Friday, October 30, 2020

Puerarin improves the bone micro-environment to inhibit OVX-induced osteoporosis via modulating SCFAs released by the gut microbiota and repairing intestinal mucosal integrity

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Publication date: December 2020

Source: Biomedicine & Pharmacotherapy, Volume 132

Author(s): Bo Li, Mingyan Liu, Yu Wang, Shiqiang Gong, Weifan Yao, Wenshuai Li, Hua Gao, Minjie Wei

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Kanglexin accelerates diabetic wound healing by promoting angiogenesis via FGFR1/ERK signaling

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Publication date: December 2020

Source: Biomedicine & Pharmacotherapy, Volume 132

Author(s): Yixiu Zhao, Xinhui Wang, Shuang Yang, Xia Song, Na Sun, Chao Chen, Yannan Zhang, Dahong Yao, Jian Huang, Jinhui Wang, Yan Zhang, Baofeng Yang

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Aspirin modified strontium-doped β-tricalcium phosphate can accelerate the healing of femoral metaphyseal defects in ovariectomized rats

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Publication date: December 2020

Source: Biomedicine & Pharmacotherapy, Volume 132

Author(s): Zhou-Shan Tao, Wan-Shu Zhou, Hong-Guang Xu, Min Yang

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The hypothalamic–pituitary–adrenal and -thyroid axes activation lasting one year after an earthquake swarm: results from a big data analysis

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Abstract

Purpose

To cope physical and/or psychological threats, the human body activates multiple processes, mediated by a close interconnection among brain, endocrine and inflammatory systems. The aim of the study was to assess the hypothalamic–pituitary–adrenal (HPA) and hypothalamic–pituitary–thyroid (HPT) axes involvement after an acute stressful event (Emilia Romagna earthquake swarm) with a big data approach.

Methods

A retrospective, observational trial was performed, collecting all biochemical examinations regarding HPA and HPT axes performed in the same laboratory the year before and the year after the earthquake swarm (20–29 May 2012).

Results

Comparing 2576 pre-earthquake to 3021 post-earthquake measurements, a cortisol serum level increase was observed (p < 0.001). Similar increase was evident for urinary free cortisol (p = 0.016), but not for adrenocorticotropic hormone (p = 0.222). The biochemical hypercortisolism incidence increased from 7.6 to 10.3% after earthquakes (p = 0.001). Comparing 68,456 pre-earthquake to 116,521 post-earthquake measurements, a reduction in thyroid-stimulating hormone (TSH) levels was evident (p = 0.018), together with an increase in free triiodothyronine and free thyroxine levels (p < 0.001 and p < 0.001). Moreover, a significant increase in altered TSH after earthquakes was registered considering the epicenter-nearest measurements (p < 0.001). No clinically relevant alterations were observed considering thyroid-specific autoantibodies.

Conclusion

A long-term HPA axis activation in the inhabitants of the earthquake-affected areas was highlighted for the first time. Moreover, an increased incidence of biochemical hypercortisolism emerged after earthquakes. We confirmed a recruitment of HPT axis after stressful events, together with increased incidence of altered TSH in the. Our big data study allowed to increase knowledge about the connection between external stressors and endocrine regulation.

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Right-Sided Congenital Diaphragmatic Hernia Caused by Hepatopulmonary Fusion

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Introduction. Hepatopulmonary fusion is a very rare finding associated with right-sided congenital diaphragmatic hernia. With less than 50 reported cases, management and outcomes of hepatopulmonary fusion are poorly understood. This report highlights that clinical presentation is not a reliable indicator of outcomes in this rare disease. Case Presentation. A term neonate admitted for tachypnea and complete opacification of the right hemithorax was diagnosed with right-sided congenital diaphragmatic hernia. Preoperative respiratory support was minimal, and the only symptom exhibited was tachypnea. During surgical repair, fusion of the lung and liver were noted, consistent with a diagnosis of hepatopulmonary fusion. Postoperatively, the patient's pulmonary hypertension worsened and required extracorporeal membrane oxygen ation. Conclusions. Many patients with hepatopulmonary fusion and only mild symptoms die postoperatively from severe pulmonary hypertension and progressive respiratory failure. Preoperative clinical status is not indicative of postoperative outcomes, and literature suggests that patients who require less support preoperatively have high mortality rates. The availability of ECMO for postoperative complications may be necessary in patients requiring repair of hepatopulmonary fusion.
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Correlation between Blood and CSF Compartment Cytokines and Chemokines in Subjects with Cryptococcal Meningitis

