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The dorsal root ganglion (DRG) serves as a pivotal site for managing chronic pain through dorsal root ganglion stimulation (DRG-S). In recent years, the DRG-S has emerged as an attractive modality in the armamentarium of neuromodulation therapy due to its accessibility and efficacy in alleviating chronic pain refractory to conventional treatments. Despite its therapeutic advantages, the precise mechanisms underlying DRG-S-induced analgesia remain elusive, attributed in part to the diverse sensory neuron population within the DRG and its modulation of both peripheral and central sensory processing pathways. Emerging evidence suggests that DRG-S may alleviate pain by several mechanisms, including the reduction of nociceptive signals at the T-junction of sensory neurons, modulation of pain gating pathways within the dorsal horn, and regulation of neuronal excitability within the DRG itself. However, elucidating the full extent of DRG-S mechanisms necessitates further exploration, particularly regarding its supraspinal effects and its interactions with cognitive and affective networks. Understanding these mechanisms is crucial for optimizing neurostimulation technologies and improving clinical outcomes of DRG-S for chronic pain management. This review provides a comprehensive overview of the DRG anatomy, mechanisms of action of the DRG-S, and its significance in neuromodulation therapy for chronic pain.
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Dor Crônica , Humanos , Dor Crônica/terapia , Gânglios Espinais , Manejo da Dor , Vias Aferentes , Células Receptoras SensoriaisRESUMO
OBJECTIVES: 4D flow MRI enables quantitative assessment of helical flow. We sought to generate normal values and elucidate changes of helical flow (duration, volume, length, velocities and rotational direction) and flow jet (displacement, flow angle) as well as wall shear stress (WSS). METHODS: We assessed the temporal helical existence (THEX), maximum helical volume (HVmax), accumulated helical volume (HVacc), accumulated helical volume length (HVLacc), maximum forward velocity (maxVfor), maximum circumferential velocity (maxVcirc), rotational direction (RD) and maximum wall shear stress (WSS) as reported elsewhere using the software tool Bloodline in 86 healthy volunteers (46 females, mean age 41 ± 13 years). RESULTS: WSS decreased by 42.1% and maxVfor by 55.7% across age. There was no link between age and gender regarding the other parameters. CONCLUSION: This study provides age-dependent normal values regarding WSS and maxVfor and age- and gender-independent normal values regarding THEX, HVmax, HVacc, HVLacc, RD and maxVcirc. KEY POINTS: ⢠4D flow provides numerous new parameters; therefore, normal values are mandatory. ⢠Wall shear stress decreases over age. ⢠Maximum helical forward velocity decreases over age.
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Aorta , Hemodinâmica , Feminino , Humanos , Adulto , Pessoa de Meia-Idade , Velocidade do Fluxo Sanguíneo , Valores de Referência , Voluntários Saudáveis , Estresse MecânicoRESUMO
Organ transplant has, arguably, been the pinnacle of the advancement in medical science so far and vascularized composite allotransplantation has been the most recent addition to it. The scope of vascularized tissue allotransplantation has been widening with each passing day and more and more reports regarding the safety and efficacy of the procedure have been described. Due to the limited available literature on the management of the complications and implications of the hand transplant, the importance of each report on the procedure is paramount. A mid-arm allotransplant is a challenge in terms of expected motor recovery, and many controversies exist over the efficacy of the procedure altogether. Moreover, our case was complicated by a long ischemia time due to logistic reasons. We share our experience of a transhumeral upper limb allotransplantation, the complications associated with it along with the early postoperative results at 10 months follow up.
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Until, sometime ago, microsurgery meant mainly covering a defect or replanting severed parts back to where they belong. Now, restoration of original function and aesthetic consideration is a must in planning reconstructive procedure. Hand transplant combines hand surgery and microsurgery with complex multidisciplinary care.At the anniversary of our first cadaveric bilateral proximal forearm transplantation done in the country's government institute, we would like to share our experience in performing the surgery, outcomes so far, complications, and lessons learned, to contribute to the growing knowledge of vascularized composite allotransplant.
