitro and in vivo for nerve regeneration support. Silk fibroin (SF) extracted directly from silkworm cocoons was put in solution at a concentration of 10wt%. Poly(ethylene oxide) (PEO) was added to the resulting SF solution to increase solution viscosity and the following three electrospinning solutions were made: (1) SF/PEO solution, (2) SF/PEO solution with nerve growth factor and ciliary neurotrophic factor, and (3) SF/PEO solution with nerve growth factor and neurotrophin-3. Each of these solutions was electrospun into a multi-layer architecture to obtain mechanically optimized aligned nanofibrous mats. For in vitro studies, aligned fibers were treated to induce β-sheet formation and thoroughly rinsed to eliminate presence of PEO. Each material was tested using rat embryo neuron cultures to evaluate neurite extension and the interaction with bio-functionalized or non-functionalized aligned fibers. For in vivo studies, the mats were rolled into 5mm long multi-, micro-channeled conduits then treated and thoroughly rinsed. The conduits were each subsequently implanted between a severed rat sciatic nerve. The effectiveness of nerve repair over a period of 8 months was extensively evaluated by cross-referencing electrophysiological, histological, and movement analysis results to comprehensively evaluate the progression of nerve repair. In vitro results show a more favorable interaction between growing neurons and bio-functionalized silk fibers compared to pure silk fibers. Neurites can also be seen having extended unidirectionally along the alignment of the nanofibers which confirms a guidance factor for the electrospun material. The in vivo study has produced positive results for the regeneration of the sciatic nerve over the length of the study, showing contrasts between the bio-functionalized material and the non-functionalized material along with comparisons to the experimental control. Nerve regeneration has been evaluated not only by histological analysis, but also by electrophysiological assessment and motion analysis of two separate natural movements. By studying these three components in parallel, the most comprehensive evaluation of nerve repair for the conduit designs can be made which can, therefore, more accurately depict their overall effectiveness. This work was supported by La Région Picardie and FEDER.

Keywords: electrospinning, nerve guidance conduit, peripheral nerve regeneration, silk fibroin

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Authors: Niloofar Nazeri, Mohammad Ali Derakhshan, Reza Faridi Majidi, Hossein Ghanbari

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Injury of peripheral nervous system (PNS) can lead to loss of sensation or movement. To date, one of the challenges for surgeons is repairing large gaps in PNS. To solve this problem, nerve conduits have been developed. Conduits produced by means of electrospinning can mimic extracellular matrix and provide enough surface for further functionalization. In this research, a conductive bilayer nerve conduit with poly caprolactone (PCL), poly (lactic acid co glycolic acid) (PLGA) and MWCNT for promoting peripheral nerve regeneration was fabricated. The conduit was made of longitudinally aligned PLGA nanofibrous sheets in the lumen to promote nerve regeneration and randomly oriented PCL nanofibers on the outer surface for mechanical support. The intra-luminal guidance channel was made out of conductive aligned nanofibrous rolled sheets which are coated with laminin via dopamine. Different properties of electrospun scaffolds were investigated by using contact angle, mechanical strength, degradation time, scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS). The SEM analysis was shown that size range of nanofibrous mat were about 600-750 nm and MWCNTs deposited between nanofibers. The XPS result was shown that laminin attached to the nanofibers surface successfully. The contact-angle and tensile tests analysis revealed that scaffolds have good hydrophilicity and enough mechanical strength. In vitro studies demonstrated that this conductive surface was able to enhance the attachment and proliferation of PC12 and Schwann cells. We concluded that this bilayer composite conduit has good potential for nerve regeneration.

Keywords: conductive, conduit, laminin, MWCNT

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Authors: Dalila Chaid, Yacine Houmel, Mohamed Lamine Belloulou

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Peripheral neuropathy is a rare but worrying complication of peripheral local anaesthesia. It is caused either by needle contact with the nerve root or by the direct toxicity of local anaesthetics, leading to nerve damage, injury or irritation. Although uncommon, it remains a major concern for anaesthetists. The aim of the study was to assess the prevalence of nerve block-associated neuropathy in knee surgery and to identify the contributing factors in order to minimise the occurrence of this complication. The study also assessed the severity and evolution of lesions, as well as the factors leading to neuropathic pain. Methodology: It is a retrospective observational study on cases of neuropathy related to nerve blocks of the lower limb for knee surgery over a period of seven years (2016-2022). The study included a total of 6,000 patients Analyse the anaesthetic and neuropathic pain-related parameters received from these patients to determine the prevalence and severity of neuropathy. Findings: the prevalence of nerve block-related neuropathy in our study is 5.8‰ for the sciatic nerve and 0.9‰ for the femoral nerve. This was higher compared to the reported rates in the literature, which were between 0.0 to 5‰ for the Sciatic nerve and 0.0 to 3.4‰ for the femoral nerve. These findings highlight the importance of identifying and implementing an ideal anesthesia procedure to reduce the risk of neuropathy associated with nerve blocks. Theoretical Importance: The findings of this study contribute to the existing literature on peripheral neuropathy following locoregional anesthesia. By identifying the prevalence and severity of neuropathy related to nerve blocks, as well as the underlying factors, we provide valuable insights for anesthetists to improve patient safety. This study also emphasizes the need for compliance with technical safety rules to minimize the occurrence of neuropathy. Data Collection and Analysis Procedures: For this study, 25 clinics with retrospective data were collected of neuropathy associated with nerve blocks for knee surgery over a span of seven years. Parameters related to anaesthesia and neuropathic pain were analysed to determine prevalence,severity, and progression of neuropathy. Comparison of our results with the existing literature in order to assess their significance. Questions Addressed: This study aims to define the following points: 1. The prevalence of neuropathy associated with nerve blocks for knee surgery. 2. The factors underlying the development of neuropathy after nerve blocks. 3. Reducing the risk of neuropathy by complying with technical safety rules. 4. Assessing the severity and evolution of neuropathic pain in these cases. Conclusion: this study highlights the need for careful consideration and implementation of anesthesia procedures during nerve blocks for knee surgery. The prevalence of neuropathy linked to these blocks was higher compared to the literature, emphasizing the importance of identifying and minimizing contributing factors. Compliance with technical safety rules is crucial to reduce the risk of peripheral neuropathy. This study provides valuable insights to anesthetists and contributes to improving patient safety in the field of locoregional anesthesia.

