Clinical anatomy of the lumbar sinuvertebral nerve with regard to discogenic low back pain and review of literature.

PURPOSE: Lumbar discogenic diffuse pain is still not understood. Authors describe the sinuvertebral nerve (SVN) as one possible cause. Body-donor studies are rare and controversial. Therefore, the aim was to revisit the origin, course and distribution in a body-donor study. METHODS: Six lumbar blocks (3 female, 3 male) aged between 59 and 94 years were dissected. After removal of the back muscles, lamina, dura mater and cauda equina, the anterior vertebral venous plexus, spinal artery and SVN were exposed and evaluated. RESULTS: 43 nerves out of 48 levels could be evaluated. The origin of the SVN was constituted by two roots: a somatic and a sympathetic branch arising from the rami communicantes. In 4/48 intervertebral canals studied (8.3%), we found two SVN at the same level. In 35/48 cases, one SVN was found. In 9/48 cases, no SVN was found. The SVN had a recurrent course below the inferior vertebral notch; in the vertebral canal it showed different patterns: ascending branch (31/43, 72.1%), common branch diverging into two branches (10/43, 23.3%), double ascending branch (1/43, 2.3%) finalizing two levels above and a descending branch (1/43, 2.3%). In 12/43 cases (27.9%) the SVN had ipsilateral connections with another SVN. The distribution ended in the middle of the vertebral body supplying adjacent structures. CONCLUSION: A thorough understanding of the anatomy of the SVN might lead to significant benefits in therapy of discogenic low back pain. We suggest blocking the SVN at the level of the inferior vertebral notch of two adjacent segments. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Differences in clinical manifestations and increased severity of systemic lupus erythematosus between two groups of Hispanics: European Caucasians versus Latin American mestizos (data from the RELESSER registry).

BACKGROUND: Systemic lupus erythematosus (SLE) is regarded as a prototype autoimmune disease because it can serve as a means for studying differences between ethnic minorities and sex. Traditionally, all Hispanics have been bracketed within the same ethnic group, but there are differences between Hispanics from Spain and those from Latin America, not to mention other Spanish-speaking populations. OBJECTIVES: This study aimed to determine the demographic and clinical characteristics, severity, activity, damage, mortality and co-morbidity of SLE in Hispanics belonging to the two ethnic groups resident in Spain, and to identify any differences. METHODS: This was an observational, multi-centre, retrospective study. The demographic and clinical variables of patients with SLE from 45 rheumatology units were collected. The study was conducted in accordance with Good Clinical Practice guidelines. Hispanic patients from the registry were divided into two groups: Spaniards or European Caucasians (EC) and Latin American mestizos (LAM). Comparative univariate and multivariate statistical analyses were carried out. RESULTS: A total of 3490 SLE patients were included, 90% of whom were female; 3305 (92%) EC and 185 (5%) LAM. LAM patients experienced their first lupus symptoms four years earlier than EC patients and were diagnosed and included in the registry younger, and their SLE was of a shorter duration. The time in months from the first SLE symptoms to diagnosis was longer in EC patients, as were the follow-up periods. LAM patients exhibited higher prevalence rates of myositis, haemolytic anaemia and nephritis, but there were no differences in histological type or serositis. Anti-Sm, anti-Ro and anti-RNP antibodies were more frequently found in LAM patients. LAM patients also had higher levels of disease activity, severity and hospital admissions. However, there were no differences in damage index, mortality or co-morbidity index. In the multivariate analysis, after adjusting for confounders, in several models the odds ratio (95% confidence interval) for a Katz severity index >3 in LAM patients was 1.45 (1.038-2.026; p = 0.02). This difference did not extend to activity levels (i.e. SLEDAI >3; 0.98 (0.30-1.66)). CONCLUSION: SLE in Hispanic EC patients showed clinical differences compared to Hispanic LAM patients. The latter more frequently suffered nephritis and higher severity indices. This study shows that where lupus is concerned, not all Hispanics are equal.

