Assessment of ulnar nerve tension directed towards understanding cubital tunnel syndrome.

Background: Ulnar nerve compression at the elbow is the second most common compressive neuropathy of the upper extremity. We hypothesize that tension on the ulnar nerve produced by elbow flexion and distraction contributes to this condition. We measured ulnar nerve tension generated during elbow flexion and proportional distraction to evaluate locations of soft tissue constraints to nerve translation. Methods: Eight fresh-frozen upper limb specimens were tested. Each specimen included the proximal humeral shaft to the wrist. The ulnar nerve was dissected proximally and clamped to the humerus 8 â€‹cm proximal to the medial epicondyle. At 8 â€‹cm distal to the medial epicondyle, the ulnar nerve was dissected and clamped distally to a load cell that was mounted on a laboratory stand. A stage on the stand could be translated distally to apply load. Soft tissue was removed distal to the load cell clamp; all soft tissue from the load cell to the proximal humeral clamp was left intact.We measured the tension generated on the nerve throughout the full arc of elbow flexion with additional distal distractions of 0%, 2.5% and 5% of nerve length applied by distal translation of the stage on the lab stand. We then repeated these steps with the nerve unclamped proximally. We then excised 1 â€‹cm of soft tissue distally, clamped the nerve 7 â€‹cm distal to the medial epicondyle, and repeated the measurements. We continued this sequential dissection and testing until the nerve was clamped to the load cell 1 â€‹cm distal to the medial epicondyle. Results: Flexion, distraction, and proximal clamping each increased nerve tension. Tension was greatest at 4, 5, and 6 â€‹cm distal to the medial epicondyle (p â€‹< â€‹0.01). Conclusion: Flexion, distraction, and proximal clamping each increased ulnar nerve tension. The greatest ulnar nerve tension was recorded between 4 and 6 â€‹cm distal to the medial epicondyle.

Effects of transplantation-related immunosuppression on co-existent neuroendocrine tumours.

BACKGROUND: Here we detail our experience of managing patients found to have a neuroendocrine neoplasm (NEN) whilst on immunosuppression for a transplanted organ. AIM: We aimed to quantify the behaviour of NENs under solid-organ transplant-related immunosuppression. DESIGN: This was an observational, retrospective case series. METHODS: Ten patients were identified from a prospectively kept database. Three were excluded. RESULTS: Four patients received a liver, two a kidney, and one a heart transplant. All but one received calcineurin-based immunosuppression. NENs were found in five patients post-transplant: one had surgery for transverse colonic neuroendocrine carcinoma NEC (pT4N1M0, Ki67 60%), was cancer-free after four years; one had cold biopsy of duodenal NEN (pT1N0M0, Ki67 2%), cancer-free at four months; one 7 mm pancreatic NEN (pT1N0M0), untreated and stable for seven years; one small-bowel NEN with mesenteric metastasis (pTxNxM1), alive four years after diagnosis; and one untreated small-bowel NEN with mesenteric metastasis, stable at 1 year after liver transplantation. Two NENs were discovered pre-transplant, one pancreatic NEN (pT1N0M0, Ki67 5%), remains untreated and stable at three years. One gastric NEN (type 3, pT1bN0M0, Ki67 2%) remains stable without treatment for two years. CONCLUSIONS: NENs demonstrate indolent behaviour in the presence of transplant-related immunosuppression.

Extra-ocular movement restriction and diplopia following orbital fracture repair.

