Comprehensive Musculoskeletal Sonographic Evaluation of the Hand and Wrist

Sonography is widely used for evaluation of hand and wrist lesions. The easy accessibility, cost‐effectiveness, and good diagnostic accuracy of sonography coupled with the numerous benefits of real‐time imaging make it desirable. The aim of this article is to describe the typical sonographic appearances of lesions in the hand and wrist that are encountered frequently in routine clinical practice, such as inflammatory arthropathies, tumors, traumatic injuries, foreign bodies, and nerve entrapment syndromes. Relevant anatomy, scanning methods, and recent developments in musculoskeletal sonography are also discussed.     

Prevalence of cerebral venous thrombosis with the use of oral contraceptive pills during the Holy month of Ramadan

Objectives:To identify the epidemiologic profile of cerebral vein thrombosis (CVT) among fasting women using oral contraceptive pills (OCPs) during the holy month of Ramadan.Methods:This retrospective study was conducted on all patients diagnosed with CVT and using OCPs from records at a tertiary care hospital in Riyadh, Saudi Arabia during 2016-2017. The study participants were categorized into 2 groups (an intermittently fasting group during the holy month of Ramadan and a non-fasting group).Results:Out of 108 female patients with CVT, 36.1% were secondary to OCP, of whom 41% participants were fasting. The most affected site was the transverse sinus. Holocephalic headache was more common amongst fasting group (68.8%) compared to non-fasting group (30.4%) (p=0.025). Dehydration (p=0.003) amongst the fasting group and protein S deficiency (p=0.027) in the non-fasting group were identified as the 2 prominent risk factors. Unfractionated heparin was the most common anticoagulant therapies used during the initiation phase for non-fasting (36.4%) and fasting groups (50%).Conclusion:All women who are using OCP should undergo formal written risk assessments for factors of CVT. Our study suggests that the negative effects of OCPs use might outweigh its benefits; thus, it should be prescribed with caution, more so in fasting patients.     

Clusterin expression is significantly enhanced in prostate cancer cells following androgen withdrawal therapy

INTRODUCTION AND OBJECTIVES: Progression of prostate cancer to androgen independence (AI) results in part from the upregulation of anti-apoptotic genes following androgen withdrawal, and androgen-independent disease remains the primary obstacle to improved survival. Testosterone-repressed prostate message-2 (TRPM-2) encodes the anti-apoptotic protein clusterin, which is upregulated in response to cellular compromise as observed in normal and malignant tissues undergoing apoptosis. Systemic administration of antisense clusterin oligonucleotides in prostate cancer xenograft models delays progression to AI and enhances chemosensitivity. The objective of this study was to define changes in clusterin expression following neoadjuvant hormone therapy (NHT) in prostate cancer patients. MATERIALS AND METHODS: Archival radical prostatectomy (RP) specimens were obtained for 128 patients who received either no NHT or treatment for 2-8 weeks, 3 months, or 8 months. Paired needle biopsy specimens were acquired for 30 patients and all tissues were subjected to clusterin immunohistochemistry. Western blot analysis was performed on frozen tissue from 5 untreated and 5 treated patients. RESULTS: Clusterin expression in malignant prostatic tissue was significantly greater in patients who underwent preoperative NHT (P < 0.001). Needle biopsies obtained prior to NHT consistently demonstrated lower staining intensity than corresponding RP specimens (P < 0.001). Western blot analysis confirmed clusterin levels increased 17-fold beginning within 4 weeks after androgen withdrawal. CONCLUSIONS: Upregulation of clusterin levels following androgen ablation therapy may represent an adaptive cell survival response following apoptotic signals like androgen withdrawal. These findings support clusterin as a valid therapeutic target in strategies employing novel multimodality therapy for advanced prostate cancer.     

Laparoscopic-Assisted Management of Impalpable Testis in Patients Older than 10 Years

Objective:

Cryptorchidism affects 1% of male births. The majority of patients with undescended testis are identified and treated in childhood, but a significant proportion of them especially in third-world countries are neglected and present late. Herein, we present our initial experience of managing impalpable testis in older children and adults with laparoscopic assistance.