The peroneocuboid joint: morphogenesis and anatomical study.

The peroneocuboid joint, between the peroneus longus tendon and the cuboid bone, has not been anatomically well-defined and no embryological study has been published. Furthermore, the ossification of the os peroneum (a sesamoid inside the peroneus longus tendon) and its associated pathology has been considered to be generated by orthostatic and/or mechanical loads. A light microscopy analysis of serially sectioned human embryonic and fetal feet, the analysis of human adult feet by means of standard macroscopic dissection, X-ray and histological techniques have been carried out. The peroneus longus tendon was fully visible until its insertion in the 1st metatarsal bone already at embryonic stage 23 (56-57 days). The peroneocuboid joint cavity appeared at the transition of the embryonic to the fetal period (8-9th week of gestation) and was independent of the proximal synovial sheath. The joint cavity extended from the level of the calcaneocuboid joint all the way to the insertion of the peroneus longus tendon in the 1st metatarsal bone. The frenular ligaments, fixing the peroneus longus tendon to the 5th metatarsal bone or the long calcaneocuboid ligament, developed in the embryonic period. The peroneus longus tendon presented a thickening in the area surrounding the cuboid bone as early as the fetal period. This thickening may be considered the precursor of the os peroneum and was similar in shape and in size relation to the tendon, to the os peroneum observed in adults. To the best of our knowledge, this is the first study to show that the os peroneum, articular facets of the peroneus longus tendon and cuboid bone, the peroneocuboid joint and the frenular ligaments appear during the embryonic/fetal development period and therefore they can not be generated exclusively by orthostatic and mechanical forces or pathological processes.

GFAP immunoreactivity within the rat nucleus ambiguus after laryngeal nerve injury.

Changes that occur in astroglial populations of the nucleus ambiguus after recurrent (RLN) or superior (SLN) laryngeal nerve injury have hitherto not been fully characterised. In the present study, rat RLN and SLN were lesioned. After 3, 7, 14, 28 or 56 days of survival, the nucleus ambiguus was investigated by means of glial fibrillary acidic protein (GFAP) immunofluorescence or a combination of GFAP immunofluorescence and the application of retrograde tracers. GFAP immunoreactivity was significantly increased 3 days after RLN resection and it remained significantly elevated until after 28 days post injury (dpi). By 56 dpi it had returned to basal levels. In contrast, following RLN transection with repair, GFAP immunoreactivity was significantly elevated at 7 dpi and remained significantly elevated until 14 dpi. It had returned to basal levels by 28 dpi. Topographical analysis of the distribution of GFAP immunoreactivity revealed that after RLN injury, GFAP immunoreactivity was increased beyond the area of the nucleus ambiguus within which RLN motor neuron somata were located. GFAP immunoreactivity was also observed in the vicinity of neuronal somata that project into the uninjured SLN. Similarly, lesion of the SLN resulted in increased GFAP immunoreactivity around the neuronal somata projecting into it and also in the vicinity of the motor neuron somata projecting into the RLN. The increase in GFAP immunoreactivity outside of the region containing the motor neurons projecting into the injured nerve, may reflect the onset of a regenerative process attempting to compensate for impairment of one of the laryngeal nerves and may occur because of the dual innervation of the posterior cricoarytenoid muscle. This dual innervation of a very specialised muscle could provide a useful model system for studying the molecular mechanisms underlying axonal regeneration process and the results of the current study could provide the basis for studies into functional regeneration following laryngeal nerve injury, with subsequent application to humans.

Expansion of autoreactive unresponsive CD21-/low B cells in Sjögren's syndrome-associated lymphoproliferation.

