Unilateral Calf Atrophy: A Case Series of Clinical and Electrodiagnostic Findings With a Review of the Literature.

Unilateral calf atrophy may result from several medical conditions, such as lumbar radiculopathy, asymmetric myopathy/dystrophy, a Baker's (popliteal) cyst leading to tibial nerve compression, and disuse atrophy. We present a case series of four patients with unilateral calf atrophy, including chronic neurogenic atrophy (benign focal amyotrophy, one patient), tibial nerve compression at the popliteal fossa by a Baker's cyst (one patient), and disuse atrophy (two patients). All four patients underwent electrodiagnostic (EDX) studies, and two of them had denervation changes of the gastrocnemius. One patient underwent an ultrasound (US), which revealed a large cyst in the popliteal fossa causing compression of the tibial nerve. The differential diagnosis of unilateral calf atrophy as well as diagnostic techniques to confirm the underlying pathology are described. EDX and US studies are useful in differentiating between the varied conditions that may cause asymmetric calf muscle wasting.

Anti-cancer therapeutic agents and carpal tunnel syndrome: Clinical, electrodiagnostic, and ultrasound findings in seven patients.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and rarely develops after drug therapy. This study describes the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in seven patients who experienced CTS due to anti-cancer therapeutic agents. METHODS: All patients underwent EDX testing, and four patients had an US study. RESULTS: CTS occurred in four patients with aromatase inhibitors, two with immune checkpoint inhibitors, and one with a selective estrogen receptor modulator. The mean duration between initiation of the anti-cancer therapeutic agents and symptom onset was 6 weeks (range: 2-12 weeks). Decreased digit sensation was noted in all patients; wasting and weakness of the abductor pollicis brevis (APB) was observed in three (42.8%) patients. The compound muscle action potentials (CMAP) of the APB and sensory nerve action potentials of the second or third digit could not be recorded in two (28.5%) and four (57.1%) patients, respectively. The needle EMG detected fibrillations and positive sharp waves in the APB in two patients. The motor unit potentials of the APB were decreased with large polyphasics in three (42.8%) patients. Of the four patients who underwent US testing, all had increased cross-sectional area of the median nerve at the carpal tunnel inlet, three (75%) had thenar muscle atrophy, and two (50%) had a loss of fascicular pattern. Three (42.8%) patients underwent a CTR. CONCLUSIONS: Physicians should be cognizant of the relationship between anti-cancer therapeutic agents and CTS. EDX studies and US play important roles in the diagnostic assessment of such patients.

Clinical Spectrum of Postsurgical Parsonage-Turner Syndrome: A Perspective From an Electrodiagnostic Laboratory.

BACKGROUND: Parsonage-Turner syndrome (PTS) is an underdiagnosed disorder characterized by the acute onset of severe pain in the shoulder/scapula/arm followed by muscle weakness/numbness in the distribution of nerves derived from the brachial plexus (BP). Surgical procedures are one of several antecedent events of PTS. This study describes the clinical spectrum of postsurgical Parsonage-Turner syndrome (PSPTS) in a large cohort of patients. MATERIALS AND METHODS: Charts of patients diagnosed with PTS during a 16-year (2006-2022) retrospective review were analyzed to identify cases of PSPTS. The clinical criteria for PSPTS included the new onset of severe pain two days to four weeks after a surgical procedure followed by weakness of muscles innervated by one or more nerves arising from the BP. EDX criteria consist of denervation localized to branches of the BP. PSPTS cases were subdivided into two categories: definite PSPTS (surgery at a remote site) and probable PSPTS (surgery of the ipsilateral upper extremity or the cervical spine). RESULTS: Of 202 patients (204 episodes) diagnosed with PTS, 111 (54%) were idiopathic and 61 (30%) were PSPTS. Of the 61 PSPTS episodes, 26 were definite and 35 were probable PSPTS. The anterior interosseous nerve (AIN) was most affected, followed by the posterior interosseous (PIN), and suprascapular nerve. CONCLUSION: In this series, surgery was the most commonly recognized antecedent event for PTS, and the AIN and PIN were the most frequent nerves affected. Surgeons should consider PTS in patients who develop postoperative severe shoulder pain and weakness of muscles innervated by the BP.

