Failure factors for carpal tunnel syndrome surgical treatment: When and how to perform a revision carpal tunnel decompression surgery.

Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Failure factors for carpal tunnel syndrome surgical treatment: When and how to perform a revision carpal tunnel decompression surgery / Fatores de insucesso do tratamento cirúrgico da síndrome do túnel do carpo: Quando e como revisar a cirurgia de descompressão do túnel do carpo

Abstract Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Resumo Apesar de ser um procedimento amplamente utilizado em todo o mundo e com elevadas taxas de remissão dos sintomas, o tratamento cirúrgico da síndrome do túnel do carpo pode apresentar resultados não satisfatórios ao paciente. Esse resultado não satisfatório pode se manifestar clinicamente pela não remissão dos sintomas, remissão dos sintomas mas recorrência desses após um período de tempo da cirurgia ou aparecimento de diferentes sintomas após a cirurgia. Diferentes fatores estão relacionados a esse insucesso do tratamento cirúrgico da síndrome do túnel do carpo (ITCSTC). A prevenção pode ser conseguida por meio de minuciosa avaliação clínica do paciente no período pré-operatório. Dessa forma o cirurgião poderá fazer diagnósticos diferenciais ou diagnósticos concomitantes, assim como identificar fatores ligados a insatisfação do paciente. Os fatores per-operatórios incluem a correta identificação das estruturas anatômicas para completa descompressão do nervo mediano. Inúmeros procedimentos têm sido descritos para o tratamento dos fatores que ocorrem no período pós-operatório. Desses o mais comum, a formação de aderências em torno do nervo mediano, tem sido tratado com relativo sucesso utilizando diferentes retalhos vascularizados ou cobertura com o uso de tecido autólogo ou homólogo. Descreveremos a abordagem do ITCSTC com maiores detalhes no texto.

The best from East and West? Acupuncture and medical training therapy as monotherapies or in combination for adult patients with episodic and chronic tension-type headache: study protocol for a randomized controlled trial.

BACKGROUND: This study aims to evaluate the feasibility and efficacy of a complex health intervention, based on the combination of conventional Western medicine and traditional Chinese medicine (TCM), in an outpatient department of a university hospital for patients with frequent episodic or chronic tension-type headaches. METHODS/DESIGN: This is a prospective randomized controlled pilot study with four balanced treatment arms (usual care, acupuncture, training, and training plus acupuncture). Each arm will have 24 patients. After the initial screening examination and randomization, a 6-week treatment period follows, with treatment frequencies decreasing at 2-week intervals. After completion of the intervention, two follow-up evaluations will be performed 3 and 6 months after the start of treatment. At predefined times, the various outcomes (pain intensity, health-related quality of life, pain duration, autonomic regulation, and heart rate variability) as well as the participants' acceptance of the complex treatment will be evaluated with valid assessment instruments (Migraine Disability Assessment, PHQ-D, GAD-7, and SF-12) and a headache diary. The acupuncture treatment will be based on the rules of TCM, comprising a standardized combination of acupuncture points and additional points selected according to individual pain localization. The training therapy comprises a combination of strength training, endurance training, and training to improve flexibility and coordination. Besides descriptive analyses of the samples, their comparability will be assessed using an analysis of variance (ANOVA) or chi-squared tests. Analyses will be performed on an intention-to-treat basis. Potential interaction effects will be calculated using a repeated-measures ANOVA to test the primary and secondary hypotheses. In supplementary analyses, the proportion of treatment responders (those with a 50% reduction in the frequency of pain episodes) will be determined for each treatment arm. DISCUSSION: This trial may provide evidence for the additive effects of acupuncture and medical training therapy as a combination treatment and may scientifically support the implementation of this complex health intervention. TRIAL REGISTRATION: Registered on 11 Feburary 2019. German Clinical Trials Register, DRKS00016723.

Intestinal insulin/IGF1 signalling through FoxO1 regulates epithelial integrity and susceptibility to colon cancer.

Obesity promotes the development of insulin resistance and increases the incidence of colitis-associated cancer (CAC), but whether a blunted insulin action specifically in intestinal epithelial cells (IECs) affects CAC is unknown. Here, we show that obesity impairs insulin sensitivity in IECs and that mice with IEC-specific inactivation of the insulin and IGF1 receptors exhibit enhanced CAC development as a consequence of impaired restoration of gut barrier function. Blunted insulin signalling retains the transcription factor FOXO1 in the nucleus to inhibit expression of Dsc3, thereby impairing desmosome formation and epithelial integrity. Both IEC-specific nuclear FoxO1ADA expression and IEC-specific Dsc3 inactivation recapitulate the impaired intestinal integrity and increased CAC burden. Spontaneous colonic tumour formation and compromised intestinal integrity are also observed upon IEC-specific coexpression of FoxO1ADA and a stable Myc variant, thus suggesting a molecular mechanism through which impaired insulin action and nuclear FOXO1 in IECs promotes CAC.