OBJECTIVE: Primary Sjögren's syndrome (SS) is an autoimmune disease associated with a high risk of developing non-Hodgkin's lymphoma. This study was undertaken to determine the nature of B cells driving lymphoproliferation in primary SS. METHODS: B cell subsets and function were analyzed in peripheral blood from 66 adult patients with primary SS (including 14 patients with B cell lymphoproliferative disease [LPD]) and 30 healthy donors, using flow cytometry, calcium mobilization, and gene array analysis. The reactivity of recombinant antibodies isolated from single B cells from patients with primary SS and LPD was tested using an enzyme-linked immunosorbent assay. RESULTS: We observed an expansion of an unusual CD21-/low B cell population that correlated with lymphoproliferation in patients with primary SS. A majority of CD21-/low B cells from patients with primary SS expressed autoreactive antibodies, which recognized nuclear and cytoplasmic structures. These B cells belonged to the memory compartment, since their Ig genes were mutated. They were unable to induce calcium flux, become activated, or proliferate in response to B cell receptor and/or CD40 triggering, suggesting that these autoreactive B cells may be anergic. However, CD21-/low B cells from patients with primary SS remained responsive to Toll-like receptor (TLR) stimulation. Molecules specifically expressed in CD21-/low B cells that are likely to induce their unresponsive stage were detected in gene array analyses. CONCLUSION: Patients with primary SS who display high frequencies of autoreactive and unresponsive CD21-/low B cells are susceptible to developing lymphoproliferation. These cells remain in peripheral blood controlled by functional anergy instead of being eliminated, and chronic antigenic stimulation through TLR stimulation may create a favorable environment for breaking tolerance and activating these cells.

Variations of the radial recurrent artery of clinical interest.

PURPOSE: The anatomy of the radial recurrent artery (RRA) is important for different clinical procedures: interventional cardiology and microsurgery of the forearm; however, few studies have analysed its morphology: number, course, relations and distribution. METHODS: The RRA was analysed in 332 upper limbs divided into two groups: (1) normal pattern of the arterial axis of the upper limb (266 cases), (2) associated with major arterial variations (66 cases). RESULTS: A second or accessory RRA existed in 31.2 % in group 1, and 30.3 % in group 2. In both groups, the second RRA originated from the brachial (100 %) and always (100 %) coursed behind the bicipital tendon. The accessory RRA supplied the brachioradialis, brachialis and biceps brachii muscles. The RRA in group 1, originated mostly from the radial artery (75 %), followed by radioulnar division and ulno-interosseous trunk. In group 2, the RRA arise from the brachioradial artery (65 %), or from the radial artery (in cases of ulnar or brachial artery variation). The course of the RRA behind the biceps brachii tendon was observed in 9.4 % of group 1 and in 6.1 % of group 2. The RRA supplied the brachioradialis, extensor carpi radialis longus and brevis, and supinator muscles. The RRA and accessory RRA anastomosed forming a ring around the biceps brachii tendon in 0.75 % in group 1 and in 13.6 % in group 2, the latter group having an important clinical interest. CONCLUSIONS: The variability of the RRA may provide an advantage for microsurgical procedures of the elbow and disadvantage during transradial catheterism.

Logistics description of a high yield cataract surgery non-profitable expedition.

PURPOSE: To describe the logistics and methodology of a high yield surgical non-profitable campaign. METHODS: A descriptive study based on previous non-profitable campaigns dedicated to cataract surgery. RESULTS: The method is based on planification, finance acquisition, volunteer support, foreign affairs with the collaborating country where the surgeries are going to be performed, team organization, and overall, summoning all the stated items to materialize a global humanitarian campaign to eradicate cataracts by clinical and surgical procedures. CONCLUSIONS: Blindness due to cataracts can be over-ruled. We consider that through our planification and methodology, other organizations may acquire some knowledge to improve their methodology and carry out similar volunteering surgical campaigns. Planification, coordination, financial aid, determination, and a strong will power are altogether compulsory for a successful non-profitable surgical campaign.

ABCB1 gene variants as risk factors and modulators of age of onset of demyelinating disease in Mexican patients.

