Prediction of Coronary Artery Disease Severity by Using CHA2DS2-VASC-HSF Score in Patients with ST-Elevation Myocardial Infarction.

CHADS2 and CHA2DS2-VASc scores are widely used in clinical practice and include similar risk factors for the development of coronary artery disease (CAD). It is known that the factors comprising the newly defined CHA2DS2-VASC-HSF score promote atherosclerosis and associated with severity of CAD. Objective of the study was to find out the association of the CHA2DS2-VASC-HSF score with the severity of CAD in patients with ST elevation myocardial infarction (STEMI). One hundred (100) patients with STEMI were enrolled in this study after considering inclusion and exclusion criteria over a one year period from October, 2017 to September, 2018 in the Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh. Coronary angiogram was done within index hospitalization and coronary artery disease severity was assessed by SYNTAX score system. Patients were divided into two groups on the basis of SYNTAX score. Patients with SYNTAX score ≥23 assigned as Group I and SYNTAX score <23 assigned as Group II. The CHA2DS2-VASC-HSF score was calculated. Cut-off value of high CHA2DS2-VASC-HSF score was ≥4.0. In this study mean age of study population was 51.8±9.8, male patients were predominant (79.0%). Among the studied patients, highest percentage had history of smoking followed by hypertension, diabetes mellitus and family history of CAD in Group I patients. It was found that DM and family history of CAD and history of stroke/TIA were significantly higher in Group I than Group II. An increasing trend of SYNTAX score was observed according to the CHA2DS2-VASc-HSF score. SYNTAX score was significantly higher in CHA2DS2-VASc-HSF score ≥4 than CHA2DS2-VASc-HSF score <4 (26.3±6.3 vs. 12.1±7.7, p<0.001). Patients with CHA2DS2-VASC-HSF score ≥4 had severe coronary artery disease than CHA2DS2-VASC-HSF score <4 assessed by SYNTAX score with 84.4% sensitivity and 81.9% specificity (AUC:0.83, 95% CI: 0.746-0.915, p<0.001). CHA2DS2-VASc-HSF score was positively correlated with the severity of CAD. This score could be considered as a predictor of coronary artery disease severity.

Procalcitonin versus C-Reactive Protein as a Biomarker for Prediction of Bacterial Infection in Children with Febrile Neutropenia in Acute Leukemia.

Febrile neutropenia (FN) is a frequently occurring treatment-related complication with significant morbidity and mortality for childhood acute leukemia. Early diagnosis and assessment of severity are essential steps for early comprehensive treatment to reduce FN-related morbidity and mortality. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) can be used to assess and predict the bacterial infection in children with febrile neutropenia. The objective of the study was to determine the role of procalcitonin and CRP as a biomarker for prediction of bacterial infection in children with FN in acute leukemia. This prospective observational study was conducted in the Department of Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from August 2020 to July 2021. Total 58 Children with acute leukemia aged 1 to <18 years with FN were analyzed in this study. A proper history and thorough physical examination were carried out. The blood sample was sent for biomarkers (Procalcitonin and CRP) within 24 hours of the onset of FN and other investigations, such as Complete blood count, Blood C/S, Urine R/E and C/S. Metabolic workup (SGPT, Serum Creatinine, Serum Electrolytes, Serum Ca+) was also done in every patient. Stool R/E & C/S, Chest X-ray, Wound swab for C/S were done when the patient presented with diarrhoea, cough, respiratory distress and focal sepsis respectively. In this study, the mean age of the patients was 6.62±4.07 years (1.10-16.0 years) and 34 patients (58.6%) were male. In 65.5% of patients, localizing signs of infection were not identified. Of the 58 patients, 12 patients (20.7%) showed positive blood culture and 2 patients (3.4%) showed positive urine culture. Klebsiella spp (41.0%) was the most frequent organism isolated followed by Acinetobacter (17.0%), Pseudomonas (17.0%) and E. coli (17.0%). The median PCT levels were significantly higher in patients with bacterial infection than patients without bacteremia (26.10µg/l versus 0.78µg/l, p=0.002) and PCT level >2µg/l was significantly associated with bacteremia. The median CRP levels in the bacteremia and without-bacteremia patients were 137.4mg/L and 54.17mg/L, respectively (p=0.036). In direct comparisons, PCT showed better overall performance than CRP with the AUC being 0.797 (95% CI 0.651-0.943) for PCT and 0.697 (95% CI 0.54-0.855) for CRP in predicting the bacterial infection. PCT and CRP both are useful biomarkers for the prediction of bacteremia, but PCT may be a superior early biomarker as compared to CRP to predict bacterial infection in children with febrile neutropenia in acute leukemia.