Keywords: phantom limb, neuropathic pain, lower limb amputee, ultrasound-guided locoreginal anesthesia

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Authors: Zainab Shaikh, Yusuf Miyanji

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Pilomatrixoma is a benign neoplasm of the hair follicle matrix that is not commonly diagnosed in general practice. This is a case report of a 9-year-old boy who presented with a one-year history of a 19mm x 11 mm swelling in the left infra-orbital region. This was previously undiagnosed in Spain, where the patient resided at the time of initial presentation, due to the language barrier the patient’s family encountered. An ultrasound and magnetic resonance imaging gave useful information regarding surrounding structures for complete tumor excision and indicated that the risk of facial nerve palsy is low. The lesion was surgically excised and a definitive diagnosis was made after histopathology. Pilomatrixoma, although not rare in its occurrence, is rarely this large at the time of excision due to early presentation. This case highlights the importance of including pilomatrixoma in the differential diagnosis of dermal and subcutaneous lesions in the head and neck region, as it is often misdiagnosed due to the lack of awareness of its clinical presentation.

Keywords: pilomatrixoma, swelling, infra-orbital, facial swelling

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Authors: Fatemeh Rasooli, Behzad Simiari, Pooya Payandemehr, Amir Nejati, Maryam Bahreini, Atefeh Abdollahi

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Introduction: Pain is a complex physiological reaction to tissue injury. In the course of painful procedures such as nerve block, ice has been shown to be a feasible and inexpensive material to control pain. It delays nerve conduction, actives other senses and reduces inflammatory and painful responses. This study assessed the effect of ice in reducing pain caused by needling and infiltration during digital block. Patient satisfaction recorded as a secondary outcome. Methods: This study was designed as a non-blinded randomized clinical trial approved by Tehran University of Medical Sciences Ethical Committee. Informed consent was taken from all the participants who were then randomly divided into two groups. Digital block performed by standard approach in selected patients. Tubes of ice were prepared in gloves and were fragmented at a time of application for circling around the finger. Tubes were applied for 6 minutes before digital nerve block in the site of needling in the case group. Patients in the control group underwent digital nerve block with the conventional method without ice administration. Numeric Rating Scale (NRS) used for grading pain. 0 used for no pain and 10 for the worst pain that patient had experienced until now. Scores were analyzed by Wilcoxon Rank Sum test and compared in case and control groups. Results: 100 patients aged 16-50 years were enrolled. Mean NRS scores with and without ice were 1.5 mm (S.D ± 1.44) and 6.8 mm (S.D ± 1.40) for needling pain and for infiltration pain were 2.7mm ( S.D ±1.65) and 8.5mm ( S.D ± 1.47), respectively (p<0.001). Besides, patients’ satisfactions were significantly higher in the ice group (p<0.001). Conclusion: Application of ice for 6 minutes significantly reduced pain of needling and infiltration in digital nerve block; thus, it seems to be a feasible and inexpensive material which acts effectively to decrease pain and stress before the procedure.

Keywords: digital block, ice, needle, pain

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Authors: E. Nakamachi, K. Matsumoto, K. Yamamoto, Y. Morita, H. Sakamoto

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In recently, electromagnetic and mechanical stimulations have been recognized as the effective extracellular environment stimulation technique to enhance the defected peripheral nerve tissue regeneration. In this study, we developed a new hybrid bioreactor by adopting 50 Hz uniform alternative current (AC) magnetic stimulation and 4% strain mechanical stimulation. The guide tube for nerve regeneration is mesh structured tube made of biodegradable polymer, such as polylatic acid (PLA). However, when neural damage is large, there is a possibility that peripheral nerve undergoes necrosis. So it is quite important to accelerate the nerve tissue regeneration by achieving enhancement of nerve axonal extension rate. Therefore, we try to design and fabricate the system that can simultaneously load the uniform AC magnetic field stimulation and the stretch stimulation to cells for enhancement of nerve axonal extension. Next, we evaluated systems performance and the effectiveness of each stimulation for rat adrenal pheochromocytoma cells (PC12). First, we designed and fabricated the uniform AC magnetic field system and the stretch stimulation system. For the AC magnetic stimulation system, we focused on the use of pole piece structure to carry out in-situ microscopic observation. We designed an optimum pole piece structure using the magnetic field finite element analyses and the response surface methodology. We fabricated the uniform AC magnetic field stimulation system as a bio-reactor by adopting analytically determined design specifications. We measured magnetic flux density that is generated by the uniform AC magnetic field stimulation system. We confirmed that measurement values show good agreement with analytical results, where the uniform magnetic field was observed. Second, we fabricated the cyclic stretch stimulation device under the conditions of particular strains, where the chamber was made of polyoxymethylene (POM). We measured strains in the PC12 cell culture region to confirm the uniform strain. We found slightly different values from the target strain. Finally, we concluded that these differences were allowable in this mechanical stimulation system. We evaluated the effectiveness of each stimulation to enhance the nerve axonal extension using PC12. We confirmed that the average axonal extension length of PC12 under the uniform AC magnetic stimulation was increased by 16 % at 96 h in our bio-reactor. We could not confirm that the axonal extension enhancement under the stretch stimulation condition, where we found the exfoliating of cells. Further, the hybrid stimulation enhanced the axonal extension. Because the magnetic stimulation inhibits the exfoliating of cells. Finally, we concluded that the enhancement of PC12 axonal extension is due to the magnetic stimulation rather than the mechanical stimulation. Finally, we confirmed that the effectiveness of the uniform AC magnetic field stimulation for the nerve axonal extension using PC12 cells.