Real-world evidence of osimertinib in Chinese patients with EGFR T790M-positive non-small cell lung cancer: a subgroup analysis from ASTRIS study.

PURPOSE: ASTRIS study aimed the largest to evaluate the effectiveness and safety of second- or higher-line osimertinib in patients with advanced/metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC) in the real-world setting. Here we report the results of Chinese patients in ASTRIS study. METHODS: Adults with EGFR T790M-positive advanced NSCLC pretreated with EGFR-tyrosine kinase inhibitor (EGFR-TKI), having a WHO performance status score of 0-2 and asymptomatic, stable central nervous system (CNS) metastases were included. All patients received once-daily osimertinib 80 mg orally. The outcomes included investigator-assessed clinical response, progression-free survival (PFS), time-to-treatment discontinuation (TTD), and safety. RESULTS: A total of 1350 patients were included. Response rate was 55.7% (95% confidence interval [CI] 0.53-0.58). The median PFS and the median TTD were 11.7 months (95% CI 11.1-12.5) and 13.9 months (95% CI 13.1-15.2), respectively. Overall, 389 patients (28.8%) had at least one protocol-specified adverse event (AE); AEs of interstitial lung diseases/pneumonitis-like events and QT prolongation were reported in 3 (0.2%) and 59 (4.4%) patients, respectively. CONCLUSION: Osimertinib was effective in Chinese patients with T790M-positive NSCLC who had progressed after first- or second-generation EGFR-TKI in real-word setting and the results were consistent with ASTRIS study overall population and AURA studies. No new safety signals or events were identified. CLINICAL TRIAL NUMBER: NCT02474355.

Etiology of spastic foot drop among 16 patients undergoing electrodiagnostic studies: patient series.

BACKGROUND: Differentiating foot drop due to upper motor neuron (UMN) lesions from that due to lower motor neuron lesions is crucial to avoid unnecessary surgery or surgery at the wrong location. Electrodiagnostic (EDX) studies are useful in evaluating patients with spastic foot drop (SFD). OBSERVATIONS: Among 16 patients with SFD, the cause was cervical myelopathy in 5 patients (31%), cerebrovascular accident in 3 (18%), hereditary spastic paraplegia in 2 (12%), multiple sclerosis in 2 (12%), chronic cerebral small vessel disease in 2 (12%), intracranial meningioma in 1 (6%), and diffuse brain injury in 1 (6%). Twelve patients (75%) had weakness of a single leg, whereas 2 others (12%) had bilateral weakness. Eleven patients (69%) had difficulty walking. The deep tendon reflexes of the legs were hyperactive in 15 patients (94%), with an extensor plantar response in 9 patients (56%). Twelve patients (75%) had normal motor and sensory conduction, 11 of whom had no denervation changes of the legs. LESSONS: This study is intended to raise awareness among surgeons about the clinical features of SFD. EDX studies are valuable in ruling out peripheral causes of foot drop, which encourages diagnostic investigation into a UMN source for the foot drop.

Etiological study of superficial radial nerve neuropathy: series of 34 patients.

Objectives: Superficial radial nerve (SRN) neuropathy is a rare focal neuropathy leading to pain and paresthesia of the dorsolateral aspect of the hand. Reported causes include trauma, extrinsic compression, or it may be idiopathic. We describe the clinical and electrodiagnostic (EDX) features of 34 patients with SRN neuropathy of varied etiology. Methods: This is a retrospective study of patients with upper limb neuropathy referred for EDX studies who were found to have SRN neuropathy based on clinical and EDX findings. Twelve patients also had ultrasound (US) evaluations. Results: Decreased pinprick sensation was noted in the distribution of the SRN in 31 (91%) patients, and a positive Tinel's sign was observed in 9 (26%). Sensory nerve action potentials (SNAPs) were not recordable in 11 (32%) patients. Of the patients who had a recordable SNAP, the latency was delayed, and the amplitude was decreased in all cases. Of the 12 patients who underwent US studies, 6 (50%) had an increased cross-sectional area of the SRN at or immediately proximal to the site of injury/compression. A cyst was located adjacent to the SRN in 2 patients. The most common cause of SRN neuropathy was trauma in 19 (56%) patients, of which 15 were iatrogenic. A compressive etiology was identified in 6 patients (18%). No specific etiology was detected in 10 patients (29%). Conclusion: This study is aimed at raising the awareness among surgeons about the clinical features and varied causes of SRN neuropathy; such knowledge may potentially lessen iatrogenic causes of injury.