PURPOSE: To report a series of patients with extra-ocular movement restriction and diplopia after orbital fracture repair, and determine the effect of timing of repair and the type of implant used. METHODS: A chart review was conducted identifying all patients >18years of age at our institution between June 2005 and June 2008 who underwent orbital fracture repair, and presented with clinically significant diplopia and extra-ocular movement restriction persisting longer than one month after repair. Data collected included timing of repair, implant used within the orbit, and need for revision. RESULTS: Ten patients were identified with a mean time to primary orbital fracture repair at 9days (range 1-48). Seven patients underwent revision of their orbital fracture repair with removal of the previously placed implant and replacement with non-porous 0.4mm Supramid Foil, whereas one patient underwent lateral and inferior rectus recessions without revision of primary fracture repair. Titanium mesh was the intra-orbital implant found in all patients requiring revision of orbital fracture repair. All revisions resulted in resolution of clinically significant diplopia. CONCLUSIONS: Clinically significant diplopia and extra-ocular movement restriction is not an uncommon complication after orbital fracture repair. In our series, there was a strong association between these complications and the use of porous titanium mesh implants. Revision of fractures significantly improved diplopia in all but one patient. This suggests that meticulous fracture repair and the use of non-porous implants primarily or secondarily may preclude the need for strabismus surgery after orbital trauma.

Efficacy of C.E.R.A. in Routine Clinical Practice for Correction of Anaemia and Maintenance of the Haemoglobin Levels in CKD Patients not on Dialysis.

INTRODUCTION: C.E.R.A. reported effective correction of anaemia and was well tolerated in International studies on CKD patients not on dialysis. OBJECTIVE: The study aimed to describe the management of renal anaemia in CKD patients not on dialysis with C.E.R.A. in routine clinical practice in India. METHODS: This was a prospective, single-arm, open-label, multi-centre, non-interventional, Phase IV study which followed 108 CKD Stage III-IV patients, not on dialysis with Hb < 10 g/dL for correction of anaemia with C.E.R.A. RESULTS: Of the 108 patients with Hb < 10 g/dL at baseline, 83 (90.2%) patients achieved target Hb of 10-12 g/dL and the time taken to achieve correction of anaemia was 9.6 weeks ± 6.13 weeks in the Intent-to-treat population. Haemoglobin concentration increased from 8.59 ± 0.808 g/dL pre-therapy to 10.91 ± 0.634 g/dL post-therapy. The change in mean ± SD Hb value was 2.32 ± 0.174 g/dL. Maintenance of Hb levels within the target range of Hb 10 - 12 g/dL was observed in 78.2% of ITT and 80.8% of the PP population for mean duration of 16.69 weeks. Four patients (3.7%) experienced 5 AEs and 2 patients (1.9%) experienced 3 SAEs in the safety population. As per the treating physician none of the AEs or SAEs was considered related to study drug. There were no deaths reported. CONCLUSIONS: This study demonstrated successful correction of anaemia in Indian patients with C.E.R.A. treatment as well as maintenance of Hb levels within the target range. C.E.R.A. was well tolerated with no new safety concerns specific to the Indian population. The less frequent up to monthly dosing schedule of C.E.R.A. may offer clinicians and patients a simplified regimen of anaemia management as compared to traditional frequently administered (thrice weekly to once weekly) ESAs.

Prognostic factors and 5-year survival of patients with carcinoma penis: Tertiary health center study.

CONTEXT: To identify prognostic factors in carcinoma penis with its impact on survival. AIMS: To find out the relation of various prognostic factors of carcinoma penis with the various outcomes. SETTINGS AND DESIGN: Retrospective cohort study. SUBJECTS AND METHODS: Each patient diagnosed as having carcinoma of penis by incision biopsy and operated from January 2004 to May 2009 at the institute was included in the study (n = 117). Data were collected and analyzed. STATISTICAL ANALYSIS USED: The Chi-square (χ2) test was used to test for the significance of association between the independent (predictor) and dependent (outcome) variables. Multivariate logistic regression analysis was used to determine predictor variables that predicted the outcome. Five year disease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan-Meier method. RESULTS: Of the total 117 patients studied, 30 patients died within 5 years (median = 25 months). Recurrences (local or systemic) were seen in 23 patients (median = 14 months). Five-year DFS was 80.34% and OS was 72.22%. Kaplan-Meier analysis showed that well to moderately differentiated grade, lymph node negative disease and low stage have higher survivals than poorly differentiated grade, lymph node positive disease and higher stage, respectively. Multiple logistic regression analysis revealed that inguinal lymph node positivity and grade were significantly associated with local or systemic recurrence. CONCLUSIONS: Penile cancer patients with advanced disease had poor survival. Tumor grade and inguinal lymph node metastasis are factors affecting DFS. Lymphadenectomy remains an integral part of the management of patients with penile cancer.