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Queimaduras por Corrente Elétrica/cirurgia , Antebraço/cirurgia , Alotransplante de Tecidos Compostos Vascularizados/métodos , Adolescente , Amputação Cirúrgica , Cadáver , Humanos , MasculinoRESUMO
AIM: Despite its importance in bone and cardiovascular disease in subjects with kidney disease, there are no data on fibroblast growth factor 23 (FGF23) perturbations in nephrotic syndrome. We evaluated FGF23 and markers of mineral bone metabolism in subjects with untreated NS. METHODS: In this cross-sectional study, we measured circulating levels of FGF23, 25-hydroxy vitamin D [25(OH)D], 1,25 di-hydroxy vitamin D [1,25(OH)2 D], serum albumin, serum calcium, phosphorus, creatinine and intact parathyroid hormone (iPTH) in 101 patients with adults onset NS and 40 healthy controls. We examined the correlation between FGF23 and markers of mineral bone metabolism. RESULTS: Compared to healthy controls, subjects with NS showed reduced levels of 25(OH)D (21.76 ± 10.18 vs 35.74 ± 40.27 nmol/L, P = 0.001), 1,25(OH)2 D (median; 37.80 vs 73.13 pmol/L, P = 0.0001) and FGF23 (37.81 ± 20.42 vs 48.20 ± 11.60 pg/mL, P = 0.004) levels. Serum phosphorus levels were marginally, but significantly higher in subjects with nephrotic syndrome compared to healthy controls (P = 0.004). Serum iPTH levels were significantly higher in subjects with NS compared to healthy controls (52.24 ± 39.58 vs 37.90 ± 14.60 pg/mL, P = 0.028). CONCLUSIONS: We conclude that FGF23 is reduced in subjects with NS compared to healthy controls. The reduced levels of Vitamin D, and urinary losses may contribute to lower levels of FGF23 in NS.
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Fatores de Crescimento de Fibroblastos/sangue , Síndrome Nefrótica/sangue , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Cálcio/sangue , Estudos de Casos e Controles , Creatinina/sangue , Estudos Transversais , Regulação para Baixo , Feminino , Fator de Crescimento de Fibroblastos 23 , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome Nefrótica/diagnóstico , Hormônio Paratireóideo/sangue , Fósforo/sangue , Albumina Sérica Humana/análise , Vitamina D/análogos & derivados , Vitamina D/sangue , Adulto JovemRESUMO
AIM: Blood levels of 25-hydroxyvitamin D [25(OH) D] are reduced in patients with nephrotic syndrome (NS). The lowering is thought to be due to urinary loss of vitamin D binding protein (DBP). A link between vitamin D deficiency and bone disease or markers of mineral metabolism has not yet been shown in NS. We hypothesized that alterations in bioavailable vitamin D levels might be linked to these abnormalities in NS. METHODS: We measured circulating levels of 25(OH)D, 1,25-dihydroxyvitamin D [1,25(OH)2 D], DBP, serum albumin and intact parathyroid hormone (iPTH) in 106 adults with sporadic idiopathic NS and 40 healthy controls. Bioavailable vitamin D was calculated from previously validated formulae. Bone mineral density (BMD) was measured at left hip (neck of femur) by DEXA. RESULTS: Compared to healthy controls, total and bioavailable 25(OH)D levels were significantly reduced in patients with NS as compared to healthy controls. Among the nephrotic patients, BMD was positively correlated with bioavailable 25(OH)D (r = 0.358; P = 0.0002) but not with total 25(OH)D (r = 0.174; P = 0.079). Total 1,25(OH)2 D and bioavailable 1,25(OH)2 D did not correlate with BMD (r = 0.131; P = 0.206 and r = 0.107, P = 0.295). Bioavailable 25(OH)D levels showed a strong inverse correlation with iPTH on univariate (r = -0.457; P < 0.0001) and multivariate (ß=-0.453, P < 0.0001) analyses. CONCLUSIONS: We conclude that bioavailable 25(OH)D is a better measure of vitamin D status with respect of BMD and mineral metabolism in patients of nephrotic syndrome.
