Merkel cell carcinoma is a rare and aggressive cutaneous tumor, and the use of checkpoint inhibitors immunotherapy is a recent indication in its metastatic setting, both first and second line. However, the widespread use of immunotherapy is associated with an increase of acute and late immune-mediated adverse events. We present a case of an elderly fit patient with metastatic Merkel cell carcinoma treated with pembrolizumab who developed diabetic ketoacidosis, a severe immune-mediated adverse event. A multidisciplinary approach was crucial to overcome the life-threatening event. Even with early treatment stop, the patient had a significant and durable response to the treatment for 15 months. Meanwhile, a progressive pancerebellar syndrome emerged, possible due to a paraneoplastic syndrome with a negative onco-neuronal antibody panel, although an autoimmune etiology associated with immunotherapy could not be excluded. Unfortunately, the situation was irreversible and refractory to immunomodulatory treatment. Despite the unpredictable toxicity, it is important to note the efficacy profile, with a progression-free survival of 15 months, which is higher than the one reported in reference clinical trials in this setting.
Objectives: (1) To assess the effects of a conventional, delayed physiotherapy protocol used by Ischemic Stroke (IS) and Hemorrhagic Stroke (HS) post-stroke patients, in their electromyographic activation patterns during hemiparetic gait; and (2) to study whether this protocol may improve the functional abilities in this population. Methods: This is an observational, descriptive, and analytical quasi-experimental trial. Forty patients with unilateral IS ([Formula: see text]) and HS ([Formula: see text]) stroke were recruited; the stroke involved the motor cortex or sub-cortical areas, and the patients were able to walk independently. Interventions with standard protocols of physiotherapy were carried out. Evaluations (clinical and gait assessment) were performed at the time of admission and at the end of the protocol. Outcome measures include Stroke Impact Scale, Timed Up and Go Test, and gait electromyographic evaluation. Results: Only IS patients (with an average of [Formula: see text] months delayed access to physiotherapy rehabilitation) had improvements in Timed Up and Go Test (change in [Formula: see text][Formula: see text]seg [Formula: see text]) and presented an anticipation of the onset in Upper leg muscles after the intervention. BF ([Formula: see text]), ST ([Formula: see text]), and RF ([Formula: see text]), started their recruitment (onset) earlier at the swing phase of the gait cycle, which is more similar to the normal pattern (grey shadow). IS and HS ([Formula: see text] months since last stroke) patients presented higher electromyographic activation, after physiotherapy, of the posterior leg muscles (gastrocnemius, semitendinosus and biceps femoris) during stance phase ([Formula: see text]). Conclusion: IS patients had improvements after delayed conventional physiotherapy. For HS limited response to intervention was observed.
Introduction: Evidence supports the importance of efficient postural control to improve performance in sports. This involves the use of strategies such as anticipatory posture adjustments and compensatory adjustments. Technology makes analysis and assessments in sports cheaper, while being valid and reliable compared to the gold-standard assessment equipment. Objectives: This article aimed to test the validity and reliability of signals extracted from the sensor’s accelerometer (Metamotion C), by comparing it to the data obtained from the gold-standard equipment (a three-dimensional video-motion-capture system). Design: Observational, cross-sectional study. Methods: We exposed 20 healthy young standing people to the pendulum impact paradigm, which consisted of predictable anteroposterior disturbances applied at the shoulder level. In order to measure this, we observed the acceleration of the center of mass in the anticipatory and compensatory phase of the disturbance and compared the signals of the two devices (Metamotion C and a motion-capture system). Results: The validation results showed the significant linear correlation of all variables with a moderate to large correlation of r ≥ 0.5 between the devices. In contrast, the reliability results between sessions obtained by filming were all significant and above 0.75, indicating excellent reliability. The APAonset variable had a reasonable to high intra-class correlation in the anticipatory phase. In the compensatory phase, the CPAtime variable showed an excellent correlation. Conclusions: Metamotion C proved reasonably valid and highly reliable in measuring the center of mass acceleration compared to the camera system in both the anticipatory and compensatory phases.
Chronic low back pain (CLBP) is associated with postural control impairments and is highly prevalent in elderly people. The objective of this study is to verify whether anticipatory postural adjustments (APAs) and compensatory postural adjustments (CPAs) are affected by CLBP in elderly people by assessing their postural control during a self-initiated perturbation paradigm induced by rapid upper arm movement when pointing to a target. The participants’ lower limb muscle onset and center of pressure (COP) displacements were assessed prior to perturbation and throughout the entire movement. T0 moment (i.e., the beginning of the movement) was defined as the anterior deltoid (DEL) onset, and all parameters were calculated with respect to it. The rectus femoris (RT), semitendinosus (ST), and soleous (SOL) showed delayed onset in the CLBP group compared with the control group: RF (control: − 0.094 ± 0.017 s; CLBP: − 0.026 ± 0.012 s, t = 12, p < 0.0001); ST (control: − 0.093 ± 0.013 s; CLBP: − 0.018 ± 0.019 s, t = 12, p < 0.0001); and SOL (control: − 0.086 ± 0.018 s; CLBP: − 0.029 ± 0.015 s, t = 8.98, p < 0.0001). In addition, COP displacement was delayed in the CLBP group (control: − 0.035 ± 0.021 s; CLBP: − 0.015 ± 0.009 s, t = 3; p = 0.003) and presented a smaller amplitude during APA COPAPA [control: 0.444 cm (0.187; 0.648); CLBP: 0.228 cm (0.096; 0.310), U = 53, p = 0.012]. The CLBP group required a longer time to reach the maximum displacement after the perturbation (control: 0.211 ± 0.047 s; CLBP 0.296 ± 0.078 s, t = 3.582, p = 0.0013). This indicates that CLBP elderly patients have impairments to recover their postural control and less efficient anticipatory adjustments during the compensatory phase. Our results suggest that people with CLBP have altered feedforward hip and ankle muscle control, as shown from the SOL, ST, and RT muscle onset. This study is the first study in the field of aging that investigates the postural adjustments of an elderly population with CLBP. Clinical assessment of this population should consider postural stability as part of a rehabilitation program.
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