The effect of TGF-beta-induced epithelial-mesenchymal transition on the expression of intracellular calcium-handling proteins in T47D and MCF-7 human breast cancer cells.

The contribution of Ca(2+) in TGF-ß-induced EMT is poorly understood. We aimed to confirm the effect of TGF-ß on the gene expression of intracellular calcium-handling proteins and to investigate the potential underlying mechanisms in TGF-ß-induced EMT. T47D and MCF-7 cells were cultured in vitro and treated with TGF-ß. The mRNA expression of EMT marker genes and intracellular calcium-handling proteins were quantified by qRT-PCR. qRT-PCR and Western blot analysis results verified the changes of EMT marker gene expression. Furthermore, we found that TGF-ß induced cell morphological changes significantly with an increase of cell surface area and cell length. These results indicated that TGF-ß induced EMT. The mRNA expression levels of SPCA1, SPCA2 and MCU were not influenced by TGF-ß treatment, while NCX1 expression was decreased in T47D cells. In addition, the mRNA levels of SERCAs and IP3Rs were significantly changed due to TGF-ß-induced EMT. The TGF-ß-treated T47D cells exhibited markedly greater response to ATP than the control cells, and the descent velocity of cytosolic calcium concentration was faster in TGF-ß-treated cells than in control cells. This is the first report to demonstrate that TGF-ß-induced EMT in human breast cancer cells is associated with alterations in endoplasmic reticulum calcium homeostasis.

Evaluation of excitation functions of proton and deuteron induced reactions on enriched tellurium isotopes with special relevance to the production of iodine-124.

Cross-section data for the production of medically important radionuclide (124)I via five proton and deuteron induced reactions on enriched tellurium isotopes were evaluated. The nuclear model codes, STAPRE, EMPIRE and TALYS, were used for consistency checks of the experimental data. Recommended excitation functions were derived using a well-defined statistical procedure. Therefrom integral yields were calculated. The various production routes of (124)I were compared. Presently the (124)Te(p,n)(124)I reaction is the method of choice; however, the (125)Te(p,2n)(124)I reaction also appears to have great potential.

Physiological characterization of the cold-shock-induced humoral factor for wing color-pattern changes in butterflies.

Butterfly wing color patterns can be modified by the application of temperature shock to pupae immediately after pupation, which has been attributed to a cold-shock-induced humoral factor called cold-shock hormone (CSH). Here, we physiologically characterized CSH and pharmacological action of tungstate, using a nymphalid butterfly Junonia orithya. We first showed that the precise patterns of modification were dependent on the time-point of the cold-shock treatment after pupation, and confirmed that the modification properties induced in a cold-shocked pupa were able to be transferred to another pupa in a parabiosis experiment. Cold-shock application after removal of the head and prothorax together still produced modified wings, excluding major involvement of the brain-retrocerebral neuroendocrine complex. Furthermore, tungstate injection induced modifications even in individuals whose head and prothorax were removed. Importantly, transplantation of tracheae isolated from cold-shocked pupae induced modifications in the recipient wings. We identified a chemical peak in hemolymph of the cold-shocked individuals using HPLC, which corresponded to dopamine, and demonstrated that dopamine and its related biogenic amines have ability to induce small color-pattern changes. Taken together, the present study suggests that CSH is likely to be secreted from trachea-associated endocrine cells upon cold-shock treatment and that tungstate may change color patterns via its direct action on wings.

A comprehensive evaluation of charged-particle data for production of the therapeutic radionuclide (103)Pd.