Patients and Methods:

This study was conducted from 2003 through 2008 at LUMHS Jamshoro. Thirty-two patients with 40 impalpable testes were included in this study. Diagnostic laparoscopy was performed in 32 anesthetized patients. Laparoscopic-assisted orchiopexy or orchiectomy was performed in patients with intraabdominal testis. Testicular vessels and vas deferens were mobilized and after obtaining sufficient length were brought through the posterior wall of the inguinal canal by creating a neo-inguinal ring medial to the epigastric vessels after a small inguinal incision.

Results:

Of 40 impalpable testis, ultrasound localized 16 (40%) of them, and on laparoscopy, 36 (90%) were localized, 30 (75%) as intraabdominal and in 6 (15%) cases vas and vessels were entering into the internal inguinal ring (intracanalicular). The remaining 4 patients were diagnosed as having vanishing testis (anorchia). Laparoscopic orchiectomy was performed in 14 (35%) of these testes, while single-stage laparoscopic-assisted orchiopexy using Prentiss'' maneuver was performed in 16 (40%) testis. No major complications occurred. Seven testes were associated with ipsilateral hernias and were simultaneously repaired laparoscopically.

Conclusion:

Laparoscopic-assisted single-stage orchiopexy is a safe and successful procedure for intraabdominal testis in adolescents and older patients. The additional benefit of shortening the usual course of spermatic cord was beneficial to fix the testis in the scrotum without tension.     

The reverse epidemiology of plasma total homocysteine as a mortality risk factor is related to the impact of wasting and inflammation.

BACKGROUND: The reason(s) for the apparently paradoxical 'reverse' association in end-stage renal disease (ESRD) patients in whom a low, rather than a high, total plasma total homocysteine (tHcy) level is an indicator of poor outcome remains unclear. The aim of this study was to examine whether the inverse association maintains, mitigates or reverses after comprehensive multivariate adjustment for the presence of wasting and inflammation as well as other potential confounders. METHODS: We studied 317 ESRD patients starting dialysis therapy. Fasting blood samples were taken for the analyses of tHcy, serum albumin, C-reactive protein (CRP), serum creatinine and plasma folate. Nutritional status was assessed by subjective global assessment (SGA). Survival was followed for up to 66 months; 105 patients died. RESULTS: Using Kaplan-Meier analysis, a low tHcy concentration (< or =30 micromol/l) was associated with higher all-cause and cardiovascular (CV) mortality (P < 0.05). Using Cox proportional analysis adjusting for age, gender, glomerular filtration rate = GFR, cardiovascular disease = CVD, plasma folate, total cholesterol and diabetes mellitus, the all-cause and CV mortality still tended to be high for patients with low tHcy. Adding nutritional and inflammation markers (Body mass index = BMI, SGA, serum creatinine, serum albumin and CRP), a low tHcy level was no longer associated with higher mortality but a trend for high tHcy was observed. CONCLUSIONS: The link between wasting inflammation and a low tHcy appears to be responsible for the reverse association between plasma tHcy and clinical outcome in ESRD patients. After adjustment for confounders including nutritional and inflammation markers, a trend towards increased death risk for high, rather than low, tHcy levels was apparent after adjustment.     

Muscle Strength and Damage Following Two Modes of Variable Resistance Training

Nautilus Machine (NM) and Elastic Resistance (ER) have gained considerable popularity among athletes and recreational lifters seeking to increase muscle strength. However, there is controversy concerning the use of ER for increasing muscle hypertrophy and strength among healthy-trained individuals. The aim of the study was to compare the effect of repeated near maximal contractions by ER/NM on indicators of muscle damage including: maximal strength decrement (MVIC), rate of muscle soreness (DOMS), concentration of plasma creatine kinase (CK) and increased high muscle signal on T2 weighted images using magnetic resonance imaging (MRI). Nine healthy male subjects completed two modalities of exercise (5 sets × 10RM ER/NM) in a counterbalance cross-over study design with three weeks “wash-out” period between experiments. The MVIC was measured and DOMS rated and recorded for 4 consecutive days while blood samples were collected on day 1, 3, 5 and 7. Prior to and forty eight hours after completion of each mode of exercise, subjects underwent MRI scanning. The average of applied forces demonstrated significantly higher value for NM compared with ER (362 ± 34.2 N vs 266.73 ± 44.6 N respectively) throughout the 5 sets of dynamic exercise (all p < 0.05). However, the indicators of muscle damage (T2 relaxation time, DOMS, MVIC and serum CK) exhibited a very similar response across both modes of training. Plasma CK increased significantly following both modes of training with the peak value on Day 3 (p < 0.05). The time course of muscle soreness reached a significant level after both modes of exercise and showed a peak value on the 2^nd day (p < 0.05). The T2 relaxation time demonstrated a statistically significant increase following ER and NM compared with the pre-test value (p < 0.05). The similarity of these responses following both the ER and NM exercise training session suggests that both modes of training provide a similar training stress; despite a considerably lower external force generation during ER. The importance of these findings is underlined by the fact that exercise-induced muscle damage has been shown to be the underlying mechanism of further muscle hypertrophy.