Iatrogenic median and ulnar nerve injuries during carpal tunnel release: clinical, electrodiagnostic, and ultrasound features in 12 patients. Patient series.

BACKGROUND: Nerve injuries during carpal tunnel release (CTR) are rare. Electrodiagnostic (EDX) and ultrasound (US) studies may be helpful in evaluating iatrogenic nerve injuries during CTR. OBSERVATIONS: Nine patients sustained a median nerve injury, and 3 patients experienced ulnar nerve damage. Decreased sensation occurred in 11 patients, and dysesthesia occurred in 1 patient. Abductor pollicis brevis (APB) weakness occurred in all patients with median nerve injury. Of the 9 patients with median nerve injury, the compound muscle action potentials (CMAPs) of the APB and sensory nerve action potentials (SNAPs) of the 2nd or 3rd digit were not recordable in 6 and 5 patients, respectively. Of the 3 patients sustaining ulnar nerve injuries, the CMAPs of the abductor digiti minimi (ADM) and SNAPs of the 5th digit were not recordable in 1 patient; 2 patients showed prolonged latency and decreased amplitude of CMAPs/SNAPs. US studies of 8 patients with a median nerve injury showed a neuroma within the carpal tunnel. One patient underwent surgical repair urgently, and 6 did so after variable intervals. LESSONS: Surgeons should be cognizant of nerve injuries during CTR. EDX and US studies are useful in evaluating iatrogenic nerve injuries during CTR.

Gunshot-related nerve injuries of the upper extremities: clinical, electromyographic, and ultrasound features in 22 patients.

Objectives: Gunshot wounds of the upper extremities may cause permanent neurovascular injuries, leading to significant morbidity, chronic pain, functional loss, and disability. While there are many reports on the incidence and intraoperative findings in gunshot-related nerve injuries (GSNI) sustained during wars, there is a paucity of details pertaining to GSNI of the upper extremities in civilians. The goal of this paper is to provide the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in 22 patients with GSNI of the upper extremities. Methods: This is a retrospective study of patients referred for EDX studies to evaluate the presence of nerve injury after sustaining GSWs to the upper extremities. All patients underwent EDX studies, and 16 patients had US evaluations. Numerous metrics were documented including presenting symptoms, neurological abnormalities, EDX findings, and US features. Results: The forearm was the most frequent location of injury (8 [36%] patients). The ulnar nerve was the most common injured nerve (10 [45%] patients), followed by the brachial plexus (7 [32%] patients). All patients complained of muscle weakness; the most frequently affected muscles were the first dorsal interosseous (FDI) (14 [64%] patients) and abductor pollicis brevis (APB) (11 [50%] patients). Muscle atrophy was noted in 19 (86%) patients, 15 of whom had atrophy of the FDI. Axonotmesis was the type of nerve injury in all patients based on EDX studies. Of the 16 patients who underwent US studies, a neuroma in continuity was noted in 4 (25%) patients and neurotmesis in 1 (6.2%) patient. Eleven (69%) patients had enlarged and/or hypoechoic nerves. Conclusions: Axonotmesis of the ulnar nerve was the most common finding among patients sustaining gunshot injuries to the upper extremities. EDX and US studies provide valuable insight into the underlying pathophysiology and guidance for management of patients with GSNI of the upper extremities.

Role of electromyography and ultrasonography in the diagnosis of double crush lumbar radiculopathy and common fibular injury: illustrative cases.