Keywords: nerve cell PC12, axonal extension, nerve regeneration, electromagnetic-mechanical stimulation, bioreactor

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Authors: Meida Laely Ramdani, Earmporn Thongkrajai, Dedy Purwito

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Lifestyle is one of the most important factors affecting health. Measurement of lifestyle behaviors is necessary for the identification of causal associations between unhealthy lifestyle and health outcomes. There was many instruments have been measured for lifestyle, but not specific for stroke recurrence. This study aimed to develop a new questionnaire of Lifestyle Adjustment Scale (LSAS) among recurrent stroke patients in Indonesia and to measure the reliability and validity of LSAS. The instrument consist of 33 items was developed from the responses of 30 recurrent stroke patients with the maximum age 60 years. Data was collected during October to November 2015. The properties of the instrument were evaluated by validity assessment and reliability measures. The content validity was judged adequate by a panel of five experts, with the result of I-CVI was 0.97. The Cronbach’s alpha analysis was carried out to measure the reliability of LSAS. The result showed that Cronbach’s alpha coefficient was 0.819. LSAS were classified under the domains of dietary habit, smoking habit, physical activity, and stress management. The results of Cronbach’s alpha coefficient for each subscale were 0.60, 0.39, 0.67, 0.65 and 0.76 respectively. LSAS instrument was valid and reliable therefore can be used as research tool among recurrent stroke patients. The development of this questionnaire has been adapted to the socio-cultural context in Indonesia.

Keywords: LSAS, recurrent stroke patients, lifestyle, Indonesia

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Authors: Arghavan Tonkaboni, Shamsolmolouk Najafi, Mohmmad Taghi Kiani, Mehrzad Gholampour, Touraj Goli

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Introduction: Recurrent aphthous stomatitis (RAS) is a multifactorial recurrent oral lesion; which is an autoimmune disease. TH1 cytokines are the most important etiological factors. Autoimmune thyroid disease (ATD) is one of the most common autoimmune diseases and generally coexists with other autoimmune diseases. This study assessed the prevalence of thyroid disease in patients with recurrent aphthous stomatitis. Materials and Methods: This case control study assessed 100 known RAS patients who were diagnosed clinically by oral medicine specialists; venous blood samples were analyzed for thyroid stimulating hormone (TSH), free triiodothyronine (fT3), total thyroxine (fT4), thyroglobulin, anti-thyroid peroxidase antibody (anti-TPO) and anti-thyroglobulin antibody (anti-TG) levels. Results: Fifty patients with RAS aged between 18-42 years (28.5±5.8) and 50 healthy volunteers aged 19-45 years (27.3±5.4) participated. In RAS patients, fT3 and TSH levels were significantly higher (P=0.031, P=0.706); however, fT4 level was lower in the RAS group (P=0.447). Anti TG and anti-TPO levels were significantly higher in the RAS group (P=0.008, P=0.067). Conclusion: Our study showed that ATD prevalence was significantly higher in RAS patients. Based on this study, we recommend assessment of thyroid hormones and antibodies in RAS patients.

Keywords: recurrent aphthous stomatitis, thyroid antibodies, thyroid hormone, thyroid autoimmune disease

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Authors: Aamna Lawrence, Ashutosh Mishra

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Tremors occur in 60% of the patients who have Multiple Sclerosis (MS), the most common demyelinating disease that affects the central and peripheral nervous system, and are the primary cause of disability in young adults. While pharmacological agents provide minimal benefits, surgical interventions like Deep Brain Stimulation and Thalamotomy are riddled with dangerous complications which make non-invasive electrical stimulation an appealing treatment of choice for dealing with tremors. Hence, we hypothesized that if the non-invasive electrical stimulation parameters (mainly frequency) can be computed by mathematically modeling the nerve fibre to take into consideration the minutest details of the axon morphologies, tremors due to demyelination can be optimally alleviated. In this computational study, we have modeled the random demyelination pattern in a nerve fibre that typically manifests in MS using the High-Density Hodgkin-Huxley model with suitable modifications to account for the myelin. The internode of the nerve fibre in our model could have up to ten demyelinated regions each having random length and myelin thickness. The arrival time of action potentials traveling the demyelinated and the normally myelinated nerve fibre between two fixed points in space was noted, and its relationship with the nerve fibre radius ranging from 5µm to 12µm was analyzed. It was interesting to note that there were no overlaps between the arrival time for action potentials traversing the demyelinated and normally myelinated nerve fibres even when a single internode of the nerve fibre was demyelinated. The study gave us an opportunity to design DC pulses whose frequency of application would be a function of the random demyelination pattern to block only the delayed tremor-causing action potentials. The DC pulses could be delivered to the peripheral nervous system non-invasively by an electrode bracelet that would suppress any shakiness beyond it thus paving the way for wearable neuro-rehabilitative technologies.