Association of Echocardiographic Epicardial Fat Thickness with the Angiographic Severity of Coronary Artery Disease in Patients with Acute Coronary Syndrome.

Estimation of visceral adipose tissue is important as it carries high cardiometabolic risk and several methods are available as its surrogate. Epicardial fat thickness (EFT) is a direct measure of visceral fat rather than anthropometric measurements. EFT can be accurately measured by two-dimensional (2D) echocardiography. It tends to be higher in patients with Acute Coronary Syndrome (ACS). The present study was intended to find out the association between echocardiographic EFT and severity of Coronary Artery Disease (CAD) in patients with ACS. This cross-sectional observational study was carried out in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from October 2017 to September 2018. Sampling technique was purposive sampling. Comparison between groups was done by unpaired-t test & dichotomous variables were compared by chi-square test. A total of 164 patients was enrolled in the study, prospectively examined EFT on echocardiography and patients were divided into 2 groups, Group I patients with EFT >4.65mm and Group II patients with EFT ≤4.65mm. Coronary angiograms were analyzed for the extent and severity of CAD using Gensini score. The mean EFT (mm) was found 6.1±1.0 in Group I and 3.5±0.7 in Group II (p<0.001). Patients with a higher EFT were associated with a high Gensini score (Group I vs. Group II, 50.3±24.1 vs. 21.9±20.0; p<0.001). Multivariate analysis showed that EFT (OR 6.07, p<0.001) and smoking (OR 2.66, p=0.03) were independent factors affecting significant coronary artery stenosis. By ROC curve analysis, EFT >4.65mm predicated the presence of significant coronary stenosis by 76.1% sensitivity and 69.9% specificity. EFT measured using Transthoracic echocardiography (TTE) significantly correlates with the severity of CAD. It is sensitive, easily available, and cost-effective and assists in the risk stratification and may be an additional marker on classical risk factors for CAD.

Free Flap Reconstruction in Head and Neck Surgery: Experience in Bangabandhu Sheikh Mujib Medical University.

Free flap reconstruction after surgical ablation of head & neck cancer greatly improve the surgical outcome. Microvascular anastomosis is an important part of Microsurgery and it is not widely practiced in every center. A retrospective review was conducted in the Head & Neck Division of Otolaryngology-Head & Neck Surgery Department, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from May 2016 to June 2017. Total 20 patients with head & neck cancer had been treated surgically between this period and 14 patients were reconstructed with free flap. The focus of this study is to establish the surgical outcome, which is more with free flap reconstruction in the patients previously diagnosed as head & neck cancer. We reconstructed 14 cases of oral cavity carcinoma (Stage IV) with the free flap. Majority cases were carcinoma involving the buccal mucosa with retromolar trigone (36%) followed by buccal mucosa (22%), buccal mucosa with lower alveolus (21%), carcinoma tongue with floor of the mouth (14%) and floor of the mouth (7%). Radial forearm freflap (RFFF) were commonly used in 10 cases (71.4%) and Anterolateral thigh flap (ALT) used in four cases (21.5%). Partial flap loss was seen in one case and wound infection occurred in another case but both were managed successfully with postoperative dressing and debridement. Microvascular free flap reconstruction can be a good choice after surgical removal of the head & neck cancer diseases and it should be practiced in every well-equipped tertiary medical center with the help of properly trained surgeon.

Scar Endometriosis - A Rare Entity: Case Series.

Endometriosis is a condition where there are functional endometrial glands and stroma in sites other than uterine mucosa. It is a unique condition which is benign but has a tendency of invasion and extension locally. Scar endometriosis is a rare entity where there is presence and proliferation of endometrial gland and stroma in the scar of the previous surgery. It is estimated to be only 0.03 to 0.15% of all cases of endometriosis. Because of its deceptive nature and lack of specific diagnostic tools, scar endometriosis is often difficult to diagnose. It is also a challenge for the clinicians as this condition is difficult to treat because it is nonresponsive to hormonal treatment and excision is often the only effective treatment. Here we present two cases of scar endometriosis that we have encountered in BIRDEM general hospital, Dhaka, Bangladesh in last five years.