BACKGROUND: Double crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may be helpful in evaluating foot drop involving overlapping pathologies. OBSERVATIONS: Case 1 involved a man who presented with left dorsiflexor weakness and left foot numbness. Electromyography (EMG) revealed a left common fibular nerve entrapment neuropathy and left L5 radiculopathy. US and magnetic resonance imaging (MRI) revealed a large cystic lesion of the left common fibular nerve treated by cyst removal. The left foot drop persisted postoperatively. Lumbar computed tomography myelography revealed severe left foraminal stenosis at L5-S1. Multilevel lumbar laminectomies and facetectomies with an L5-S1 fusion were performed. Within 1 month postoperatively, the left foot drop had improved. Case 2 involved a man who developed a right foot drop caused by right lumbar foraminal stenosis at L4-5 and L5-S1. EMG and US of the right common fibular neuropathy showed large fascicles involving the right common fibular nerve. MRI revealed a hyperintense signal of the right common fibular nerve. Spontaneous improvement occurred within 6 months without surgery. LESSONS: Spine surgeons should recognize double crush in the lower extremities. EMG and US are valuable in detecting peripheral nerve abnormalities, especially in cases with overlapping lumbar pathology.

Early-Onset Dropped Head Syndrome and Person-in-the-Barrel Syndrome After Radiation Therapy: Clinical, Electromyographic, and MRI Findings.

Dropped head syndrome (DHS) involves severe weakness of the neck extensor muscles causing the mandible to drop to the chest wall. Isolated neck extensor weakness is a rare complication of radiotherapy. This condition may result within a few weeks or months following radiotherapy (early-onset) or several years after radiotherapy (late-onset), with the latter more commonly encountered. Person-in-the-barrel syndrome is marked by bilateral brachial diplegia, intact cranial nerves, and preserved lower extremity strength. We describe the unique clinical profile of a patient with a six-week history of significant neck and bilateral upper extremity weakness who was diagnosed three months prior to the onset of these symptoms with moderately differentiated squamous cell carcinoma within the base of the tongue (Stage III T2N1M0) and metastasis to the cervical lymph nodes. She underwent concurrent chemotherapy with three cycles of cisplatin (197 mg {100 mg/m2} x 197 m2) and hyperfractionated external beam radiation therapy (total dose cGy 7000 cGy in 35 fractions {200 cGy per fraction}). She reported the rapid onset of neck and bilateral upper extremity weakness six weeks following cisplatin termination and four weeks after radiation termination. A cervical MRI suggested myositis of the cervical paraspinal muscles, and electrodiagnostic studies indicated an inflammatory myopathic process involving the cervical paraspinal and shoulder girdle muscles. The patient attained a complete resolution of her symptoms eight months after onset. This case illustrates the rare phenomenon of early-onset DHS and person-in-the-barrel syndrome caused by radiation-induced myositis. Prompt recognition of the symptoms associated with DHS and timely treatment offer the best prognosis for recovery.

Comparison of adenoma detection in different colorectal segments between deep-sedated and unsedated colonoscopy.

To investigate if deep-sedated colonoscopy affects adenoma detection in certain colorectal segment. Review of colonoscopy reports, electronic images and medical records of individuals underwent screening colonoscopy with or without propofol sedation between October 2020 and March 2021 from seven hospitals in China. A total of 4500 individuals were analyzed. There was no significant difference in ADR between deep-sedated colonoscopy and unsedated colonoscopy [45.4% vs. 46.3%, P > 0.05]. The APP of deep-sedated colonoscopy was lower than unsedated colonoscopy (1.76 ± 0.81 vs. 2.00 ± 1.30, P < 0.05). Both average number of adenomas and luminal distention score of splenic flexure and descending colon were lower in deep-sedated colonoscopy (P < 0.05), and average number of adenomas was positively correlated with an improved distension score in splenic flexure and descending colon (splenic flexure r = 0.031, P < 0.05; descending colon r = 0.312, P < 0.05). Linear regression model showed deep-sedated colonoscopy significantly affected luminal distention of splenic flexure and descending colon as well as average number of adenomas detected in splenic flexure (P < 0.05). Deep-sedated colonoscopy decreased adenoma detection in splenic flexure and the luminal distention of splenic flexure and descending colon compared with unsedated colonoscopy.

Multifocal intradural extramedullary ependymoma, MYCN amplified: illustrative case.