Keywords: demyelination, Hodgkin-Huxley model, non-invasive electrical stimulation, tremor

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Authors: Mohamed A. Eid, Sobhy M. Aly

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Background: About 75% of children with spastic hemiplegic cerebral palsy walk independently, but most still show abnormal gait patterns because of contractures across the joints and muscle spasticity. Objective: The purpose of this study was to investigate and compare the effects of extracorporeal shock wave therapy (ESWT) versus functional electrical stimulation (FES) on spasticity, function, and gait parameters in children with hemiplegic cerebral palsy (CP). Methods: A randomized controlled trail was conducted for 45 children with hemiplegic CP ranging in age from 6 to 9 years. They were assigned randomly using opaque envelopes into three groups. Physical Therapy (PT) group consisted of 15 children and received the conventional physical therapy program (CPTP) in addition to ankle foot orthosis (AFO). ESWT group consisted of 15 children and received the CPTP, AFO in addition to ESWT. FES group also consisted of 15 children and received the CPTP, AFO in addition to FES. All groups received the program of treatment 3 days/week for 12 weeks. Evaluation of spasticity by using the Modified Ashworth Scale (MAS), function by using the Pediatric Evaluation Disability Inventory (PEDI) and gait parameters by using the 3-D gait analysis was conducted at baseline and after 12 weeks of the treatment program. Results: Within groups, significant improvements in spasticity, function, and gait (P = 0.05) were observed in both ESWT and FES groups after treatment. While between groups, ESWT group showed significant improvements in all measured variables compared with FES and PT groups (P ˂ 0.05) after treatment. Conclusion: ESWT induced significant improvement than FES in decreasing spasticity and improving function and gait in children with hemiplegic CP. Therefore, ESWT should be included as an adjunctive therapy in the rehabilitation program of these children.

Keywords: cerebral palsy, extracorporeal shock wave therapy, functional electrical stimulation, function, gait, spasticity

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Authors: Arijit Basuray, Saibal Chatterjee

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Pulsed Power in the form of Recurrent Surge Generator (RSG) can be used for testing various parameters of Motor or Transformer windings including inter-turn, interlayer insulation. Windings with solid insulation in motor and transformer have many interfaces and undesirable defects, and these defects can be exposed under this nondestructive testing methodology. Due to rapid development in power electronics variable frequency drives (VFD), Dry Type or cast resin Transformer used with PWM Sine wave inverters for solar power, solid insulation system used nowadays are shifting more and more to a high-frequency application. Authors have used the recurrent surge generator for testing winding integrity as well as Partial Discharge(PD) at fast rising voltage enabling PD measurement at closer situation under which the insulation system is supposed to work. Authors have discussed test results on a different system with recurrent surge voltages of different rise time.

Keywords: fast rising voltage, partial discharge, pulsed power, recurrent surge generator, solid insulation

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Authors: Ardiana Murtezani, Ilirijana Dallku, Teuta Osmani Vllasolli, Sabit Sllamniku

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Background: The use of foot orthoses are always indicated when there are alterations of the optimal biomechanics' position of the foot. Orthotics are very effective and very suitable for the majority of patients with pain due to overload which can be related to biomechanical disorders. Aim: To assess the frequency of patients requiring foot orthoses, type of orthoses and analysis of their disease leading to the use of foot orthoses. Material and Methods: Our study included 128 patients with various foot pathologies, treated at the outpatient department of the Ortho-Prosthetic Center of Kosovo (OPCK) in Prishtina. Prospective-descriptive clinical method was used during this study. Functional status of patients was examined, and the following parameters are noted: range of motion measurements for the affected joints/lower extremities, manual test for muscular strength below the knee and foot of the affected extremity, perimeter measurements of the lower extremities, measurements of lower extremities, foot length measurement, foot width measurements and size. In order to complete the measurements the following instruments are used: plantogram, pedogram, meter and cork shoe lift appliances. Results: The majority of subjects in this study are male (60.2% vs. 39.8%), and the dominant age group was 0-9 (47.7%), 61 subjects respectively. Most frequent foot disorders were: congenital disease 60.1%, trauma cases 13.3%, consequences from rheumatologic disease 12.5%, neurologic dysfunctions 11.7%, and the less frequented are the infectious cases 1.6%. Congenital anomalies were the most frequent cases, and from this group majority of cases suffered from pes planovalgus (37.5%), eqinovarus (15.6%) and discrepancies between extremities (6.3%). Furthermore, traumatic amputations (2.3%) and arthritis (0.8%). As far as neurologic disease, subjects with cerebral palsy are represented with (3.1%), peroneal nerve palsy (2.3%) and hemiparesis (1.6%). Infectious disease osteomyelitis sequels are represented with (1.6%). Conclusion: Based on our study results, we have concluded that the use of foot orthoses for patients suffering from rheumatoid arthritis and nonspecific arthropaty was effective treatment choice, leading to decrease of pain, less deformities and improves the quality of life.