INTRODUCTION: The C1236T, G2677T/A, and C3435T variants of the ABCB1 gene alter the functioning of P-glycoprotein and the transport of endogenous and exogenous substances across the blood-brain barrier, and act as risk factors for some neurodegenerative diseases. This study aimed to determine the association between demyelinating disease and the C1236T, G2677T/A, and C3435T variants of ABCB1 and its haplotypes and combinations of genotypes. METHODS: Polymerase chain reaction with restriction fragment length polymorphism analysis (PCR-RFLP) and Sanger sequencing were used to genotype 199 patients with demyelinating disease and 200 controls, all Mexicans of mixed race; frequencies of alleles, genotypes, haplotypes, and genotype combinations were compared between patients and controls. We conducted a logistic regression analysis and calculated chi-square values and 95% confidence intervals (CI); odds ratios (OR) were calculated to evaluate the association with demyelinating disease. RESULTS: The TTT and CGC haplotypes were most frequent in both patients and controls. The G2677 allele was associated with demyelinating disease (OR: 1.79; 95% CI, 1.12-2.86; P =  .015), as were the genotypes GG2677 (OR: 2.72; 95% CI, 1.11-6.68; P =  .025) and CC3435 (OR: 1.82; 95% CI, 1.15-2.90; P =  .010), the combination GG2677/CC3435 (OR: 2.02; 95% CI, 1.17-3.48; P =  .010), and the CAT haplotype (OR: 0.21; 95% CI, 0.05-0.66; P =  .001). TTTTTT carriers presented the earliest age of onset (23.0 ±â€¯7.7 years, vs 31.6 ±â€¯10.7; P =  .0001). CONCLUSIONS: The GG2677/CC3435 genotype combination is associated with demyelinating disease in this sample, particularly among men, who may present toxic accumulation of P-glycoprotein substrates. In our study, the G2677 allele of ABCB1 may differentially modulate age of onset of demyelinating disease in men and women.

Concern about COVID-19 among the Spanish population: Validation of a scale and associated symptoms.

BACKGROUND: The health crisis caused by the COVID-19 pandemic has led to a considerable increase in the psychopathology of COVID-19 patients and among the general population. This study aims to conduct the psychometric analysis of the scale of concern about COVID-19 in the Spanish population and to estimate the level of concern and dysfunctional anxiety present one year after the lockdown measures in Spain aimed at resisting the spread of the viral disease among the population. METHODS: The factorial structure of the instrument, its reliability for the general population and for COVID patients, and its construct validity have been analyzed, and measurements of dysfunctional concern have been obtained from a sample of 502 adults. RESULTS: The scale of concern about COVID-19 showed optimal results of reliability and validity for the Spanish population, confirming that it is an ideal instrument for estimating the concern regarding coronavirus contagion. LIMITATIONS: This study used a cross-sectional design and thus, could not compare the changes in the incidence of anxiety symptoms before and after the COVID-19 outbreak. Furthermore, the use of mental health services prior to the COVID-19 restrictions was not assessed in this study, and therefore, no comparisons between the two time points could be made. CONCLUSIONS: After a year of the confinement measures that was instilled to avoid further spread of the disease, the Spanish population presented levels of concern and anxiety that may require clinical attention, with a significant percentage of participants meeting the requirements to be diagnosed with generalized anxiety disorders.

The carotid axis revisited.