Key points

• Exercise induced muscle soreness increased levels of plasma CK, increased MRI T2 signal and prolonged strength loss indicate the moderate to intense nature of the training protocol.
• The similarity of these responses following both the Elastic Resistance and Nautilus Machine exercise training session suggests that both modes of training provide a similar training stress; despite a considerably lower external force generation during ER.
• The data in the present study suggest elastic training is a viable mode of resistance exercise that can provide a training stimulus greater than that employed in rehabilitation settings.

Key words: Elastic resistance training, magnetic resonance imaging, muscle strain, muscle hypertrophy     

Renal allograft biopsies in the era of C4d staining: the need for change in the Banff classification system.

C4d immunostaining in the peritubular capillaries (PTC) is a marker of antibody-mediated rejection (AMR). We evaluated the histopathologic diagnoses of 388 renal transplant biopsies since the implementation of routine C4d immunostaining at our center. Of these, 155 (40%) biopsies had evidence of acute cellular rejection (ACR), out of which 119 (77%) had pure ACR, 31 (20%) had ACR with concomitant features of AMR, and five (3%) had ACR with focal C4d staining. Sixty-four (16%) biopsies exhibited features of AMR [33 (52%) pure AMR, and 31(48%) concomitant AMR and ACR]. One hundred and fifty-five (40%) biopsies had features of interstitial fibrosis and tubular atrophy (IFTA). Of these, 20 (13%) had concomitant AMR [13 (8.5%) had pure AMR and seven (4.5%) had concomitant ACR and AMR]. Creatinine at the time of biopsy was higher in patients with mixed ACR and AMR and the clinical behavior of mixed lesions is more aggressive over time. Despite having a lower serum creatinine at the time of biopsy, patients with IFTA experienced gradual decline in graft function over time. The pathologic findings in renal allograft biopsies are often mixed and mixed lesions appear to have more aggressive clinical behavior. These findings suggest the need for change in the Banff classification system to better capture the complexity of renal allograft pathologies.     

The preventative analgesic effect of preincisional peritonsillar infiltration of two low doses of ketamine for postoperative pain relief in children following adenotonsillectomy. A randomized, double-blind, placebo-controlled study

Background:  In literature, the use of ketamine for the preventative analgesia in the management of postoperative pain is controversial. The purpose of the present study was the clinical assessment of the efficacy of preincisional peritonsillar infiltration of two doses of ketamine on postoperative pain relief compared with peritonsillar saline in children undergoing adenotonsillectomy.
Methods/materials:  Seventy-five ASA physical status I and II patients, aged 3–12 years, scheduled for adenotonsillectomy were enrolled in this randomized, double-blind, placebo-controlled study. Patients were divided into three groups of 25 each and received a local peritonsillar infiltration of 0.9% saline (group S), ketamine 0.5 mg·kg⁻¹ (group K1), or ketamine 1 mg·kg⁻¹ (group K2). All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale were used to evaluate pain levels and sedative conditions, respectively.
Results:  Group S had significantly higher CHEOPS scores than group K1 and K2. Both K1 and K2 groups had comparable scores, which were not statistically significant ( P  > 0.05). During 24 h after surgery, 16 patients in group S and no patients in groups K1 or K2 needed analgesics ( P  <   0.001).
Conclusions:  A 0.5 or 1 mg·kg⁻¹ dose of ketamine given at approximately 3 min before surgery by peritonsillar infiltration provides efficient pain relief during 24 h after surgery without side-effects in children undergoing adenotonsillectomy.