BACKGROUND: Ependymomas are the most frequent tumors of the adult spinal cord, representing 1.9% of all central nervous system tumors and 60% of spinal cord tumors. Spinal ependymomas are usually solitary, intramedullary lesions. While intradural extramedullary (IDEM) ependymomas are infrequent, multifocal IDEM ependymomas are exceptionally rare. OBSERVATIONS: The authors reported the first case in the literature of a patient diagnosed with multifocal IDEM ependymomas who was treated with tumor resection and brain and spinal radiotherapy. The patient presented with a 10-day history of bilateral leg numbness extending to the umbilicus and gait instability. Magnetic resonance imaging (MRI) studies revealed multiple enhancing nodular nodules throughout the entire spinal canal. Brain MRI revealed no abnormal lesions. A World Health Organization grade II ependymoma was confirmed histologically. At 31 months postoperatively, the patient remained clinically asymptomatic. Although cervical and thoracic MRI revealed stable intradural nodules and several areas of leptomeningeal enhancement, no malignant cells were seen in the cerebrospinal fluid (CSF). He underwent genetic testing to determine the appropriate chemotherapeutic agent if activation of the tumor should arise. LESSONS: Because complete resection of multifocal IDEM ependymomas is not feasible, continued monitoring with brain and spine MRI is warranted to detect potential tumor dissemination in the CSF.

Flaccid Brachial Monoplegia As Initial Presentation in a Patient With Progressive Multifocal Leukoencephalopathy.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease caused by activation of John Cunningham virus (JCV) replication in the setting of impaired cellular immunity. A positive polymerase chain reaction (PCR) assay for JCV DNA in the cerebrospinal fluid (CSF) in conjunction with clinical findings and neuroimaging are diagnostic of PML. A false negative JCV PCR in the CSF may occur, necessitating PML confirmation by brain biopsy. We describe the unique clinical profile of a patient with no prior history of immunocompromise, referred to us for electrodiagnostic evaluation, who initially presented with rapidly progressive weakness of the right upper extremity. The unusual pattern of motor weakness suggested a conduction block or disconnection at the subcortical level. The patient was later diagnosed with atypical small cell lymphocytic lymphoma although not treated with monoclonal antibodies or other forms of chemotherapy. The CSF was negative for JCV, and PML was subsequently confirmed by brain biopsy. This case illustrates an uncommon presentation of PML and highlights the need for a high index of suspicion to diagnose PML.

New progress in understanding roles of nitric oxide during hepatic ischemia-reperfusion injury.

Hepatic ischemia-reperfusion injury (HIRI) is a major clinical cause of morbidity and mortality in liver surgery and transplantation. Many studies have found that nitric oxide (NO) plays an important role in the HIRI and its increase or decrease can affect the progression and outcome of HIRI. However, the role of NO in HIRI is controversial and complicated. NO derived by endothelial NO synthase (eNOS) shows a protective role in HIRI, while excessive NO derived by inducible NO synthase (iNOS) accelerates inflammation and increases oxidative stress, further aggravating HIRI. Nevertheless, the overexpression of eNOS may exacerbate HIRI and iNOS-derived NO in some cases reduces HIRI. Here we review the new progress in the understanding of the roles of NO during HIRI: (1) NO possesses different roles in HIRI by increasing NO bioavailability, down-regulating leukotriene C4 synthase, inhibiting the activation of the nuclear factorκB (NFκB) pathway, enhancing cell autophagy, and reducing inflammatory cytokines and reactive oxygen species (ROS). And NO has both protective and deleterious effects by regulating apoptotic factors; (2) eNOS promotes NO production and suppresses its own overexpression, exerting a hepatoprotective effect reversely. Its activation is regulated by the PI3K/Akt and KLF2/AMPK pathways; and (3) iNOS derived NO mainly has deteriorating effects on HIRI, while it may have a protective function under some conditions. Their expression should reach a balance to reduce the adverse side and make NO protective in the treatment of HIRI. Thus, it can be inferred that NO modulating drugs may be a new direction in the treatment of HIRI or may be used as an adjunct to mitigate HIRI for the purpose of protecting the liver.

Nerve Ultrasound Findings before and after Surgery in a Patient with Charcot-Marie-Tooth Disease Type 1A and Comorbid Carpal Tunnel Syndrome.