The aim was to determine the variations in the level of origin of carotid bifurcation and diameters of the common, internal, and external carotid arteries which is clinically important for several interventional procedures. Therefore, 165 human embalmed corpses were dissected. The data collected were analyzed using the Chi square-test and the Pearson correlation test. The results of previous studies have been reviewed. In relation to the level of the carotid bifurcation, taking as a reference point the hyoid bone, the values ranged from 4 cm below the hyoid body to 2.5 cm above the body of the hyoid, being the average height-0.33 cm, with a standard deviation of 1.19 cm. The right carotid bifurcation was established at a higher level (x = - 0.19 cm.) than the left one (x = - 0.48 cm.) (p = 0.046). On the contrary, no significant gender differences could be observed. The arterial calibres of the common and internal carotid arteries were higher in male than female. In the internal carotid artery (X = 0.76 cm.), the left was greater than the right (X = 0.72 cm.) (P = 0.047). However, no differences in the distribution of the calibre of the external carotid artery were found neither by side nor gender. Variations in the level of bifurcation and calibres of carotid arteries are relevant for interventional radiology procedures and head and neck surgeries. Knowledge of these anatomical references might help clinicians in the interpretation of the carotid system.

Perceived discrimination in patients with multiple sclerosis and depressive symptomatology.

BACKGROUND: Multiple Sclerosis is the central nervous system's most common demyelinating disease and the second leading cause of neurological disability in young adults. Its natural development involves physical and cognitive impairment. Patients commonly perceive discrimination against them, regardless of its occurrence, accepting it as an inherent part of the disease. OBJECTIVE: This study aimed to determine the association between perceived discrimination and the depressive symptoms and physical disability present in patients diagnosed with multiple sclerosis, treated at the Demyelinating Diseases Clinic of the National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez. METHODS: A cross-sectional study was conducted in 98 patients diagnosed with multiple sclerosis. Demographic and clinical variables were obtained through clinical interviews. The severity of the disease was determined using the Extended Disability Status Scale (EDSS), depressive symptoms were assessed with the Beck Depression Inventory (BDI), and perceived discrimination was rated using the King Internalized Stigma Scale. RESULTS: The studied sample's mean age was 36.3 years, schooling 13.6 years, symptoms onset was at 26.2 years (with a delay in diagnosis of 3.2 years), and a disease evolution of 10.9 years. 71.4% were single; 52% had an unpaid work activity and 57.1% were women. The EDSS average was 3.5 points; 24.5% presented moderate to severe depressive symptoms and 53.1% referred perceived discrimination. CONCLUSIONS: Perceived discrimination in patients with multiple sclerosis was associated with earlier disease onset, depressive symptoms, and the lack of caregivers. Medical care and life quality improvement for this vulnerable group require greater education regarding the disease and the establishment of patient support programs.

ABCB1 gene variants as risk factors and modulators of age of onset of demyelinating disease in Mexican patients. / Variantes del gen ABCB1 como factores de riesgo y factores moduladores de la edad de inicio en pacientes mexicanos con enfermedad desmielinizante.

INTRODUCTION: The C1236T, G2677T/A, and C3435T variants of the ABCB1 gene alter the functioning of P-glycoprotein and the transport of endogenous and exogenous substances across the blood-brain barrier, and act as risk factors for some neurodegenerative diseases. This study aimed to determine the association between demyelinating disease and the C1236T, G2677T/A, and C3435T variants of ABCB1 and its haplotypes and combinations of genotypes. METHODS: Polymerase chain reaction with restriction fragment length polymorphism analysis (PCR-RFLP) and Sanger sequencing were used to genotype 199 patients with demyelinating disease and 200 controls, all Mexicans of mixed race; frequencies of alleles, genotypes, haplotypes, and genotype combinations were compared between patients and controls. We conducted a logistic regression analysis and calculated chi-square values and 95% confidence intervals (CI); odds ratios (OR) were calculated to evaluate the association with demyelinating disease. RESULTS: The TTT and CGC haplotypes were most frequent in both patients and controls. The G2677 allele was associated with demyelinating disease (OR: 1.79; 95% CI: 1.12-2.86; P=.015), as were the genotypes GG2677 (OR: 2.72; 95% CI: 1.11-6.68; P=.025) and CC3435 (OR: 1.82; 95% CI: 1.15-2.90; P=.010), the combination GG2677/CC3435 (OR: 2.02; 95% CI, 1.17-3.48; P=.010), and the CAT haplotype (OR: 0.21; 95% CI: 0.05-0.66; P=.001). TTTTTT carriers presented the earliest age of onset (23.0±7.7 years, vs. 31.6±10.7; P=.0001). CONCLUSIONS: The GG2677/CC3435 genotype combination is associated with demyelinating disease in this sample, particularly among men, who may present toxic accumulation of P-glycoprotein substrates. In our study, the G2677 allele of ABCB1 may differentially modulate age of onset of demyelinating disease in men and women.

