Differential diagnosis of a rare case of upper limb pain: Paget-Schroetter syndrome in a doner kebab chef

[Purpose] Paget-Schroetter syndrome (PSS) is an uncommon deep vein thrombosis of the axillary and subclavian veins which may occur spontaneously, but is usually caused by excessive upper limb activity. PSS is clinically similar to other upper limb musculoskeletal disorders and soft tissue infections, and this may lead to delay in correct diagnosis in its early stages. The aim of our case report is to discuss this rare condition with reference to the available literature. [Subjects and Methods] Here we report the case of a doner kebab chef who complained of swelling and pain in his right arm around the biceps muscle. The initial diagnosis was biceps tendon rupture, for which the patient underwent magnetic resonance imaging (MRI) of the right arm and shoulder. Since the MRI revealed no pathological findings, right upper limb venous Doppler ultrasound analysis was performed. Subacute thrombosis materials were detected in the subclavian, axillary, and brachial veins. [Results] With rapid anticoagulant therapy, the patient’s symptoms quickly improved. [Conclusion] Early diagnosis and treatment of PSS is critical for preventing potentially fatal complications such as pulmonary embolism. Prophylaxis is important for preventing recurrent thrombosis and for avoiding the development of post-thrombotic syndrome. PSS should be considered a possible cause of painful swelling of the upper limbs, especially in young, active patients who use their arms excessively.Key words: Doner kebab chef, Effort thrombosis, Paget-Schroetter syndrome     

Navigational area of the cranio-orbital foramen and its significance in orbital surgery

The cranio-orbital foramen (COF) is located on the lateral wall of the orbit. It is a potential source of hemorrhage during deep lateral orbital dissection, since it functions as an anastomosis between the lacrimal artery and the middle meningeal artery. The aim of this study was to guide and facilitate the surgical procedures in the orbit, so as to determine a navigational area and the precise location of the COF and to standardize certain anatomical marks. The navigational area of the COF and topographical features were studied in 75 craniums with presented COF. 33 bilateral main COFs, 41 (18 on the right, 23 on the left) unilateral main COFs at the main cranium and 19 accessory COFs were studied for their navigational features on the orbit. The distances between the COF and the fronto-zygomatic suture, supraorbital notch, lateral angle of the superior orbital fissure (SOF) and Whitnall’s tubercle were measured. The mean distance of the COF from the fronto-zygomatic suture, supraorbital notch, lateral angle of the SOF and Whitnall’s tubercle was 26.3, 37.3, 92 and 27.1 mm, respectively. For the navigational area signs of the COF, areas of the orbit that form the transversal and vertical lines are generated on the reference points. Whilst the upper outer area of the orbit contains a potential bleeding risk, the bottom section of the outer column is identified as safe for the surgical operations of the lateral orbital wall. The fronto-zygomatic suture and Whitnall’s tubercle are recommended as the most reliable navigational landmarks for identifying the COF. Hence, the transversal and vertical orientation of the COF should be mastered by the surgeons reconstructing the anterior base of the skull and the orbit.     

Risk Factors of Germinal Matrix Intraventricular Hemorrhage in Premature Infants

Objective

To determine whether some clinical parameters can be used to predict the hemorrhage and whether the relationship between these clinical variables and the grades of hemorrhage is linear.

Methods

A total of 230 premature infants, born at a gestational age less than 34 weeks were retrospectively reviewed. Germinal matrix-intraventricular hemorrhage (GM-IVH), the grade of the hemorrhage, and clinical data were assessed with a checklist. Variables were analyzed by using Mann Whitney U and Fisher’s exact tests and then multiple logistic regression analysis was used to evaluate the independent risk factors.

Findings

Resuscitation, gestational age, hypotension, multiple birth, and birth weight were found to be independent risk factors. We determined non-linear relationship between the grades of hemorrhage and the clinical parameters. But when we classified hemorrhages as grade 1, grade 2-3 and grade 4, the relationships were found linear.

Conclusion

Premature infants who had resuscitation, low gestational age, hypotension, multiple birth, and low birth weight are more likely to have GM-IVH. The relationship between the clinical variables and the grades of GM-IVH does not seem to be linear.     

MicroRNAs bind to Toll-like receptors to induce prometastatic inflammatory response

MicroRNAs (miRNAs) are small noncoding RNAs, 19-24 nucleotides in length, that regulate gene expression and are expressed aberrantly in most types of cancer. MiRNAs also have been detected in the blood of cancer patients and can serve as circulating biomarkers. It has been shown that secreted miRNAs within exosomes can be transferred from cell to cell and can regulate gene expression in the receiving cells by canonical binding to their target messenger RNAs. Here we show that tumor-secreted miR-21 and miR-29a also can function by another mechanism, by binding as ligands to receptors of the Toll-like receptor (TLR) family, murine TLR7 and human TLR8, in immune cells, triggering a TLR-mediated prometastatic inflammatory response that ultimately may lead to tumor growth and metastasis. Thus, by acting as paracrine agonists of TLRs, secreted miRNAs are key regulators of the tumor microenvironment. This mechanism of action of miRNAs is implicated in tumor-immune system communication and is important in tumor growth and spread, thus representing a possible target for cancer treatment.     