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Densidade Óssea , Remodelação Óssea , Colo do Fêmur/metabolismo , Síndrome Nefrótica/sangue , Deficiência de Vitamina D/sangue , Vitamina D/análogos & derivados , Absorciometria de Fóton , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Estudos de Casos e Controles , Estudos Transversais , Regulação para Baixo , Feminino , Colo do Fêmur/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Síndrome Nefrótica/diagnóstico , Síndrome Nefrótica/fisiopatologia , Hormônio Paratireóideo/sangue , Valor Preditivo dos Testes , Albumina Sérica/análise , Albumina Sérica Humana , Vitamina D/sangue , Deficiência de Vitamina D/diagnóstico , Deficiência de Vitamina D/fisiopatologia , Proteína de Ligação a Vitamina D/sangue , Adulto JovemRESUMO
BACKGROUND: Influenza infection is rarely associated with cardiac conduction disorder. Cardiac arrhythmias due to such an infection have a full spectrum with ventricular arrythmias being the most common. METHODS: In our systematic review from PubMed, OVID Medline and EMBASE we have identified 23 articles describing arrythmias associated with different influenza infection. Most of them were case reports where ventricular arrhythmias were the most common. RESULTS: Complete heart block after influenza infection is usually temporary and a permanent pacemaker is rarely needed. There are reports of Influenza associated with arrhythmias in adults, neonates, and even fetuses in pregnant woman. Different mechanisms were described in literatures by which influenza causes arrhythmias such as interleukin 6 & tumor necrosis factor-alpha mediated inflammatory response, sympathetic overactivation, focal myocarditis and cleavage of angiotensin converting enzyme 2 protein which is cardioprotective. CONCLUSIONS: ACE 2 binder influenza viruses have more prone to be associated with cardiac conduction disorder. Oseltamivir for influenza infection is also associated with bradycardia and can shorten or lengthen QT segment. Influenza vaccination has found to be protective from cardiac arrhythmia.
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Influenza Humana , Miocardite , Adulto , Recém-Nascido , Gravidez , Feminino , Humanos , Influenza Humana/complicações , Arritmias Cardíacas/etiologia , Bradicardia/etiologia , OseltamivirRESUMO
BACKGROUND: The relationship between skin diseases and psychiatric illnesses is bi-directional and is manifested as cause and effect. Psychiatric disorders such as stress, anxiety, and depression are seen to be instrumental in the development and progression of dermatological diseases on one hand, while on the other hand, cosmetic disfigurement caused by dermatological diseases is responsible for psychological distress in patients. The present study was conducted to investigate the spectrum of dermatological disorders in psychiatric patients to offer them holistic treatment and provide them with a better quality of life. METHODS: This cross-sectional, observational study was conducted at a tertiary medical care center. A total of 170 psychiatric patients referred to the dermatology department for different dermatological manifestations were enrolled in the study. A demographic profile of the patients was done, and an association between dermatological diseases and psychiatric illnesses was done. RESULTS: Out of 170 study participants, 88 (51.8%) were females, and the rest (82, 48.2%) were males. A total of 13 major types of dermatological conditions were noted; among them, fungal infection (43, 25.3%) was the most common, followed by eczema (18, 10.6%), parasitic infestation (17, 10.0%), pigmentary disorder (13, 7.6%), acne (11, 6.5%), bacterial infection (11, 6.5%), pruritic disorder (11, 6.5%), hair disorder (9, 5.3%), drug reaction (9, 5.3%), papulosquamous disorder (7, 4.1%), and viral infection (6, 3.5%). Skin conditions other than the above-mentioned were present in 15 (8.8%) patients. The most common psychiatric illness in the present study was major depressive disorder (41, 24.1%), followed by generalized anxiety disorder (38, 22.4%) and psychosis not otherwise specified (34, 20.0%). Other psychiatric illnesses included in the study were bipolar affective disorder (22, 12.9%), schizophrenia (18, 10.6%), obsessive-compulsive disorder (12, 7.1%), and mixed anxiety depressive disorder (5, 2.9%). CONCLUSION: The findings of the present study depict that psychiatric patients with dermatological manifestations show a spectrum of dermatological conditions, primarily of infectious (fungal, parasitic, or viral) nature. This might be associated with a relatively poor hygienic status of psychiatric patients and thus their increased susceptibility to these disorders. Most of the time, the susceptibility to these skin conditions seemed to be opportunistic and unaffected by the type, duration, and level of control of psychiatric illness.