Effect of different lipid apheresis methods on plasma polyunsaturated fatty acids.

Lipoprotein apheresis has been shown to improve the cardiovascular outcome in patients with atherosclerotic disease and therapy-refractory hypercholesterolemia or elevated lipoprotein (a) (Lp(a)). An elevated intake of omega-3 polyunsaturated fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) has also been associated with a reduced cardiovascular risk. However, until now only little is known about the effect of apheresis treatment on the levels of omega-6 and omega-3 polyunsaturated fatty acids (n-6 PUFA and n-3 PUFA) in patients. Using gas chromatography (GC) the present study analyzed the content of n-6 and n-3 PUFA as well as saturated fatty acids and monounsaturated fatty acids in the plasma of 20 patients with hyperlipidemia undergoing regular lipoprotein apheresis procedures in direct pre- and post-therapy measurements. Lipoprotein apheresis uniformly reduced the concentrations of arachidonic acid (AA), EPA and DHA fatty acids analyzed in the plasma. However, the three different apheresis methods analyzed (heparin precipitation, membrane filtration and direct absorption) had different effects on the fatty acid profile in the plasma. We found that heparin precipitation and direct absorption apheresis procedures led to a significant decrease of plasma n-3 and n-6 PUFA by 40-50%. In contrast, patients undergoing membrane filtration apheresis, levels pre- and post-apheresis did not change significantly, with AA and EPA being only reduced by approximately 10% while levels of DHA were maintained pre- and post-apheresis. In contrast, total triglyceride levels were lowered most potently by membrane filtration apheresis. In summary, heparin precipitation and direct absorption apheresis approaches significantly lowered polyunsaturated fatty acids in plasma, while membrane filtration did not. This might have implications for cardiovascular and inflammatory risk/benefit profiles associated with n-6 and n-3 PUFA levels in the body.

[Fulminant, life-threatening influenza A/H1N1 virus infection]. / Fulminante, lebensbedrohliche Influenza-A/H1N1-Virusinfektion.

HISTORY AND CLINICAL FINDINGS: A 52-year-old man presented with unproductive cough, fever and chill in our emergency department. Self-medication with amoxicillin over 3 days failed to improve his condition. The patient was in poor general condition. His body temperature was 38.4 C, with a heart rate of 124/min, a blood pressure of 120/70 mmHg and a positive shock index. At auscultation of the chest fine rales were heard over both lungs with diminished percussion sounds basal. The respiratory rate was 30/min and the oxygen saturation of 84% at room air. INVESTIGATIONS: Laboratory: signs of inflammation; blood gas analysis: pronounced hypoxemia. A chest radiogram revealed signs of extensive pulmonary infiltrates on both sides. TREATMENT AND COURSE: The patient was admitted to our Intensive Care Unit. He received piperacillin, sulbactam and levoflaxacin, ample fluid and non-invasive ventilation as well as intermittent catecholamine treatment. As there was no clinical improvement the patient was intubated on day 3. On bronchoscopy viral etiology was suspected. At this time the respiratory situation deteriorated. Acute respiratory distress syndrome (ARDS) was diagnosed. An antifungal and antiviral treatment (voriconazol, oseltamivir) was started and a cortisone pulse was attempted. The patient was transferred to another clinic where extracorporeal membranoxygenation (ECMO) was performed on the same day. The following day influenza A/H1N1-test was confirmed. Ten days after transfer, the patient regained spontaneous respiration, and he most likely survives the infection. CONCLUSION: The incidence of influenza (A/H1N1) has increased in Germany and severe and lethal courses have occurred. Therefore, the diagnostic and treatment algorithms need to be reconsidered in order to rapidly diagnose and treat infections.

New sources and instrumentation for neutrons in biology.

Neutron radiation offers significant advantages for the study of biological molecular structure and dynamics. A broad and significant effort towards instrumental and methodological development to facilitate biology experiments at neutron sources worldwide is reviewed.

Crystallization of a large single crystal of cubic insulin for neutron protein crystallography.

The growth of a large single crystal of cubic porcine insulin for characterization of hydrogen and hydration in cubic insulin crystals by neutron diffraction analysis is reported. Growth in D2O was investigated based on the phase diagram for cubic insulin to determine appropriate growth conditions, and a large single crystal was then successfully grown by a dialysis method to a size of 4.0 x 4.0 x 1.3 mm3. Neutron diffraction analysis of the cubic insulin crystals was carried out using a single-crystal diffractometer at the JRR-3M reactor of the Japan Atomic Energy Research Institute. In preliminary analysis, Npi appears to be protonated and Ntau deprotonated in His5 in the B-chain, whereas both Npi and Ntau are protonated in His10.