Diabetes: an Overview for Clinical Oncologists.

Diabetes and cancer are common conditions highly prevalent in the general population. The co-existence of diabetes and cancer in a patient is therefore not unexpected. Diabetes increases the risk of mortality from cancer and morbidity from the treatment of cancer. Furthermore, many cancer chemotherapeutic regimens increase glucose levels, especially those involving glucocorticoids. Many clinical oncologists will deal with patients with diabetes in their clinical work, and some working knowledge of diabetes diagnosis and management is helpful when managing such patients. This overview aims to summarise the clinical diagnosis and management of diabetes, review the potential links between diabetes and cancer, and provide some practical guidance on the management of hyperglycaemia in patients undergoing cancer therapy.

Challenges in the management of people with diabetes and cancer.

Although micro- and macrovascular complications of diabetes are the most important cause of mortality and morbidity in people with diabetes, it is increasingly recognized that diabetes increases the risk of developing cancer. Diabetes and cancer commonly co-exist, and outcomes in people with both conditions are poorer than in those who have cancer but no diabetes. There is no randomized trial evidence that treating hyperglycaemia in people with cancer improves outcomes, but therapeutic nihilism should be avoided, and a personalized approach to managing hyperglycaemia in people with cancer is needed. This review aims to outline the link between diabetes therapies and cancer, and discuss the reasons why glucose should be actively managed people with both. In addition, we discuss clinical challenges in the management of hyperglycaemia in cancer, specifically in relation to glucocorticoids, enteral feeding and end-of-life care.

Oxygen tension modulates the effects of TNFα in compressed chondrocytes.

OBJECTIVE AND DESIGN: Oxygen tension and biomechanical signals are factors that regulate inflammatory mechanisms in chondrocytes. We examined whether low oxygen tension influenced the cells response to TNFα and dynamic compression. MATERIALS AND METHODS: Chondrocyte/agarose constructs were treated with varying concentrations of TNFα (0.1-100 ng/ml) and cultured at 5 and 21 % oxygen tension for 48 h. In separate experiments, constructs were subjected to dynamic compression (15 %) and treated with TNFα (10 ng/ml) and/or L-NIO (1 mM) at 5 and 21 % oxygen tension using an ex vivo bioreactor for 48 h. Markers for catabolic activity (NO, PGE2) and tissue remodelling (GAG, MMPs) were quantified by biochemical assay. ADAMTS-5 and MMP-13 expression were examined by real-time qPCR. 2-way ANOVA and a post hoc Bonferroni-corrected t test were used to analyse data. RESULTS: TNFα dose-dependently increased NO, PGE2 and MMP activity (all p < 0.001) and induced MMP-13 (p < 0.05) and ADAMTS-5 gene expression (pp < 0.01) with values greater at 5 % oxygen tension than 21 %. The induction of catabolic mediators by TNFα was reduced by dynamic compression and/or L-NIO (all p < 0.001), with a greater inhibition observed at 5% than 21 %. The stimulation of GAG synthesis by dynamic compression was greater at 21 % than 5 % oxygen tension and this response was reduced with TNFα or reversed with L-NIO. CONCLUSIONS: The present findings revealed that TNFα increased production of NO, PGE2 and MMP activity at 5 % oxygen tension. The effects induced by TNFα were reduced by dynamic compression and/or the NOS inhibitor, linking both types of stimuli to reparative activities. Future therapeutics should develop oxygen-sensitive antagonists which are directed to interfering with the TNFα-induced pathways.

Surgical Management of Desmoid Tumor of the Female Pelvis: A Case Report.