(103)Pd is an important radionuclide having a half-life of 16.99d, which is suitable for internal radiation therapy, especially used for the treatment of prostate cancer. Its production in no-carrier-added form is done via charged-particle-induced reactions and the data are available in EXFOR library. We evaluated six charged-particle-induced reactions, namely (nat)Ag(p,x)(103)Pd, (103)Rh(p,n)(103)Pd, (103)Rh(d,2n)(103)Pd, (100)Ru(alpha,n)(103)Pd, (101)Ru(alpha,2n)(103)Pd, and (102)Ru((3)He,2n)(103)Pd process. In the first case, analysis was done up to about 100MeV but in other cases only up to about 25 or 40MeV. Furthermore, an evaluation of the data for the (nat)Ag(p,x)(103)Ag process was also done since it may serve as a typical example for the (103)Ag-->(103)Pd precursor system. A statistical procedure supported by nuclear model calculations using the codes STAPRE, EMPIRE 2.19, and TALYS was used to validate and fit the experimental data. The recommended sets of data derived together with confidence limits are reported. The application of those data, particularly in the calculation of integral yields, is discussed. A comparison of the investigated routes from the viewpoint of practical applicability to the production of (103)Pd is given. Presently the (103)Rh(p,n)(103)Pd reaction is the method of choice.

Pill-induced esophageal injury: endoscopic features and clinical outcomes.

BACKGROUND AND STUDY AIMS: Pill-induced esophageal injury is a common but under-reported problem. The purpose of this study was to explore the clinical and endoscopic features, and the outcome of pill-related esophageal injury. PATIENTS AND METHODS: Endoscopy records for the period from January 1997 to June 2003 were searched for reports of esophageal pathology. The records of patients with pill-induced esophageal injury were evaluated. RESULTS: A total of 92 patients with pill-induced esophageal injury were identified (33 men, 59 women; mean age 59, range 25-87). Common symptoms were odynophagia (n = 69, 75 %), chest pain (n = 55, 60 %), vomiting (n = 53, 58 %), dysphagia (n = 31, 33 %), and hematemesis (n = 14, 15 %). The endoscopic findings in the esophagus were: erythema in 76 patients (83 %), erosions in 53 patients (58 %), ulcers in 24 patients (26 %), seven of which were "kissing" ulcers, esophageal ulcer with bleeding in 17 patients (18 %), and esophageal strictures in seven patients (8 %). The causative pills were nonsteroidal anti-inflammatory drugs in 38 patients (41 %), tetracyclines in 20 patients (22 %), potassium chloride tablets in nine patients (10 %), alendronate in eight patients (9 %), and other drugs in 17 patients (18 %). Underlying diseases included diabetes in 60 patients (65 %), ischemic heart disease in 39 patients (42 %), and hypothyroidism in four patients (4 %). The mean hospital stay was 1.94 days; 14 patients (15 %) required injection of epinephrine 1 : 10,000 to control bleeding; and two patients died. CONCLUSIONS: Pill-induced injury may present as erosions, kissing ulcers, and multiple small areas of ulceration with bleeding, mainly in the middle third of the esophagus. Advanced age, female gender, diabetes, and ischemic heart disease were common associations. The majority of patients made an uneventful recovery.

Irritable bowel syndrome in health care professionals in Pakistan.

OBJECTIVE: To evaluate the symptomatology of irritable bowel syndrome (IBS) among health care professionals attending an IBS symposium in a tertiary care university hospital. METHOD: A questionnaire designed to incorporate Manning and Rome II criteria was distributed among participants of an IBS symposium, most of them were health care professionals. A total of 100 questionnaires were distributed, 41 had symptoms fulfilling criteria of IBS. In these patients male: female ratio was 28:13 with age range 18-68. RESULTS: The predominant symptom was abdominal pain 87.8 % (36/41) which was aggravated post-prandially 72.2% (29/41), relieved following defecation in 87% (35/41) with a sense of incomplete evacuation 85.3% (35/41) and distention after defecation in 80.4% (33/41). Anxiety and depression was present in 80% (33/41) as an extraintestinal symptom. CONCLUSION: Irritable bowel syndrome is common in health care workers with intestinal and extraintestinal manifestations being equally common.