The diagnosis of comorbid carpal tunnel syndrome (CTS) in patients with Charcot-Marie-Tooth (CMT) disease is challenging due to the overlapping symptoms and inconclusive electrodiagnostic studies (EDX). This case report is aimed at illustrating the value of ultrasonography (US) in a patient with CMT1 disease and comorbid CTS. A 28-year-old woman presented with symptoms of painful paresthesia and weakness of both hands. EDX demonstrated a demyelinating sensory-motor polyneuropathy in the upper and lower extremities, consistent with CMT1 disease. US showed an increased cross-sectional area (CSA) of the median nerve at the carpal tunnel inlet (CTI) with a significant drop in the diameter within the carpal tunnel, confirming concurrent CTS. Genetic testing confirmed PMP22 duplication consistent with CMT1A. Bilateral carpal tunnel releases were performed with partial symptom resolution within 3 weeks. Postoperative EDX demonstrated improved motor conduction across the wrist, but the sensory potentials continued to be unrecordable. US showed a significant reversal of the diameter-drop of the median nerve within the carpal tunnel and decrease in CSA at the CTI. US imaging is a valuable technique for identifying comorbid CTS in patients with CMT and directing appropriate treatment.

Brachioradial Pruritus: Clinical, Electromyographic, and Cervical MRI Features in Nine Patients.

Background Brachioradial pruritus (BRP) is a neuropathic dysesthesia manifesting as pruritus over the dorsolateral forearm. While the etiology is unknown, intensive sun exposure and cervical spine disease have been proposed. This study describes the clinical, electrodiagnostic (EDX), and cervical MRI findings in nine patients diagnosed with BRP. Materials and methods All patients underwent EDX and cervical MRIs. Numerous metrics were documented including presenting symptoms, neurological examination, EDX findings, and cervical MRI features. Results All nine patients experienced pruritus of the arms/forearms, typical of BRP, which was unilateral in eight (89%) cases. Decreased pinprick sensation was noted in the arms/forearms (five [56%] patients) or of the thumbs, index, and/or middle fingers (four [44%] patients). Four (44%) patients had either decreased or absent biceps and brachioradialis deep tendon reflexes (DTRs), while one (11%) patient had decreased triceps and brachioradialis DTRs. The EDX revealed abnormalities in eight (89%) patients. Increased polyphasic units, decreased motor units, and/or denervation changes were recorded by needle electromyography (EMG) in eight (89%) patients: the biceps in seven (88%) and both the brachioradialis and triceps in four (50%) patients. The EMG abnormalities indicated chronic radiculopathy involving C6 in six patients and C5 and C6 in one patient. All nine patients had cervical spine disease, encompassing disc protrusions, spondylosis, spinal stenosis, and/or foraminal stenosis. Conclusions BRP in this series of patients was accompanied by chronic cervical radiculopathy involving predominantly C6 and C5. EDX and cervical spine MR imaging should be considered essential investigations in the evaluation of patients with BRP.

Varied Presentation and Importance of MR Neurography of the Common Fibular Nerve in Slimmer's Paralysis.

Slimmer's paralysis refers to a common fibular nerve palsy caused by significant and rapid weight loss. This condition usually results from entrapment of the common fibular nerve due to loss of the fat pad surrounding the fibular head. Several etiologies of common fibular nerve palsy have been proposed, including trauma, surgical complications, improperly fitted casts or braces, tumors and cysts, metabolic syndromes, and positional factors. We present 5 cases of slimmer's paralysis in patients who had lost 32-57 kg in approximately 1 year. In 2 cases, MR neurogram of the knee demonstrated abnormalities of the common fibular nerve at the fibular head. Two patients underwent a common fibular nerve decompression at the fibular head and attained improved gait and sensorimotor function. Weight loss, diabetes mellitus, and immobilization may have contributed to slimmer's paralysis in 1 case. Awareness of slimmer's paralysis in patients who have lost a significant amount of weight in a short period of time is imperative to detect and treat a fibular nerve neuropathy that may ensue.

Hypertrophy of the tensor fascia lata: A pseudotumor due to lumbar radiculopathy.