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Background. Though peripheral blood is a crucial sample to study immunology, it is unclear whether the immune environment in the peripheral vasculature correlates with that at the end-organ site of infection. Using cryptococcal meningitis as a model, we investigated the correlation between serum and cerebrospinal fluid biomarkers over time. Methods. We analyzed the cerebrospinal fluid and serum of 160 subjects presenting with first episode cryptococcal meningitis for soluble cytokines and chemokines measured by Luminex assay. Specimens were collected at meningitis diagnosis, 1-week, and 2-week post cryptococcal diagnosis. We compared paired samples by Spearman's correlation and the value was set at
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High level of CD10 expression is associated with poor overall survival in patients with head and neck cancer

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CD10 is a common zinc-dependent metalloid protease that is expressed in numerous tissues, including malignant cells. Genomic alterations of CD10 are frequently observed in haematopoietic and non-haematopoietic tumours. In the present study, we analysed the CD10 expression in head and neck squamous cell carcinoma (HNSCC) and its association with tumour prognosis using bioinformatic analysis and explored the potential of a CD10-driven signalling pathway in a tumour-immune microenvironment. Briefly, data mining analysis showed strengthened CD10 expression in HNSCC patients.
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Immediate dental and skeletal influence of distractor position on surgically assisted rapid palatal expansion with or without pterygomaxillary disjunction

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The outcome of surgically assisted rapid palatal expansion (SARPE) can be affected by pterygomaxillary disjunction (PMD) and the distractor position. In this study, SARPE was performed, with or without PMD, in 20 fresh cadaver heads. Transverse expansion was conducted twice using a bone-borne distractor in the anterior and posterior positions, resulting in four groups (n=10). Cone beam computed tomography scans were completed before and after SARPE to evaluate maxillary changes. A comparative anterior decrease and posterior increase in midpalatal opening resulted from SARPE with PMD combined with a posteriorly placed distractor.
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Comparison of three different types of splints and templates for maxilla repositioning in bimaxillary orthognathic surgery: a randomized controlled trial

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The selection and implementation of a plan for maxillary surgery is of the utmost importance in achieving the desired outcome for the patient undergoing two-jaw orthognathic surgery. Some splint-based and splintless methods, accompanied by computer-assisted techniques, are helpful in improving surgical plan implementation. However, randomized controlled trials focused on this procedure are lacking. This study included 61 patients who underwent bimaxillary surgeries. The patients were randomly assigned to a conventional resin occlusal splint (CROS) group, a digital occlusal splint (DOS) group, or a digital templates (DT) group, in a 1:1:1 ratio.
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Endoscopic Management of Primary Acquired Cholesteatoma

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Endoscopic ear surgery is increasingly accepted as a primary modality for cholesteatoma surgery. A major advantage is the enhanced visualization of the middle ear in traditionally poorly accessible locations by the microscope. We discuss novel techniques for selective mastoid obliteration when a canal wall down mastoidectomy is necessary. Postoperatively, indications for non-echo planar diffusion-weighted imaging MRI versus second-look surgery are discussed. Finally, outcome data for endoscopic versus microscopic ear surgery are reviewed, which show equivalent outcomes regarding residual and recurrent disease, similar rates of complications, decreased pain, and shorter healing time.
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Acute handlebar syndrome: Two extremes of a challenging diagnosis

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Fabio Veiga de Castro Sparapani1, Marcela Fernandes2, Leonardo Favi Bocca1, Luis Renato Nakachima2, Sergio Cavalheiro1
  1. Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Rua Napoleão de Barros, 720, 6th floor, Sao Paulo, Brazil,
  2. Department of Orthopedics and Traumatology, Universidade Federal de São Paulo , Rua Napoleão de Barros, 720, 1st floor, Sao Paulo, Brazil.