A 25 years married women having one child delivered vaginaly presented in the department of Obs & Gynae, Bangabandhu Sheikh Mujib Medical University, Bangladesh on April 2013 with pelvic pain and discomfort. No history of previous pelvic trauma was present. Patient examination showed a isolated mass in the right lower abdomen, right adnexa, extending to the pelvic wall upto lower end of ureter. Tumor markers were within normal limit. Intravenous pyelogram (IVP) showed mild right hydroureter and hydronephrosis with obstruction at the lower end of ureter. She was diagnosed as a case of adnexal mass with mild hydroureter & mild hydronephrosis and it was decided to operate on the patient. The surgical approach was transabdominal. On laparotomy a pseudocystic lesion 12×10cm in size was found over the right paracolic gutter and extending down into the pelvis involving the right parametrium. No abnormality was found in the uterus or tubes. The histological examination revealed a desmoid tumor of the pelvis. The patient's recovery was uneventful.

Functional Outcome Changes in Surgery for Pituitary Adenomas After Intraoperative Occurrence of the Trigeminocardiac Reflex: First Description in a Retrospective Observational Study.

Trigeminocardiac reflex (TCR) represents now a nearly ubiquitary phenomenon in skull base surgery. Functional relevance of the intrainterventional TCR occurrence is hitherto only proven for vestibular schwannoma. In a retrospective observational study, 19 out of 338 (8%) enrolled adult patients demonstrated a TCR during transsphenoidal/transcranial surgery for pituitary adenomas. The 2 subgroups (TCR vs non-TCR) had similar patient's characteristics, risk factors, and histology. Preoperatively, there was a similar distribution of normal pituitary function in the TCR and non-TCR subgroups. In this TCR subgroup, there was a significant decrease of that normal pituitary function after operation (37%) compared to the non-TCR group (60%) (P < 0.03). The TCR subgroup therefore demonstrated a 3.15 times (95%CI 1.15-8.68) higher risk for non-normalizing of postoperative pituitary function compared with the non-TCR subgroup (P < 0.03). It is presented, for the first time, an impact of TCR on the functional hormonal outcome after pituitary surgery and strongly underline again the importance of the TCR in clinical daily practice. As a consequence, TCR should be considered as a negative prognostic factor of hormonal normalization after surgery for pituitary adenomas that should be included into routine practice.

C-type natriuretic peptide signalling drives homeostatic effects in human chondrocytes.

Signals induced by mechanical loading and C-type natriuretic peptide (CNP) represent chondroprotective routes that may potentially prevent osteoarthritis (OA). We examined whether CNP will reduce hyaluronan production and export via members of the multidrug resistance protein (MRP) and diminish pro-inflammatory effects in human chondrocytes. The presence of interleukin-1ß (IL-1ß) increased HA production and export via MRP5 that was reduced with CNP and/or loading. Treatment with IL-1ß conditioned medium increased production of catabolic mediators and the response was reduced with the hyaluronan inhibitor, Pep-1. The induction of pro-inflammatory cytokines by the conditioned medium was reduced by CNP and/or Pep-1, αCD44 or αTLR4 in a cytokine-dependent manner, suggesting that the CNP pathway is protective and should be exploited further.

Management of diabetes in patients with cancer.

Diabetes is common amongst patients with cancer. The co-occurrence of diabetes and cancer may lead to poorer prognosis and complications in patients undergoing cancer therapy. There is no randomized trial evidence that treating hyperglycaemia in patients with cancer improves outcomes, and therefore a pragmatic approach to managing hyperglycaemic in such patients is required. We discuss the management of hyperglycaemia in relation to cancer chemotherapy, glucocorticoids and enteral feeding. We also discuss management of glucose in diabetic patients with cancer approaching end of life care.

Optimal diabetes care--can we afford it?: evidence-based diabetes care could be highly cost effective.

Management of diabetes is expensive and set to get costlier. Managing the condition and it's devastating complications imposing a huge societal and economic toll on healthcare systems worldwide. While many interventions to reduce complications are available, a number of interventions do not have a strong basis in evidence, and lack cost effectiveness. In a time of economic austerity, and unprecedented pressure to reduce costs of health care in the UK, are there ways improving care, without driving up cost?

Adolescent female C57BL/6 mice with vulnerability to activity-based anorexia exhibit weak inhibitory input onto hippocampal CA1 pyramidal cells.