[Fracture and embolization of implantable subclavian venous catheter fragments due to costoclavicular compression: pinch-off syndrome]. / Sección y embolización de catéter permanente por síndrome de pinzamiento costoclavicular (pinch-off).

The fracture of an implantable subclavian venous access device and the subsequent embolization of a catheter fragment is a known complication that is usually associated with a set of clinical and radiologic signs of costoclavicular compression. This scenario is also known as pinch-off syndrome. We describe 2 cases of venous port fracture which led us to review the efficacy of follow-up procedures used in our hospital. As a result, we added instructions for radiologic and clinical verification of catheter placement, taking into consideration the dynamic nature of compression. We also established protocols for coordinating the involvement of different services.

Quality of life in patients with multiple sclerosis and its association with depressive symptoms and physical disability.

OBJECTIVE: The aim of this work was to evaluate the quality of life of patients with multiple sclerosis and its association with depressive symptoms and physical health. METHOD: A total of 117 patients clinically diagnosed with Multiple Sclerosis (MS) were studied. The MSQOL-54 scale was applied. The depressive symptoms were assessed using the Beck Depression Inventory (BDI), while degree of physical disability was evaluated with the EDSS (Expanded Disability Status Scale). The results of these last two instruments were associated with MSQOL-54 to determine its influence on the perception of quality of life. RESULTS: We evaluated 65 women (56%) and 52 men (44%), with a mean age of 35 years, a mean age of 27 years at the time of diagnosis, and a mean evolution of 8 years. 88% of the patients showed the relapsing-remitting subtype; 42% had paid employment; 29% of the studied patients required help to perform daily activities; 75% took disease-modifying medications. They obtained on average a score of 3.62 ±â€¯2.30 on the EDSS and 11.5 ±â€¯9.21 on the BDI. The general average in MSQOL-54 was 64.67 ±â€¯17.52. CONCLUSIONS: Quality of life, in patients with multiple sclerosis is an issue that worries health personnel, it is essential to implement strategies for reducing the impact of the disease on patients' lives, mainly through the application of programs aimed to decrees depression and improve social support.

Metacarpophalangeal portal safety. An anatomical study. / Seguridad de los portales metacarpofalángicos. Estudio anatómico.

AIM: To quantify the risk of dorsal innervation injury when performing direct metacarpophalangeal joint portals of the second to fifth fingers. MATERIAL AND METHOD: An anatomical study of 11 upper limbs of fresh corpses was carried out. After placing them in a traction tower, the metacarpophalangeal portals were developed on both sides of the extensor tendon. The dorsal sensory branches were dissected and the distances between the portal and the nearest nerve were measured by a digital caliper. The portals of all the fingers were compared globally to assess the safest finger and two to two radial and ulnar portals were compared in each of the fingers to assess the safest portal within each finger. RESULTS: The overall comparison of all portals and fingers showed that the third finger is the safest in any of its portals, while the ulnar side of the second and radial of the fourth are the portals with the highest risk of nerve injury (P=8.96·10-5). Comparing two to two of the radial and ulnar portals in each of the fingers showed that the ulnar portal is safer than the radial on the fourth finger (P=.042), while the radial is safer than the ulnar on the fifth finger (P=.003). CONCLUSIONS: The third finger was the safest to perform metacarpophalangeal portals, while the ulnar side of the second finger and radial side of the fourth had the highest risk of nerve injury.