Correspondence Address:
Luis Renato Nakachima
Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Rua Napoleão de Barros, 720, 6th floor, Sao Paulo, Brazil,

DOI:10.25259/SNI_606_2020

Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Fabio Veiga de Castro Sparapani1, Marcela Fernandes2, Leonardo Favi Bocca1, Luis Renato Nakachima2, Sergio Cavalheiro1. Acute handlebar syndrome: Two extremes of a challenging diagnosis. 29-Oct-2020;11:366

How to cite this URL: Fabio Veiga de Castro Sparapani1, Marcela Fernandes2, Leonardo Favi Bocca1, Luis Renato Nakachima2, Sergio Cavalheiro1. Acute handlebar syndrome: Two extremes of a challenging diagnosis. 29-Oct-2020;11:366. Available from: https://surgicalneurologyint.com/surgicalint-articles/10356/

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Date of Submission
04-Sep-2020

Date of Acceptance
30-Sep-2020

Date of Web Publication
29-Oct-2020

Abstract

Background: Ulnar nerve mononeuropathy diagnosis can be challenging depending on where neural lesion is present. Repetitive trauma during cycling is a rare cause of ulnar neuropathy.

Case Description: We describe two patients who developed the handlebar syndrome, an ulnar nerve palsy at Guyon's canal after cycling. The first patient had the syndrome after a short-distance ride and she was treated surgically, while the second patient developed the classical syndrome after a long ride and received conservative treatment. Surgical treatment of the first patient led to functional recovery.

Conclusion: Handlebar syndrome is a neuropathy caused by extrinsic repetitive compression of ulnar nerve at wrist. Increasing incidence of this disease can be expected after increasing popularity of cycling sports. Avoid of repetitive trauma is the main management goal, with surgical treatment reserved for failure of conservative treatment.

Keywords: Cycling, Guyon's canal, Nerve compression syndrome, Ulnar neuropathy

INTRODUCTION

The diagnosis of the ulnar nerve lesion at Guyon's canal could be challenging. The characteristic sensory loss at the ulnar portion of the hand and weakness of all ulnar intrinsic hand muscles occurs when both the superficial and deep branches are affected.[ 7 , 10 ]

When only the terminal superficial or deep branches are affected, both due to intrinsic or extrinsic causes, uncommon clinical features could be seen. These unusual clinical presentations can be difficult to be interpreted by nonspecialists. Misdiagnosis can lead to equivocal treatment, delaying or preclude nerve recovery.

CASE DESCRIPTION

Case 1

A 55-year-old female presented to our outpatient facility complaining about 4 weeks history of weakness and clumsiness of the left hand without pain or sensory loss. She spontaneously denied any unusual situation but, after a thorough anamnesis, she remembered some light exercises, including a short bike ride on a weekend trip. Her medical records are unremarkable. Physical examination showed marked weakness and atrophy of all ulnar supplied intrinsic left hand muscles, except for the hypothenar muscles [ Figure 1 ]. No cutaneous sensory deficit and nerve tenderness (Tinel's sign) over Guyon's canal were present.


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Figure 1:

Dorsal view of left hand. Note interosseous muscles atrophy, specially seen between I and II metacarpal bones (white arrow).

 

Before our evaluation, magnetic resonance imaging (MRI) of the cervical spine was performed showing no cervical myelopathy or compression of cervical roots and an electroneurography (ENMG), done just after initial symptoms, showed an unspecific axonal multineuropathy without motor conduction block. With these examinations, a suspected diagnosis of amyotrophic lateral sclerosis was performed by general physician and patient was sent to our institution. After our evaluation, a forelimb MRI was performed and no nerve compression was observed. The patient was submitted to another ENMG that confirmed ulnar neuropathy.