Anorexia nervosa (AN) is an eating disorder characterized by self-imposed severe starvation and often linked with excessive exercise. Activity-based anorexia (ABA) is an animal model that reproduces some of the behavioral phenotypes of AN, including the paradoxical increase in voluntary exercise following food restriction (FR). Although certain rodents have been used successfully in this animal model, C57BL/6 mice are reported to be less susceptible to ABA. We re-examined the possibility that female C57BL/6 mice might exhibit ABA vulnerability during adolescence, the developmental stage/sex among the human population with particularly high AN vulnerability. After introducing the running wheel to the cage for 3 days, ABA was induced by restricting food access to 1h per day (ABA1, N=13) or 2 h per day (ABA2, N=10). All 23 exhibited increased voluntary wheel running (p<0.005) and perturbed circadian rhythm within 2 days. Only one out of five survived ABA1 for 3 days, while 10 out of 10 survived ABA2 for 3 days and could subsequently restore their body weight and circadian rhythm. Exposure of recovered animals to a second ABA2 induction revealed a large range of vulnerability, even within littermates. To look for the cellular substrate of differences in vulnerability, we began by examining synaptic patterns in the hippocampus, a brain region that regulates anxiety as well as plasticity throughout life. Quantitative EM analysis revealed that CA1 pyramidal cells of animals vulnerable to the second ABA2 exhibit less GABAergic innervation on cell bodies and dendrites, relative to the animals resilient to the second ABA (p<0.001) or controls (p<0.05). These findings reveal that C57BL/6J adolescent females can be used to capture brain changes underlying ABA vulnerability, and that GABAergic innervation of hippocampal pyramidal neurons is one important cellular substrate to consider for understanding the progression of and resilience to AN.

Added value of abdominal cross-sectional imaging (CT or MRI) in staging of Wilms' tumours.

AIM: To assess the added information gained from computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen over abdominal ultrasound in children undergoing staging of Wilms' tumours. MATERIALS AND METHOD: Fifty-two consecutive patients with histologically proven Wilms' tumours were identified. Each had an initial staging abdominal ultrasound followed by either a CT or MRI examination of the abdomen. Details including tumour size, site, and characteristics, presence of lymph nodes, local invasion, evidence of nephroblastomatosis, and any other relevant finding were gathered from the report of each ultrasound and CT or MRI. Each CT/MRI was then re-reviewed by a consultant paediatric radiologist and a paediatric radiology fellow. The difference in findings between the ultrasound and cross-sectional imaging were noted. RESULTS: Twelve patients were excluded from the study because the CT/MRI was performed before the ultrasound, or imaging was incomplete. Twenty-six patients were female, 14 male. The ages ranged from 9 months to 10.8 years (mean 3.75 years). Twenty-one patients out of the remaining 40 had additional findings detected on the CT or MRI examination that had not been reported on the ultrasound. The most important additional findings included three patients with nephroblastomatosis and two with contralateral tumours. Other findings included two patients with tumour haemorrhage, four with abdominal lymph node enlargement, three with inferior vena cava (IVC)/renal vein thrombus, four with adjacent organ invasion, one patient where the origin of the abdominal tumour was confirmed as renal, and one patient where possible liver invasion was excluded. CONCLUSION: In over half the patients, CT or MRI added additional information in the local staging of Wilms' tumours. Sole reliance on ultrasound for Wilms' staging risks missing significant abnormalities.

Electrosurgical smoke: a real concern.

Electrosurgical techniques including laser surgery have expanded greatly in recent years. Pyrolysis of tissue produces smoke. Recently the smoke is being analyzed using Gas Chromatography-Mass Spectrometry. The nature of smoke depends on the rise of temperature of tissue during electro-surgery. The smoke produced at high temperatures contains low concentration of Group-I carcinogens (IARC) such as Benzene, Hydrogen cyanide, Formaldehyde 1,3-Butadiene and Acrylonitrile. Bioaerosol produced at low temperature as in harmonic scissors may contain live multidrug resistant Mycobacterium tuberculosis, viral DNA of HBV, HCV, HIV and HPV. It also contains live malignant cells and dead cellular materials. These produce an unquantified infection risk. The obnoxious smoke causes ocular and upper respiratory tract irritation, creates visual problems for surgeons. Surgical masks are not capable of filtering the produced bioaerosol. Removal of smoke from the site of operation by local exhaust ventilation is not complete. When produced in a closed cavity as in laparoscopic surgery the patient also suffers from carboxyhaemoglobinaemia and methaemoglobinaemia. Methemoglobinaemia is not detected by standard pulse-oximetry. Laser smoke produces congestive interstitial pneumonia, bronchiolitis and emphysema in rats. Chromosomal aberration and sister chromatid exchange have been found in lymphocyte culture of operating room personnel. Occupational safety and health authorities like Occupational Safety and Health Administration (OSHA), National Institute for Occupational safety and Health (NIOSH), American National Standard Institute (ANSI) and Association of Operating room nurses (AORN) are trying to find effective ways for removal of smoke from site of operation and also the real risk to operating room personnel. Answer lies in minimizing the use of electrocautery whenever possible and completes removal of harmful smoke.