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Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a severe hereditary arrhythmia syndrome predominantly affecting children and young adults. It manifests through bidirectional or polymorphic ventricular arrhythmia, often culminating in syncope triggered by physical exertion or emotional stress which can lead to sudden cardiac death. Most cases stem from mutations in the gene responsible for encoding the cardiac ryanodine receptor (RyR2), or in the Calsequestrin 2 gene (CASQ2), disrupting the handling of calcium ions within the cardiac myocyte sarcoplasmic reticulum. Diagnosing CPVT typically involves unmasking the arrhythmia through exercise stress testing. This diagnosis emerges in the absence of structural heart disease by cardiac imaging and with a normal baseline electrocardiogram. Traditional first-line treatment primarily involves ß-blocker therapy, significantly reducing CPVT-associated mortality. Adjunctive therapies such as moderate exercise training, flecainide, left cardiac sympathetic denervation and implantable cardioverter-defibrillators have been utilized with reasonable success. However, the spectrum of options for managing CPVT has expanded over time, demonstrating decreased rates of arrhythmic events. Furthermore, ongoing research into potential new therapies including gene therapies has the potential to further enhance treatment paradigms. This review aims to succinctly encapsulate the contemporary understanding of the clinical characteristics, diagnostic approach, established therapeutic interventions and the promising future directions in managing CPVT.
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Hypothenar hammer syndrome (HHS) is a rare vascular disorder leading to ulnar artery thrombosis or aneurysm and causing acute or chronic limb ischemia. The optimal approaches to managing this condition lack a definitive consensus and are essentially empirical, typically necessitating conservative methods for symptomatic relief, with surgical intervention reserved for cases for which conservative measures prove inadequate or when acute limb ischemia ensues. Limited data are available on percutaneous management for this condition. We present the case of a 36-year-old male powerlifter who developed acute digital ischemia due to HHS in the left hand that was managed successfully through an innovative approach using antegrade left brachial artery access and combining percutaneous thrombosuction and intra-arterial thrombolysis. This comprehensive approach resulted in restoration of blood flow and resolution of acute limb ischemia. The patient was subsequently prescribed short-term anticoagulation therapy and remained symptom free at 3 months of follow-up. This innovative strategy challenges traditional surgical approaches in HHS management, underscoring the importance of using minimally invasive techniques as a promising alternative and highlighting potential avenues for further research.
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Background: The rotational direction (RD) of helical blood flow can be classified as either a clockwise (RD+) or counter-clockwise (RD-) flow. We hypothesized that this simple classification might not be sufficient for analysis in vivo and a simultaneous existence of RD+/- may occur. We utilized volumetric velocity-sensitive cardiovascular magnetic resonance imaging (4D flow MRI) to analyze rotational blood flow in the thoracic aorta. Methods: Forty volunteers (22 females; mean age, 41±16 years) and seventeen patients with bicuspid aortic valves (BAVs) (9 females; mean age, 42±14 years) were prospectively included. The RDs and the calculation of the rotating blood volumes (RBVs) in the thoracic aorta were performed using a pathline-projection strategy. Results: We could confirm a mainly clockwise RD in the ascending, descending aorta and in the aortic arch. Furthermore, we found a simultaneous existence of RD+/RD-. The RD+/--volume in the ascending aorta was significantly higher in BAV patients, the mean RD+/RD- percentage was approximately 80%/20% vs. 60%/40% in volunteers (P<0.01). The maximum RBV always occurred during systole. There was significantly more clockwise than counter-clockwise rotational flow in the ascending aorta (P<0.01) and the aortic arch (P<0.01), but no significant differences in the descending aorta (P=0.48). Conclusions: A simultaneous occurrence of RD+/RD- indicates that a simple categorization in either of both is insufficient to describe blood flow in vivo. Rotational flow in the ascending aorta and in the aortic arch differs significantly from flow in the descending aorta. BAV patients show significantly more clockwise rotating volume in the ascending aorta compared to healthy volunteers.