BACKGROUND: Pseudotumor of the tensor fascia lata (TFL) consists of a rare, benign soft tissue mass/hypertrophy of the TFL that appears on the anterolateral aspect of the proximal thigh. Notably, this condition often mimics a malignant tumor and may be misdiagnosed as a sarcoma. CASE DESCRIPTION: A 45-year-old male presented with left hip/groin pain, swelling, and a painful mass on the anterolateral aspect of the left hip/thigh. The symptoms had started 3 months ago following an L1-S1 lumbar laminectomy/fusion. The initial diagnosis was hip disease, and the patient underwent a left MR arthrogram. When this study demonstrated a tear of the left anterosuperior acetabular labrum plus an increased alpha angle causing femoroacetabular impingement, the patient then underwent a left hip arthroscopy. However, as he continued to complain of the hip mass, he was referred to an orthopedic oncologist whose presumptive diagnosis favored a sarcoma. Nevertheless, the pelvic MRI scan and ultrasound (US) confirmed the diagnosis of hypertrophy of the left TFL (US left 33.4 mm vs. right 14.4 mm). The patient was first treated with 50 units of locally injected botulinum. As there was no symptomatic relief, the plan was to repeat the injection within the next few months. CONCLUSION: Hypertrophy of TFL may mimic a neoplasm such as a sarcoma and contributes to what appears to be a lumbar radiculopathy. However, MR and US imaging should readily identify TFL and rule out malignant lesions such as sarcomas.

A tomato NAC transcription factor, SlNAM1, positively regulates ethylene biosynthesis and the onset of tomato fruit ripening.

Fruit ripening in tomato (Solanum lycopersicum) is the result of selective expression of ripening-related genes, which are regulated by transcription factors (TFs). The NAC (NAM, ATAF1/2, and CUC2) TF family is one of the largest families of plant-specific TFs and members are involved in a variety of plant physiological activities, including fruit ripening. Fruit ripening-associated NAC TFs studied in tomato to date include NAC-NOR (non-ripening), SlNOR-like1 (non-ripening like1), SlNAC1, and SlNAC4. Considering the large number of NAC genes in the tomato genome, there is little information about the possible roles of other NAC members in fruit ripening, and research on their target genes is lacking. In this study, we characterize SlNAM1, a NAC TF, which positively regulates the initiation of tomato fruit ripening via its regulation of ethylene biosynthesis. The onset of fruit ripening in slnam1-deficient mutants created by CRISPR/Cas9 (clustered regularly interspaced short palindromic repeats and CRISPR-associated protein 9) technology was delayed, whereas fruit ripening in OE-SlNAM1 lines was accelerated compared with the wild type. The results of RNA-sequencing (RNA-seq) and promoter analysis suggested that SlNAM1 directly binds to the promoters of two key ethylene biosynthesis genes (1-aminocyclopropane-1-carboxylate synthase: SlACS2 and SlACS4) and activates their expression. This hypothesis was confirmed by electrophoretic mobility shift assays and dual-luciferase reporter assay. Our findings provide insights into the mechanisms of ethylene production and enrich understanding of the tomato fruit ripening regulatory network.

Differentiation of vascular claudication due to bilateral common iliac artery stenosis versus neurogenic claudication with spinal stenosis.

BACKGROUND: Differentiating between neurogenic and vascular claudication may be difficult. Vascular claudication due to aortic and iliac artery occlusions may present as low back, hip, and buttock pain while walking short distances. These findings are often very similar to those seen for neurogenic claudication attributed to lumbar stenosis. CASE DESCRIPTION: A 68-year-old female presented with low back, right hip, and groin pain while walking short distances. She had previously undergone lumbar and cardiac surgery. Now, with negative repeated lumbar studies, the CT angiogram (CTA) revealed a dense calcified plaque in the right common iliac artery resulting in 90% stenosis at its origin and <50% stenosis of the left common iliac artery. Once bilateral common iliac artery kissing stents were placed, the patient's symptoms resolved. CONCLUSION: Spine surgeons should be aware that vascular and neurogenic claudication may mimic each other. Obtaining MR studies of the lumbar spine and EMG/NCV, along with the appropriate vascular studies (CTAs), help differentiate between the two, and result in the appropriate operative choices.