Vibrational dynamics of myoglobin determined by the phonon-assisted Mössbauer effect.

The phonon-assisted Mössbauer effect is used to determine the partial phonon density of states of the iron within the active center of deoxymyoglobin, carboxymyoglobin, and dry and wet metmyoglobin between 40 and 300 K. Between 0 and 1 meV the iron density of states increases quadratically with the energy, as in a Debye solid. Mean sound velocities are extracted from this slope. Between 1 and 3 meV a nearly quadratic "Debye-like" increase follows due to the similar strength of intermolecular and intramolecular forces. Above 3 meV, optical vibrations are characteristic for the iron-ligand conformation. The overall mean square displacements of the heme iron atom obtained from the density of states agree well with the values of Mössbauer absorption experiments below 180 K. In the physiological temperature regime the data confirm the existence of harmonic vibrations in addition to the protein specific dynamics measured by Mössbauer absorption. In the Debye energy regime the mean square displacement of the iron is in agreement with that of the hydrogens measured by incoherent neutron scattering demonstrating the global character of these modes. At higher energies the vibration of the heavy iron atom at 33 meV in metmyoglobin is as large as that of the lightweight hydrogens at that energy. A freeze dried, rehydrated (h=0.38 g H2O/g protein) metmyoglobin sample shows an excess of states above the Debye law between 1 and 3 meV, similar to neutron scattering experiments. The room temperature density of states below 3 meV exhibit an increase of the density compared to the low temperature data, which can be interpreted as mode softening.

The X-ray absorption spectroscopy Debye-Waller factors of an iron compound and of met-myoglobin as a function of temperature.

Protein dynamics can be characterized by the mean square displacements of the individual atoms of a molecule. This concept is extended to X-ray absorption spectroscopy (XAS) of proteins where the physical information in the Debye-Waller factor is in general neglected. In a first step, a procedure for the investigation of the temperature dependence of XAS spectra has been developed for a small iron compound. Subsequently, experiments have been performed on met-myoglobin. It is shown that the mean square displacements of XAS are smaller than those obtained by Mössbauer spectroscopy and far smaller than crystallographic mean square displacements. This behavior is explained by the different sensitivity of the methods. XAS measures a relative mean square displacement between the absorbing and backscattering atoms only. A comparison with mean square displacements calculated from normal modes shows that static displacements contribute significantly. It becomes obvious that the atoms of the active center show a high correlation of their motions.

Dynamical transition of myoglobin in a crystal: comparative studies of X-ray crystallography and Mössbauer spectroscopy.

The crystallographic normal mode refinements of myoglobin at a wide range of temperature from 40 K to 300 K were carried out to study the temperature dependence of the internal atomic fluctuations. The refinement method decomposes the mean square displacement from the average position, (deltar2), into the contributions from the internal degrees of freedom and those from the external degrees of freedom. The internal displacements show linear temperature dependence as (deltar2)=alphaT+beta, throughout the temperature range measured here, and exhibit no obvious change in the slope alpha at the dynamical transition temperature (Tc=ca. 180 K). The slope alpha is practically the same as the value predicted theoretically by normal mode analysis. Such linear dependence is considered to be due to the following reason. The crystallographic Debye-Waller factor represents the static distribution caused by convolution of temperature-dependent normal mode motions and a temperature-independent set of the conformational substates. In contrast, Mössbauer absorption spectroscopy shows a clear increase in the gradient alpha at Tc. This difference from X-ray diffraction originates from the incoherent nature of the Mössbauer effect together with its high-energy resolution, which yields the self-correlation, and the temporal behavior of individual Fe atoms in the myoglobin crystal.

Nuclear forward scattering of synchrotron radiation by deoxymyoglobin.

Nuclear forward scattering of synchrotron radiation is used to determine the quadrupole splitting and the mean square displacement of the iron atom in deoxymyoglobin in the temperature range between 50 K and 243 K. Above 200 K an abnormally fast decay of the forward scattered intensity at short times after the synchrotron flash is observed, which is caused by protein-specific motions. The results strongly support the picture that protein dynamics seen at the position of the iron can be understood by harmonic motions in the low temperature regime while in the physiological regime diffusive motions in limited space are present. The shape of the resonance broadening function is investigated. An inhomogeneous broadening with a Lorentzian distribution indicating dipole interactions results in a better agreement with the experimental data than the common Gaussian distribution.