Keywords: orthoses, epidemiological analysis, rheumatoid arthritis, rehabilitation

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Authors: Jerry Q. Cheng

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Currently, in analyzing large-scale recurrent event data, there are many challenges such as memory limitations, unscalable computing time, etc. In this research, a divide-and-conquer method is proposed using parametric frailty models. Specifically, the data is randomly divided into many subsets, and the maximum likelihood estimator from each individual data set is obtained. Then a weighted method is proposed to combine these individual estimators as the final estimator. It is shown that this divide-and-conquer estimator is asymptotically equivalent to the estimator based on the full data. Simulation studies are conducted to demonstrate the performance of this proposed method. This approach is applied to a large real dataset of repeated heart failure hospitalizations.

Keywords: big data analytics, divide-and-conquer, recurrent event data, statistical computing

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Authors: Asmaa Hamdy, Israa Nassar, Tarek Aly

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Introduction: Femoral fractures are the most common presentation in the Emergency Department (ED), and they can present as isolated injuries or as part of a polytrauma situation. To provide optimum pain management care to these patients, practitioners must be well prepared and current with utilizing modern evidence-based knowledge and practices. Management of pain associated with fracture femur in the emergency department has a critical role in the satisfaction of patients and preventing further complications. This study aimed to evaluate the analgesic efficacy of ultrasound-guided femoral nerve block compared with intravenous fentanyl in fractures of the femur in patients presented to the Emergency Department. Patients and Methods: Fifty patients with femur fractures were divided into two groups: Group A: In this group (twenty-five patients) were given intravenous fentanyl 2 micro-grams/kg and re-assessed for pain by Visual Analogue Score (VAS). Group B: In this group (twenty-five patients) underwent ultrasonography-guided femoral nerve block and were re-assessed for pain by VAS. Results: VAS score on the movement of the fractured limb between group A and group B at a 10-minute post-intervention period shows P= 0.043, and hence the difference is significant. VAS score on the movement of the fractured limb between group A and group B during a 10-minute post-intervention period showed a significant difference. Seventeen patients in group A had major PID with a percentage of 63% VS 10 patients in group B with a percentage of 37%. conclusion: both femoral nerve block and intravenous fentanyl are effective in relieving pain in patients with femur fractures. But femoral nerve block provides better and more intense analgesia and major pain intensity difference in less time. Moreover, the use of FNB had fewer side effects and more Hemodynamics stability compared to opioids.

Keywords: femur fracture, nerve block, fentanyl, ultrasound guided

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Authors: Eiji Nakamachi, Ryota Sakiyama, Koji Yamamoto, Yusuke Morita, Hidetoshi Sakamoto

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The regeneration of injured central nerve network caused by the cerebrovascular accidents is difficult, because of poor regeneration capability of central nerve system composed of the brain and the spinal cord. Recently, new regeneration methods such as transplant of nerve cells and supply of nerve nutritional factor were proposed and examined. However, there still remain many problems with the canceration of engrafted cells and so on and it is strongly required to establish an efficacious treating method of a central nerve system. Blackman proposed the electromagnetic stimulation method to enhance the axonal nerve extension. In this study, we try to design and fabricate a new three-dimensional (3D) bio-reactor, which can load a uniform AC magnetic field stimulation on PC12 cells in the extracellular environment for enhancement of an axonal nerve extension and 3D nerve network generation. Simultaneously, we measure the morphology of PC12 cell bodies, axons, and dendrites by the multiphoton excitation fluorescence microscope (MPM) and evaluate the effectiveness of the uniform AC magnetic stimulation to enhance the axonal nerve extension. Firstly, we designed and fabricated the uniform AC magnetic field stimulation bio-reactor. For the AC magnetic stimulation system, we used the laminated silicon steel sheets for a yoke structure of 3D chamber, which had a high magnetic permeability. Next, we adopted the pole piece structure and installed similar specification coils on both sides of the yoke. We searched an optimum pole piece structure using the magnetic field finite element (FE) analyses and the response surface methodology. We confirmed that the optimum 3D chamber structure showed a uniform magnetic flux density in the PC12 cell culture area by using FE analysis. Then, we fabricated the uniform AC magnetic field stimulation bio-reactor by adopting analytically determined specifications, such as the size of chamber and electromagnetic conditions. We confirmed that measurement results of magnetic field in the chamber showed a good agreement with FE results. Secondly, we fabricated a dish, which set inside the uniform AC magnetic field stimulation of bio-reactor. PC12 cells were disseminated with collagen gel and could be 3D cultured in the dish. The collagen gel were poured in the dish. The collagen gel, which had a disk shape of 6 mm diameter and 3mm height, was set on the membrane filter, which was located at 4 mm height from the bottom of dish. The disk was full filled with the culture medium inside the dish. Finally, we evaluated the effectiveness of the uniform AC magnetic field stimulation to enhance the nurve axonal extension. We confirmed that a 6.8 increase in the average axonal extension length of PC12 under the uniform AC magnetic field stimulation at 7 days culture in our bio-reactor, and a 24.7 increase in the maximum axonal extension length. Further, we confirmed that a 60 increase in the number of dendrites of PC12 under the uniform AC magnetic field stimulation. Finally, we confirm the availability of our uniform AC magnetic stimulation bio-reactor for the nerve axonal extension and the nerve network generation.