A surgical exploration was indicated after clinical complementary evaluation confirmed ulnar neuropathy. The procedure revealed a mild compression of the deep ulnar branch under the origin of the flexor digiti quinti brevis and opponens digiti quinti muscles [ Figure 2 ].


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Figure 2:

Surgical view showing the pisohamate hiatus. The fibrous arch (white arrow) must be divided to release the deep branch of ulnar nerve. Note the deep branch of ulnar nerve (red arrow) passing posterior to the fibrous arch and the superficial branch of ulnar nerve (black arrow) passing anterior to the arch.

 

During the outpatient follow-up, the patient had an uneventful recovery with motor and sensory improvement.

Case 2

A 45-year-old female complained about weakness of the left hand with local pain and sensory loss in the IV, V fingers and hypothenar volar region in the 4th day of a 500 km road cycling amateur competition. After the end of the competition, the pain has gone but the rest of the symptoms remained. The patient presented to our outpatient facility 3 weeks after the end of cycling event. Her medical records were unremarkable.

Physical examination revealed mild weakness (Grade IV) and atrophy of all ulnar supplied intrinsic left hand muscles, including the hypothenar muscles, and hypoesthesia in the V finger [ Figure 3 ]. The nerve tenderness (Tinel's sign) over Guyon's canal was not present.


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Figure 3:

Physical examination of hands. (a) Ventral view of hands, atrophy of ulnar innerved intrinsic hand muscles. (b) Close aspect of hypothenar region. Note left hypothenar region atrophy (white arrow).

 

A forearm and wrist MRI were requested and she denied being submitted an electroneuromyography. The MRI did not reveal any anomalies except the amyotrophy related. A conservative treatment was done with a good recovery.

DISCUSSION

The handlebar is one of the three contact areas that support the cyclist, beyond pedals, and the seat. Continuous and hyperextended position of the hand could compress and stretch both ulnar and median nerves at the wrist.[ 4 ]

The Guyon's canal lesions are usually divided into four places with distinct clinical aspects. Cavallo et al. proposed a clinical classification to distal ulnar neuropathy that can be easily applied to clinical practice.[ 3 ] The most common is the lesion proximal to the Guyon's canal (Type 1) characterized by sensory loss at the ulnar portion of the hand and weakness of all ulnar intrinsic hand muscles, last alteration being the most seen clinical aspect of it. More distal lesions inside the Guyon's canal (Type 2) cause an isolated palsy of the deep terminal motor branch without sensory loss. This lesion could be differentiated from Type 3 because the latter spares the hypothenar muscles. Type 4 affects the superficial branch only leading to sensory loss.[ 3 ]

The most reported etiologies of these lesions are the compressive in nature: lipoma, cysts, anomalies of ligaments or muscles, hook of the hamate fracture, and ulnar artery aneurysms. Extrinsic causes, such as chronic repetitive trauma or chronic pressure together with vibration, are not commonly reported, except if applied for months or years.[ 8 ] The most common sports associated with injuries of the ulnar nerve at the wrist is cycling.[ 9 ] Weightlift, rowing, gymnastics, and table tennis are more related to lesions of ulnar nerve at the elbow.[ 9 ] Wheelchair sports could affect both sites.[ 9 ]

The prevalence of ulnar and median nerve compression in long-distance cyclists ranges from 1 0% to 70%[ 5 ] with its characteristics motor or sensory disturbances. When no sensory involvement or pain is triggered by the sport, the cyclist can prolongate the activity without any change in the hand's position, leading to lesion progression.