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Background: The role of acute mechanical circulatory support (aMCS) in patients with stress-induced cardiomyopathy (SIC) complicated by cardiogenic shock (CS) is not well studied. Here, we describe the incidence and outcomes of aMCS use in SIC-CS using a large national database. Methods: Using the Nationwide Readmissions Database from January 2016 to November 2019, we identified patients hospitalized with SIC who received isolated intra-aortic balloon pump (IABP), microaxial flow pump (Impella, Abiomed), or extracorporeal membrane oxygenation (ECMO) during the index hospitalization. Results: A total of 902 among 94,709 hospitalizations for SIC (1.0%) required aMCS during the index hospitalization: 611 had IABP (67.7%), 189 had Impella (21.0%) and 102 had ECMO (11.3%). Patients with ECMO or Impella had higher in-hospital mortality rates than those with IABP (37.3% vs 29.1% vs 18.5%, respectively). There was an increased adjusted risk of in-hospital death with Impella (adjusted odds ratio [aOR], 1.98; 95% CI, 1.12-3.49) and ECMO (aOR, 4.15; 95% CI, 1.85-9.32) vs IABP. Impella was associated with an increased adjusted risk of 30-day readmission compared to IABP (aOR, 2.53; 95% CI, 1.16-5.51). Patients with ECMO or Impella had a higher incidence of renal replacement therapy and vascular/bleeding complications compared to those who received IABP. Conclusions: In this nationwide analysis using an administrative database, patients who received ECMO and Impella showed higher rates of in-hospital mortality, renal replacement therapy, and vascular/bleeding complications compared to those who received IABP. Patients with more comorbidities may receive more aggressive hemodynamic support which may account for observed mortality differences. Future prospective studies with objective and universal characterization of baseline clinical and hemodynamic characteristics of patients with CS secondary to SIC are needed.
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Background: India has over 50 million workers employed in industries with exposure to very high sound levels, predisposing them to noise-induced hearing loss (NIHL). Methods: We conducted a systematic review and meta-analysis by using the following criteria: (1) Observational or experimental studies conducted in India; (2) English language studies; (3) Published during January 2010-December 2019; (4) Primary outcome: proportion of participants detected with NIHL. We reviewed bibliographic databases (PubMed, Scopus, and DOAJ) and Google Scholar, and extracted the relevant data. Results: A total of 160 documents were identified after removing duplicates, and 33 full texts were screened, of which 22 studies were included. The mean (SD) effective sample size of the studies was 107.1 (78.9). The pooled proportion of participants with NIHL irrespective of the category was 0.49 (95%CI: 0.22-0.76) and that of hearing loss was 0.53 (95%CI: 0.28- 0.78). Most studies reported that none of the workers, especially in the informal sectors, used auditory protection. Conclusions: NIHL is a major neglected public health occupational health challenge in India linked with adverse social determinants of health. Sustained advocacy for implementation of legislative and behavior change communication for protecting the hearing of workers is warranted.
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Hemophagocytic lymphohistiocytosis is a life-threatening disorder characterized by persistent pathologic activation of cytotoxic T lymphocytes, natural killer cells, and macrophages. We present details of a young patient who presented with high-grade fever, jaundice, and breathlessness. On investigations, he had hepatitis, anemia, neutropenia, and coagulopathy. He also had hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia. Bone marrow aspiration revealed histiocytosis, and transjugular liver biopsy revealed necrotizing granulomas positive for Mycobacterium tuberculosis on acid-fast bacilli staining. He was successfully managed with a combination of immunosuppressants and antitubercular therapy. Tuberculosis associated hemophagocytosis syndrome is rare and should be considered in patients with unexplained hemophagocytosis syndrome, especially in tuberculosis-endemic regions. Prompt recognition and treatment with antitubercular treatment and immunosuppressants are associated with good outcomes.
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Tissue expansion is a technique, which uses the biomechanical properties of skin and thereby aiding in wound closure. Commercially available devices for external expansion are not cost-effective. Hence, in this article, we would like to share our experience of innovative use of ziplock as external tissue expansion.
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Blisters are characteristic finding of second-degree superficial burns. Varied opinions for the management of burn blisters are available in literature. Most accepted one is to puncture it in a sterile way, keep the overlying skin as a biological cover, and over that put a moist sterile biological dressing. Fluid in the blister is ultrafiltrate of the plasma, which is rich in proteins such as immunoglobulins, various cytokines, prostaglandins, and interleukins. This fluid is pro-inflammatory, and the evidence regarding its effect on wound healing is varied. Instead of drainage, the burn blister fluid can be aspirated and immediately sprayed over the other areas of the same wound. We found this method feasible as an adjuvant therapy for second-degree superficial burn wounds. In this case report, we share our experience of the same.
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CONTEXT: In today's era of medical advancement, various modalities of treatment options and dressing materials are available for burn wound management. Bilaminar dermal regeneration template is doubtful in developing countries because of its high cost availability and affordability. AIMS AND OBJECTIVES: The aim of this research was to study the use of innovative indigenous cost-effective bilaminar dermal regeneration template in burn raw area. SETTINGS AND DESIGN: This study was conducted in the department of plastic surgery in a tertiary care centre from April 2019 to May 2019. Study design is experimental study.