Keywords: nerve regeneration, axonal extension , PC12 cell, magnetic field, three-dimensional bio-reactor

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Authors: Justin Lee, Siraj Shaikh, Alice Chu MD

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Children with cerebral palsy (CP) commonly present with upper extremity impairment, affecting one or both extremities, and are classified using the Manual Ability Classification Scale (MACS). The MACS defines bimanual hand abilities for children ages 4-18 years in everyday tasks and is a gradient scale, with I being nearly normal and V requiring total assistance. Children with more severe upper extremity impairment (MACS III-V) are often underrepresented, and relatively few effective therapies have been identified for these patients. Current orthoses are static and are only meant to prevent the progression of contractures in these patients. Other limitations include cost, comfort, accessibility, and longevity of the orthoses. Taking advantage of advances in 3D printing technology, we have created a highly customizable upper extremity orthotic that can be produced at a low cost. Iterations in our design have resulted in an orthotic that is custom fit to the patient based on scans of their arm, made of rigid polymer when needed to provide support, flexible material where appropriate to allow for comfort, and designed with a mechanical pulley system to allow for some functional use of the arm while in the orthotic. Preliminary data has shown that our orthotic can be built at a fraction of the cost of current orthoses and provide clinically significant improvement in assisting hand assessment (AHA) and pediatric quality of life scores (PedsQL).

Keywords: upper extremity orthosis, upper extremity, orthosis, 3-D printing, cerebral palsy, occupational therapy, spasticity, customizable

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Authors: M. Alam, P. Seshaiyer

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The rupture predictability of intracranial aneurysm is one of the most important parameters for physicians in surgical treatment. As most of the intracranial aneurysms are asymptomatic, still the rupture potential of both symptomatic and asymptomatic lesions is relatively unknown. Moreover, an intracranial aneurysm constrained by a nerve tissue might be a common scenario for a physician to deal with during the treatment process. Here, we perform a computational modeling of nerve tissue constrained intracranial saccular aneurysm to show a protective role of constrained tissue on the aneurysm. A comparative parametric study of the model also performs taking long constraint, medium constraint, short constraint, point contact, narrow neck aneurysm, wide neck aneurysm as parameters for the analysis. Results show that contact constraint aneurysm generates less stress near the fundus compared to no constraint aneurysm, hence works as a protective wall for the aneurysm not to be ruptured.

Keywords: rupture potential, intracranial saccular aneurysm, anisotropic hyper-elastic material, finite element analysis

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Authors: V. K. Tewari, M. Hussain, H. K. D. Gupta

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Background: Nitric Oxide Donars (NODs) (intrathecal sodium nitroprusside (ITSNP) and oral tadalafil 20mg post ITSNP) has been studied in this context in cerebral palsy patients for fast recovery. This work proposes two mechanisms for acute cases and one mechanism for chronic cases, which are interrelated, for physiological recovery. a) Retrograde Neurotransmission (acute cases): 1) Normal excitatory impulse: at the synaptic level, glutamate activates NMDA receptors, with nitric oxide synthetase (NOS) on the postsynaptic membrane, for further propagation by the calcium-calmodulin complex. Nitric oxide (NO, produced by NOS) travels backward across the chemical synapse and binds the axon-terminal NO receptor/sGC of a presynaptic neuron, regulating anterograde neurotransmission (ANT) via retrograde neurotransmission (RNT). Heme is the ligand-binding site of the NO receptor/sGC. Heme exhibits > 10,000-fold higher affinity for NO than for oxygen (the 10,000-fold effect) and is completed in 20 msec. 2) Pathological conditions: normal synaptic activity, including both ANT and RNT, is absent. A NO donor (SNP) releases NO from NOS in the postsynaptic region. NO travels backward across a chemical synapse to bind to the heme of a NO receptor in the axon terminal of a presynaptic neuron, generating an impulse, as under normal conditions. b) Vasopasm: (acute cases) Perforators show vasospastic activity. NO vasodilates the perforators via the NO-cAMP pathway. c) Long-Term Potentiation (LTP): (chronic cases) The NO–cGMP-pathway plays a role in LTP at many synapses throughout the CNS and at the neuromuscular junction. LTP has been reviewed both generally and with respect to brain regions specific for memory/learning. Aims/Study Design: The principles of “generation of impulses from the presynaptic region to the postsynaptic region by very potent RNT (10,000-fold effect)” and “vasodilation of arteriolar perforators” are the basis of the authors’ hypothesis to treat cerebral palsy cases. Case-control prospective study. Materials and Methods: The experimental population included 82 cerebral palsy patients (10 patients were given control treatments without NOD or with 5% dextrose superfusion, and 72 patients comprised the NOD group). The mean time for superfusion was 5 months post-cerebral palsy. Pre- and post-NOD status was monitored by Gross Motor Function Classification System for Cerebral Palsy (GMFCS), MRI, and TCD studies. Results: After 7 days in the NOD group, the mean change in the GMFCS score was an increase of 1.2 points mean; after 3 months, there was an increase of 3.4 points mean, compared to the control-group increase of 0.1 points at 3 months. MRI and TCD documented the improvements. Conclusions: NOD (ITSNP boosts up the recovery and oral tadalafil maintains the recovery to a well-desired level) acts swiftly in the treatment of CP, acting within 7 days on 5 months post-cerebral palsy either of the three mechanisms.