When history is unclear and the clinical findings are not specific, further diagnostic workups are needed. ENMG and an MRI of the hand should be performed for the exclusion of pathological structures at Guyon's canal. Important differential diagnosis should be discarded, including radiculopathy of C8 and/or T1 roots. In pure motor syndromes, amyotrophic lateral sclerosis, multifocal motor neuropathy, and hereditary neuropathy with liability to pressure palsy (HNPP) should be ruled out.[ 2 ]

In our first case, the initial diagnosis caused intense stress and great suffering to the patient and her family. Her short history of cycling was an unusual cause of distal ulnar neuropathy, usually related to long-distance and repetitive cycling. Since the first report by Simpson[ 7 ] in 1895, literature reports describe cases of long-distance or prolonged cycling as possible extrinsic etiology for ulnar neuropathy. Few reports of ulnar neuropathy following short-distance cycling can be found, as Capitani and Beer[ 1 ] described in 2002, three cases of handlebar syndrome, one case of them was an unexperienced mountain biker that developed ulnar neuropathy after only one downhill mountain bike trip. Authors theorized the ri der posture, leaning too forward and an inadequate frame or handlebar grip as facilitating factors to rapid developing symptoms presented in that patient.

Although handlebar syndrome tends to recover with conservative management, it has to be early diagnosed to avoid a worsening of the case, as presented by the second patient. There is a lack of evidence-based recommendations on literature regarding handlebar syndrome treatment.[ 1 ] Most authors use Delphi consensus strategy recommendations derived from European HANDGUIDE study to guide their treatment. For mild-to-moderate symptoms, recommendations start with avoidance of local pressure and/ or limit mechanical overload including repetitive or static movements of the wrist and splinting the wrist in a neutral position in a fingers free splint for 1–12 weeks at night.[ 6 ] Surgery is reserved to patients with chronic symptoms or a severe presentation and consists of ulnar nerve exploration in the canal.[ 6 ]

CONCLUSION

Handlebar syndrome is a distal ulnar neuropathy cause by extrinsic repetitive compression of ulnar nerve at wrist. Its differential diagnosis can be challenging and must be ruled out before definitive diagnosis.

The incidence of handlebar syndrome should increase more and more with the increasing popularity of cycling sports, including mountain bike or long-distance cycling, so clinicians must be aware of this diagnosis. Surgical treatment is reserved to conservative management failure or anatomical anomaly found after imaging evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Brown CK, Stainsby B, Sovak G. Guyon canal syndrome: Lack of management in a case of unresolved handlebar palsy. J Can Chiropr Assoc. 2014. 58: 413-20

2. Capitani D, Beer S. Handlebar palsy-a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking. J Neurol. 2002. 249: 1441-5

3. Cavallo M, Poppi M, Martinelli P, Gaist G. Distal ulnar neuropathy from carpal ganglia: A clinical and electrophysiological study. Neurosurgery. 1988. 22: 902-5

4. Cohen GC. Cycling injuries. Can Fam Physician. 1993. 39: 628-32

5. Dettori NJ, Norvell DC. Non-traumatic bicycle injuries: A review of the literature. Sports Med. 2006. 36: 7-18

6. Hoogvliet P, Coert JH, Fridén J, Huisstede BM. How to treat guyon's canal syndrome? Results from the European handguide study: A multidisciplinary treatment guideline. Br J Sports Med. 2013. 47: 1063-70

7. Neal S, Shane-Tubbs R.editors. Peripheral nerve injury of the upper extremity. Nerves and Nerve Injuries. London: Elsevier Ltd; 2015. p. 510-2

8. Shea JD, McClain EJ. Ulnar-nerve compression syndromes at and below the wrist. J Bone Joint Surg Am. 1969. 51: 1095-103

9. Sparapani F, Spinner R, Petraglia AL, Bailes JE, Day AL.editors. Peripheral nerve injuries in athletes. Handbook of Neurological Sports Medicine Concussion and Other Nervous System Injuries in the Athlete. Champaign, United States: Human Kinetics; 2015. p. 341-5

10. Streib EW, Sun SF, Cochran RM, Leibrock LG. Distal ulnar neuropathy. Clinical and electrophysiologic aspects. Surg Neurol. 1985. 23: 281-6

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