Ligand binding and conformational motions in myoglobin.

Myoglobin, a small globular haem protein that binds gaseous ligands such as O2, CO and NO reversibly at the haem iron, serves as a model for studying structural and dynamic aspects of protein reactions. Time-resolved spectroscopic measurements after photodissociation of the ligand revealed a complex ligand-binding reaction with multiple kinetic intermediates, resulting from protein relaxation and movements of the ligand within the protein. To observe the structural changes induced by ligand dissociation, we have carried out X-ray crystallographic investigations of carbon monoxy-myoglobin (MbCO mutant L29W) crystals illuminated below and above 180 K, complemented by time-resolved infrared spectroscopy of CO rebinding. Here we show that below 180 K photodissociated ligands migrate to specific sites within an internal cavity--the distal haem pocket--of an essentially immobilized, frozen protein, from where they subsequently rebind by thermally activated barrier crossing. Upon photodissociation above 180 K, ligands escape from the distal pocket, aided by protein fluctuations that transiently open exit channels. We recover most of the ligands in a cavity on the opposite side of the haem group.

Protein dynamics in an intermediate state of myoglobin: optical absorption, resonance Raman spectroscopy, and x-ray structure analysis.

A metastable state of myoglobin is produced by reduction of metmyoglobin at low temperatures. This is done either by irradiation with x-rays at 80 K or by electron transfer from photoexcited tris(2, 2'-bipyridine)-ruthenium(II) at 20 K. At temperatures above 150 K, the conformational transition toward the equilibrium deoxymyoglobin is observed. X-ray crystallography, Raman spectroscopy, and temperature-dependent optical absorption spectroscopy show that the metastable state has a six-ligated iron low-spin center. The x-ray structure at 115K proves the similarity of the metastable state with metmyoglobin. The Raman spectra yield the high-frequency vibronic modes and give additional information about the distortion of the heme. Analysis of the temperature dependence of the line shape of the Soret band reveals that a relaxation within the metastable state starts at approximately 120 K. Parameters representative of static properties of the intermediate state are close to those of CO-ligated myoglobin, while parameters representative of dynamics are close to deoxymyoglobin. Thus within the metastable state the relaxation to the equilibrium is initiated by changes in the dynamic properties of the active site.

From metmyoglobin to deoxy myoglobin: relaxations of an intermediate state.

Metmyoglobin has been reduced at low temperature (below 100 K) using x-rays or by excitation of tris(2,2,bipyridine)ruthenium(II) chloride with visible light. Upon reduction, an intermediate state is formed where the structure of the protein is very similar to that of metmyoglobin with the water molecule still bound to the heme iron, but the iron is II low spin. The nature of the intermediate state has been investigated with optical spectroscopy. The Q(O) and Q(V) bands of the intermediate state are split, suggesting that the protoporphyrin is distorted. The intermediate state undergoes a relaxation observed by a shifting of the Soret band at temperatures above 80 K. Above 140 K, the protein begins to relax to the deoxy conformation. The relaxation kinetics of the protein have been monitored optically as a function of time and temperature from minutes to several hours and from 150 K to 190 K. By measuring the entire visible spectrum, we are able to distinguish between electron transfer processes and the protein relaxation from the intermediate state to deoxy myoglobin. The relaxation has been measured in both horse myoglobin and sperm whale myoglobin with the relaxation occurring on faster time scales in horse myoglobin. Both the reduction kinetics and the relaxation show non-exponential behavior. The reduction kinetics can be fit well to a stretched exponential. The structural relaxation from the intermediate state to the deoxy conformation shows a more complex, dynamical behavior and the reaction is most likely affected by the relaxation of the protein within the intermediate state.

Non-specific interstitial pneumonia (NIP): immunohistologic screening of etiologic agents.

Non-specific interstitial pneumonia (NIP) occurs frequently in patients with HIV-infection. To elucidate the etiology of this pulmonary disorder, we searched for 13 different microorganisms in transbronchial biopsies from 15 patients with NIP, 15 patients with Pneumocystis carinii pneumonia (PCP) and 20 patients with lung diseases not related to HIV-infection using monoclonal antibodies and the APAAP- or PAP-technique for immunostaining. Chlamydia trachomatis and parainfluenza III were detected frequently and in great number. Adenovirus, influenza B, varicella zoster and cytomegalovirus were also found frequently, but not in great number. Measles virus, respiratory syncytial virus, influenza A and herpesviruses 1&2 were not found. Also not found were parainfluenza I, mycoplasma pneumoniae and coronavirus. In seven out of fifteen NIP patients at least one organism was shown, compared to nine out of fifteen patients with PCP and eight out of twenty patients in the control group.