Keywords: cerebral palsy, intrathecal sodium nitroprusside, oral tadalafil, perforators, vasodilations, retrograde transmission, the 10, 000-fold effect, long-term potantiation

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Authors: Jeong-Hyun Hong, Wonsuk Choi, Hyungdal Park, Jinseok Kim, Junesun Kim

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Identifying the chronic functions of an implanted neural electrode is an important factor in acquiring neural signals through the electrode or restoring the nerve functions after peripheral nerve injury. The purpose of this study was to investigate the biocompatibility of the chronic implanted neural electrode into the sciatic nerve. To do this, a sieve-type neural electrode was implanted at proximal and distal ends of a transected sciatic nerve as an experimental group (Sieve group, n=6), and the end-to-end epineural repair was operated with the cut sciatic nerve as a control group (reconstruction group, n=6). All surgeries were performed on the sciatic nerve of the right leg in Sprague Dawley rats. Behavioral tests were performed before and 1, 4, 7, 10, 14, and weekly days until 5 months following surgery. Changes in sensory function were assessed by measuring paw withdrawal responses to mechanical and cold stimuli. Motor function was assessed by motion analysis using a Qualisys program, which showed a range of motion (ROM) related to the joints. Neurofilament-heavy chain and fibronectin expression were detected 5 months after surgery. In both groups, the paw withdrawal response to mechanical stimuli was slightly decreased from 3 weeks after surgery and then significantly decreased at 6 weeks after surgery. The paw withdrawal response to cold stimuli was increased from 4 days following surgery in both groups and began to decrease from 6 weeks after surgery. The ROM of the ankle joint was showed a similar pattern in both groups. There was significantly increased from 1 day after surgery and then decreased from 4 days after surgery. Neurofilament-heavy chain expression was observed throughout the entire sciatic nerve tissues in both groups. Especially, the sieve group was showed several neurofilaments that passed through the channels of the sieve-type neural electrode. In the reconstruction group, however, a suture line was seen through neurofilament-heavy chain expression up to 5 months following surgery. In the reconstruction group, fibronectin was detected throughout the sciatic nerve. However, in the sieve group, the fibronectin was observed only in the surrounding nervous tissues of an implanted neural electrode. The present results demonstrated that the implanted sieve-type neural electrode induced a focal inflammatory response. However, the chronic implanted sieve-type neural electrodes did not cause any further inflammatory response following peripheral nerve injury, suggesting the possibility of the chronic application of the sieve-type neural electrodes. This work was supported by the Basic Science Research Program funded by the Ministry of Science (2016R1D1A1B03933986), and by the convergence technology development program for bionic arm (2017M3C1B2085303).

Keywords: biocompatibility, motor functions, neural electrodes, peripheral nerve injury, sensory functions

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Authors: John Yahng, Riteesh Bookun

Abstract:

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 stenmosis 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 by21mm 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: Vaidehi Iyer, Konstantin Borozdin

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Time series prediction problems have many important practical applications, but are notoriously difficult for statistical modeling. Recently, machine learning methods have been attracted significant interest as a practical tool applied to a variety of problems, even though developments in this field tend to be semi-empirical. This paper explores application of Long Short Term Memory based Recurrent Neural Networks to the one-step prediction of time series for both trend and stochastic components. Two types of data are analyzed - daily stock prices, that are often considered to be a typical example of a random walk, - and weather patterns dominated by seasonal variations. Results from both analyses are compared, and reinforced learning framework is used to select more efficient between Recurrent Neural Networks and more traditional auto regression methods. It is shown that both methods are able to follow long-term trends and seasonal variations closely, but have difficulties with reproducing day-to-day variability. Future research directions and potential real world applications are briefly discussed.

Keywords: long short term memory, prediction methods, recurrent neural networks, reinforcement learning

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Authors: Yin Yuanling

Abstract:

A Deep Feedback Recurrent Neural Network (DFRNN) and Bidirectional Long Short-Term Memory (BiLSTM) are designed to address the problem of low accuracy of traditional relationship extraction models. This method combines a deep feedback-based recurrent neural network (DFRNN) with a bi-directional long short-term memory (BiLSTM) approach. The method combines DFRNN, which extracts local features of text based on deep feedback recurrent mechanism, BiLSTM, which better extracts global features of text, and Self-Attention, which extracts semantic information. Experiments show that the method achieves an F1 value of 76.69% on the CEC dataset, which is 0.0652 better than the BiLSTM+Self-ATT model, thus optimizing the performance of the deep learning method in the event relationship extraction task.

Keywords: event relations, deep learning, DFRNN models, bi-directional long and short-term memory networks

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Authors: John Yahng, Hansraj Riteesh Bookun

Abstract:

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

Procedia PDF Downloads 373

Authors: Arun Prasad

Abstract:

Introduction: Laparoscopic surgery of hernia started in early 1990 and has had a mixed acceptance across the world, unlike laparoscopic cholecystectomy that has become a gold standard. Laparoscopic hernia repair claims to have less pain, less recurrence, and less wound infection compared to open hernia repair leading to early recovery and return to work. Materials and Methods: Laparoscopic hernia repair has been done in 2100 patients from 1995 till now with a follow-up data of 1350 patients. Data was analysed for results and satisfaction. Results: There is a recurrence rate of 0.1%. Early complications include bleeding, trocar injury and nerve pain. Late complications were rare. Conclusion: Laparoscopic inguinal hernia repair has a steep learning curve but after that the results and patient satisfaction are very good. It should be the procedure of choice in all bilateral and recurrent hernias.