Longitudinal oscillations and linear Landau damping in quark-gluon plasma.

On the basis of the semiclassical kinetic Vlasov equation for quark-gluon plasma and the Yang-Mills equation in covariant gauge, linear Landau damping for electrostatic perturbations such as Langmuir waves is investigated for the extreme-relativistic and strongly relativistic cases. It has been observed that for the extreme-relativistic case, wherein the thermal speed of the particles exceeds the phase velocity of the perturbations, the linear Landau damping is absent as has been reported in the literature. However, a departure from extreme-relativistic case generates an imaginary component of the frequency giving rise to linear Landau damping effect. The relevant integral for the conductivity tensor has been evaluated and the dispersion relation for the longitudinal part of the oscillation was obtained. Further, it is also noted that both the real part of the oscillation frequency and the damping rate are sensitive to the choice of the wave number k and the Debye length lambda(D) associated with quark-gluon plasma.

Immuno-histochemical analysis of estrogen receptors on the malignant gallbladder tissue.

Sex steroids play an important part in the functioning of normal gallbladder, formation of gallstones and possibly in the pathogenesis of gallbladder cancer. Steroids receptors have been previously demonstrated on normal and malignant gall bladder tissues. To study this phenomenon further, we correlated clinicopathological features and survival with estrogen receptor (ER) status of the tumour in 30 patients with histologically-proven adenocarcinoma of the gallbladder. Estrogen receptor assay was performed immuno-histochemically utilizing Universal Immunoperoxidase Staining Kit. Tumor tissue was obtained either surgically or with fine needle aspiration of the gallbladder mass. There were 27 females and 3 males. Eighteen patients had estrogen receptors expressed on the malignant tissue, 12 were negative. Comparison of clinicopathological characteristics and survival between the two groups demonstrated no significant difference in gender, mean age, marital status and parity. Similarly, presence of gallstones, histologic grade or survival did not correlate with the estrogen receptor status. There is, however, a trend in favour of poorly differentiated tumors being more often receptor negative. Further studies are necessary to elucidate the biologic significance of these receptors.

Hepatitis C virus (HCV) genotypes and chronic liver disease in Pakistan.

UNLABELLED: Hepatitis C virus (HCV) is classified into different types depending on nucleotide sequence variability. Detailed information on the distribution of various HCV genotypes in some geographical areas is available but little is known about Pakistan. In this study, a 5' non-coding region (NCR)-based restriction fragment length polymorphism (RFLP) genotyping assay was used to investigate the genotype distribution in a large series of HCV-infected patients in Karachi, Pakistan. Serum samples from 74 hepatitis B surface antigen (HBsAg)-negative patients with a clinical diagnosis of chronic liver disease (60 patients) and hepatocellular carcinoma (HCC) (14 patients) were assayed for anti-HCV antibody by second generation enzyme immunoassay and 48 were confirmed anti-HCV-positive (33 males, 15 females). Other causes of chronic liver disease (e.g. haemochromatosis, Wilson's disease and immune-mediated injury) were ruled out. Liver biopsy was done in 27/48 anti-HCV-positive patients and in all HCC patients. Genotypes were determined for 45/48 anti-HCV-positive study patients; 39/45 (87%) were type 3; four (9%) were type 1; one was type 2; and one was type 5. Past blood transfusion was the main identifiable risk factor found in 10 patients, all type 3. Seven of the 14 HCC patients were anti-HCV positive, (six were type 3). Most patients with hepatitis C presented with established cirrhosis and complications of portal hypertension and liver failure. IN CONCLUSION: (i) genotype 3 is the most common isolate in HCV-associated chronic liver disease in Pakistan; (ii) a significant proportion of HBsAg-negative cirrhotics are non-B, non-C in aetiology; and (iii) half of the patients with HCC have serological evidence of HCV infection.