Diabetes and cancer.

Diabetes and cancer are common conditions, and their co-diagnosis in the same individual is not infrequent. A link between the two conditions has been postulated for almost 80 years, but only in the past decade has significant epidemiological evidence been amassed to suggest that diabetes and cancer are associated, and the link appears causal. Hyperinsulinaemia, adipocytokines, growth factors and epigenetic changes may be implicated in the pathogenesis of cancer amongst patients with diabetes, and recently, diabetes therapies have also been implicated. There is reasonable circumstantial evidence that metformin may decrease the risk of cancer amongst diabetic patients. Much more research is required to elucidate the link between diabetes and cancer, particularly the potential link with diabetes treatments.

Comparison of normal and abnormal cardiotocography with pregnancy outcomes and early neonatal outcomes.

Cardiotocography (CTG) is the most commonly used test for antepartum and intrapartum foetal surveillance in the majority hospitals of developed countries. The purpose of this study was to compare the pregnancy outcome and early neonatal outcome among the normal and abnormal CTG groups. In this prospective study, fifty consecutive normal and fifty consecutive abnormal CTG were collected within one hour before delivery from patients who have singleton pregnancy with gestational age >or=32 weeks and having obstetric or medical indication for CTG. In this study, the measure of pregnancy outcomes were mode of delivery, indications of caesarean section, percentage requiring caesarean section for foetal distress, oligohydramnios, meconium stained liquor, small placenta and cord around the neck. Early neonatal outcomes included apgar score, birth weight, admission into neonatal intensive care unit (NICU), duration of stay in NICU and perinatal mortality. There were significant differences between the two groups regarding pregnancy outcomes and early neonatal outcomes. So, CTG is an important test to assess the foetal condition in both antepartum and intrapartum period. The sensitivity of CTG was 87%, specificity was 66%, positive predictive value was 54% and negative predictive value was 92% in the prediction of abnormal outcomes. So, normal CTG is more predictive of normal outcomes than abnormal CTG regarding abnormal outcomes.

Purinergic pathway suppresses the release of .NO and stimulates proteoglycan synthesis in chondrocyte/agarose constructs subjected to dynamic compression.

Mechanical loading plays a fundamental role in the physiological and pathological processes of articular cartilage. The application of dynamic compression to chondrocytes cultured in agarose, downregulates the release of nitric oxide (NO) and enhances cell proliferation and proteoglycan synthesis. We hypothesize that the observed metabolic changes in response to dynamic compression involve a purinergic signaling pathway. Chondrocyte/agarose constructs were subjected to dynamic compression (15%, 1 Hz, 48 h) in the presence of antagonists for the purinergic pathway. Gadolinium was used as a putative inhibitor of stretch-activated calcium ion channels including adenosine 5'-triphosphate (ATP) release channels; suramin was employed as a P2 receptor antagonist and apyrase was used to catalyze the hydrolysis of extracellular ATP. The data presented demonstrate that in the absence of the inhibitor, dynamic compression suppressed .NO release. Treatment with gadolinium and suramin caused a compression-induced upregulation of .NO release, a response abolished with apyrase. Compression-induced stimulation of cell proliferation was reversed with gadolinium, suramin, or apyrase. By contrast, compression-induced stimulation of proteoglycan synthesis was abolished under all treatment conditions. Thus, the purinergic pathway is important in suppressing the release of .NO and stimulation of proteoglycan synthesis. Indeed, high levels of .NO could trigger a downstream catabolic response and mediate the compression-induced inhibition of cell proliferation. The current study demonstrates for the first time the importance of a purinergic pathway in mediating the metabolic response to dynamic compression and suppressing an inflammatory effect.