Keywords: laparoscopy, hernia, mesh, surgery

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Authors: Konstantinos Perifanos, Eirini Florou, Dionysis Goutsos

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This paper presents and benchmarks a number of end-to-end Deep Learning based models for metaphor detection in Greek. We combine Convolutional Neural Networks and Recurrent Neural Networks with representation learning to bear on the metaphor detection problem for the Greek language. The models presented achieve exceptional accuracy scores, significantly improving the previous state-of-the-art results, which had already achieved accuracy 0.82. Furthermore, no special preprocessing, feature engineering or linguistic knowledge is used in this work. The methods presented achieve accuracy of 0.92 and F-score 0.92 with Convolutional Neural Networks (CNNs) and bidirectional Long Short Term Memory networks (LSTMs). Comparable results of 0.91 accuracy and 0.91 F-score are also achieved with bidirectional Gated Recurrent Units (GRUs) and Convolutional Recurrent Neural Nets (CRNNs). The models are trained and evaluated only on the basis of training tuples, the related sentences and their labels. The outcome is a state-of-the-art collection of metaphor detection models, trained on limited labelled resources, which can be extended to other languages and similar tasks.

Keywords: metaphor detection, deep learning, representation learning, embeddings

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

Abstract:

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: Ana Teixeira, Joao Orvalho

Abstract:

This paper describes experiments using Scratch games, to check the feasibility of employing cerebral palsy users gestures as an alternative of interaction with a computer carried out by students of Master Human Computer Interaction (HCI) of IPC Coimbra. The main focus of this work is to study the usability of a Web Camera as a motion tracking device to achieve a virtual human-computer interaction used by individuals with CP. An approach for Human-computer Interaction (HCI) is present, where individuals with cerebral palsy react and interact with a scratch game through the use of a webcam as an external interaction device. Motion tracking interaction is an emerging technology that is becoming more useful, effective and affordable. However, it raises new questions from the HCI viewpoint, for example, which environments are most suitable for interaction by users with disabilities. In our case, we put emphasis on the accessibility and usability aspects of such interaction devices to meet the special needs of people with disabilities, and specifically people with CP. Despite the fact that our work has just started, preliminary results show that, in general, computer vision interaction systems are very useful; in some cases, these systems are the only way by which some people can interact with a computer. The purpose of the experiments was to verify two hypothesis: 1) people with cerebral palsy can interact with a computer using their natural gestures, 2) scratch games can be a research tool in experiments with disabled young people. A game in Scratch with three levels is created to be played through the use of a webcam. This device permits the detection of certain key points of the user’s body, which allows to assume the head, arms and specially the hands as the most important aspects of recognition. Tests with 5 individuals of different age and gender were made throughout 3 days through periods of 30 minutes with each participant. For a more extensive and reliable statistical analysis, the number of both participants and repetitions in further investigations should be increased. However, already at this stage of research, it is possible to draw some conclusions. First, and the most important, is that simple scratch games on the computer can be a research tool that allows investigating the interaction with computer performed by young persons with CP using intentional gestures. Measurements performed with the assistance of games are attractive for young disabled users. The second important conclusion is that they are able to play scratch games using their gestures. Therefore, the proposed interaction method is promising for them as a human-computer interface. In the future, we plan to include the development of multimodal interfaces that combine various computer vision devices with other input devices improvements in the existing systems to accommodate more the special needs of individuals, in addition, to perform experiments on a larger number of participants.

Keywords: motion tracking, cerebral palsy, rehabilitation, HCI

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Authors: Frikha Rim, Abdelmoula Bouayed Nouha, Rebai Tarek

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Pregnancy is a hypercoagulable state which causing a defective maternal haemostatic response and leading to thrombosis of the uteroplacental vasculature, that might cause pregnancy complications as recurrent pregnancy loss (RPL). Since heritable Thrombophilic defects are associated with increased thrombosis, their prevalence was evaluated in patients with special emphasis on combinations of the above pathologies. Especially, Factor V Leiden (FVL) G1691A, methylene tetra hydro folate reductase (MTHFR) C677T, and factor II (FII) G20210A mutations are three important causes of thrombophilia, which might be related to recurrent pregnancy loss (RPL). In this study we evaluated the presence of these three mutations [factor V Leiden (FVL), prothrombin G20210A (PTG) and methylenetetrahydrofolate reductase (MTHFR) C677T] amongst 35 Tunisian women with more than 2 miscarriages, referred to our genetic counseling. DNA was extracted from peripheral blood samples and PCR-RFLP was performed for the molecular diagnosis of each mutation. Factor V Leiden and Prothrombin mutation were detected respectively in 5.7% and 2.9% of women with particular history of early fetal loss and thrombotic events. Despites the luck of strength of this study, we insist that testing for the most inherited thrombophilia (FVL and FII mutation) should be performed in women with RPL in the context of thrombotic events. Multi-centre collaboration is necessary to clarify the real impact of thrombotic molecular defects on the pregnancy outcome, to ascertain the effect of thrombophilia on recurrent pregnancy loss and then to evaluate the appropriate therapeutic approach.

Keywords: thrombophilia, recurrent pregnancy loss, factor V Leiden, prothrombin G20210A, methylene tetra hydro folate reductase

Procedia PDF Downloads 432