Comparison of liver histology in chronic active hepatitis C and chronic active hepatitis B.

OBJECTIVE: To study the histological features of chronic active hepatitis C (CAH-C) and to compare these with those of chronic active hepatitis B (CAH-B). METHODS: Thirty-two liver biopsy specimens from patients with chronic active hepatitis and presence of antibodies to hepatitis C on second generation enzyme immunoassay were studied and compared with those in 34 patients with CAH-B. Seventeen of the 32 CAH-C patients had fully developed or developing cirrhosis of liver whereas the remainder had only chronic active hepatitis. RESULTS: Among 32 patients with CAH-C, fatty change (20), Kupffer cell hyperplasia (30), sinusoidal lymphocytosis (27) lymphoid follicles aggregates in portal tracts (26) and bridging necrosis (16) were regular features. Focal necrosis, bile duct necrosis, cholestasis and ground glass cells were however seen much less often. On the other hand, in patients with CAH-B, fatty change (no patient), sinusoidal lymphocytosis (one patient) and lymphoid follicles/aggregates in portal tracts (one patient) were rare. Also, Kupffer cell hyperplasia (22 patients) was seen less commonly in patients with CAH-B as compared to CAH-C. Focal necrosis (34 patients), bile ductular proliferation (9 patients), cholestasis (17 patients) and ground glass cells (15 patients) were more prominent in CAH-B. CONCLUSION: Presence of certain histological features can help in distinguishing between CAH-C and CAH-B.

Primary pulmonary hypertension developing 11 years after a splenorenal shunt for portal hypertension in hepatic cirrhosis.

OBJECTIVE: To describe a patient with pulmonary and portal hypertension and to review the pathogenesis and management of this condition. PATIENT: A 22-year-old woman with portal hypertension and liver cirrhosis who later developed pulmonary hypertension. INTERVENTIONS: The patient received antibiotic therapy and underwent a splenectomy and proximal splenorenal shunt for portal hypertension. She later received hydralazine, digoxin and warfarin for pulmonary hypertension. MAIN OUTCOME MEASURES: After undergoing a splenorenal shunt the patient made a good recovery. However, she later developed pulmonary hypertension and died after undergoing a hysterectomy and a bilateral salpingo-oophorectomy. CONCLUSIONS: The concomitant development of portal and pulmonary hypertension in the same patient has a poor prognosis. The treatment available for patients with these conditions is unsatisfactory and most patients eventually die as a result of cardiovascular disease. Cardiopulmonary and liver transplantation should be considered in suitable patients.

Neonatal cholestasis. New approaches to diagnostic evaluation and therapy.

Neonatal cholestasis remains a major diagnostic challenge despite increasing knowledge regarding its pathogenesis. The time constraint and urgency in the investigational process is underscored by the age-dependent success rate of the surgical corrective procedures for EHBA. Appropriate interpretation of imaging and pathologic studies requires a pediatric center familiar with the entities causing neonatal cholestasis. When liver failure or progressive hepatic dysfunction is likely to occur, early referral to a liver transplant center is recommended. Despite the increasing experience and excellent results of pediatric liver transplantation, at this point, surgical corrective procedures such as the Kasai procedure remain the first line of treatment for most patients with EHBA.

Yet another cause of chronic viral hepatitis?

The clinical features, course and histology of liver in 20 patients; mostly middle aged to elderly females, closely resembling chronic Non A Non B hepatitis is presented. They presented quite late in their disease and therefore, complications such as variceal bleeds, ascites and encephalopathy were frequent. Our patients were negative for hepatitis B and C virus serology. Metabolic and immune causes of chronic liver disease were also ruled out. To the best of our knowledge, this is the first study of its kind elaborating the clinical features, course and histology of liver in chronic Non B Non C hepatitis and raises a number of questions as to the nature of the infecting virus and the epidemiology of disease.