Pregnancy and liver adenoma management: PALMstudy

ABSTRACT: BACKGROUND: Hepatocellular adenoma (HCA) in pregnant women requires special considerations because of the risk of hormone induced growth and spontaneous rupture, which may threaten the life of both mother and child. Due to scarcity of cases there is no evidence-based algorithm for the evaluation and management of HCA during pregnancy. Most experts advocate that women with HCA should not get pregnant or advise surgical resection before pregnancy. Whether it is justified to deny a young woman a pregnancy, as the biological behavior may be less threatening than presumed depends on the incidence of HCA growth and the subsequent clinical events during pregnancy. We aim to investigate the management and outcome of HCA during pregnancy and labor based on a prospectively acquired online database in the Netherlands. Methods/design The Pregnancy And Liver adenoma Management (PALM) - study is a multicentre prospective study in three cohorts of pregnant patients. In total 50 pregnant patients, [greater than or equal to] 18 years of age with a radiologically and/or histologically proven diagnosis of HCA will be included in the study. Radiological diagnosis of HCA will be based on contrast enhanced MRI. Lesions at inclusion must not exceed 5 cm. The study group will be compared to a healthy control group of 63 pregnant patients and a group of 63 pregnant patients with diabetes mellitus without HCA. During their pregnancy HCA patients will be closely monitored by means of repetitive ultrasound (US) at 14, 20, 26, 32 and 38 weeks of gestation and 6 and 12 weeks postpartum. Both control groups will undergo US of the liver at 14 weeks of gestation to exclude HCA lesions in the liver. All groups will be asked to fill out quality of life related questionnaires. DISCUSSION: The study will obtain information about the behaviour of HCA during pregnancy, the clinical consequences for mother and child and the impact of having a HCA during pregnancy on the health related quality of life of these young women. As a result of this study we will propose a decision-making model for the management of HCA during pregnancy. Trial registration Dutch trial register: NTR3034.     

nNOS expression in the brain of rats after burn and the effect of the ACE inhibitor captopril

Objective

To investigate the role of endogenous neuronal nitric oxide synthase (nNOS) on brain injury after burn and the effects of the captopril.

Methods

Wistar albino rats (200–250 g) were exposed on the dorsal surface to 90 °C (burn) or 25 °C (sham) water for 10 s. The ACE group was treated with intraperitoneal 10 mg/kg captopril immediately after burn and this treatment was repeated twice daily. At the end of the 24 h brain samples were taken. nNOS was studied in brain areas by immunohistochemistry.

Results

There was no difference between the cerebellar and hypothalamic areas the nNOS expression of all groups. nNOS expression increased in the frontal cortex, striatum and midbrain in the burn group compared to the control group. In the frontal cortex, nNOS expression significantly decreased after ACE inhibitor treatment (p < 0.05). The striatal nNOS of the ACE group significantly increased when compared to the control group (p = 0.001). In the midbrain of the animals, nNOS decreased in the ACE group. Hippocampal nNOS expression did not change after burn and significantly increased after ACE inhibitor therapy (p < 0.05).

Conclusions

Our data showed that the pathophysiological events following burn appear to be related to an acute inflammatory reaction which is associated with nNOS in the frontal cortex, striatum and midbrain, and captopril treatment abrogates the nNOS response in the frontal cortex and midbrain.     

Comparison of microscopic (pT3a) and gross extravesical extension (pT3b) in pathological staging of bladder cancer: analysis of patient outcomes

Objective

To determine the prognostic value of pT3 bladder urothelial carcinoma substaging in patients without lymphatic involvement.

Patients and methods

Pathologic and clinical data were reviewed on patients who underwent radical cystectomy for urothelial carcinoma between 1991 and 2010. Of the 460 reviewed patients, 74 patients were diagnosed with pathologic T3No urothelial carcinoma of the bladder. The impact of pathologic substaging (pT3a vs. pT3b) was examined to determine the effect on overall and disease-specific survival.

Results

Five years disease-specific and overall survival rates were 46.9 % and 39.6 % for patients with pT3aNo tumor, whereas these ratios were 34.4 and 30.3 %, respectively, for patients with pT3bNo tumor (p > 0.05). Mean disease-specific survival time was 43.94 ± 6.50 months for pT3aNo, while it was 39.01 ± 7.19 months for pT3bNo (p = 0.539). In multivariate cox regression analysis, age (p = 0.459), gender (p = 0.710), urinary diversion type (p = 0.088), and pT3 substaging (p = 0.554) were not noticed as an independent predictive factor for survival.

Conclusion

Macroscopic extravesical extension (pT3b) is not associated with a worse outcome than pT3a disease in lymph node-negative cases of bladder urothelial carcinoma.     

Dehiscence and fenestration in patients with different vertical growth patterns assessed with cone-beam computed tomography

Abstract Objective: To test the null hypothesis that the presence of alveolar defects (dehiscence and fenestration) was not different among patients with different vertical growth patterns. Materials and Methods: A total of 1872 teeth in 26 hyper-divergent (mean age: 24.4 ± 4.8?years), 27 hypo-divergent (mean age: 25.1 ± 4.5?years), and 25 normo-divergent (mean age: 23.6 ± 4.1?years) patients with no previous orthodontic treatment were evaluated using cone-beam computed tomography. Axial and cross-sectional views were evaluated with regard to whether dehiscence and/or fenestration on buccal and lingual surfaces existed or not. For statistical analysis, the Pearson chi-square test was used at a P < .05 significance level. Results: According to the statistical analysis, the hypo-divergent group (6.56%) had lower dehiscence prevalence than the hyper-divergent (8.35%) and normo-divergent (8.18%) groups (P = .004). Higher prevalences of dehiscence and fenestration were found on buccal sides in all vertical growth patterns. While fenestration was a common finding for the maxillary alveolar region, dehiscence was a common finding in the mandible in all groups. Conclusion: The null hypothesis was rejected. Although the prevalence of fenestrations was not different, significant differences for dehiscences were found in patients with different vertical growth patterns.