CD4(+) T cells of myasthenia gravis patients are characterized by ıncreased IL-21, IL-4, and IL-17A productions and higher presence of PD-1 and ICOS

Myasthenia gravis (MG) is an autoimmune disease mediated by autoantibodies predominantly against the acetylcholine receptor (AChR). Specific T cell subsets are required for long-term antibody responses, and cytokines secreted mainly from CD4(+) T cells regulate B cell antibody production. The aim of this study was to assess the differences in the cytokine expressions of CD4(+) T cells in MG patients with AChR antibodies (AChR-MG) and the effect of immunosuppressive (IS) therapy on cytokine activity and to test these findings also in MG patients without detectable antibodies (SN-MG). Clinically diagnosed AChR-MG and SN-MG patients were included. The AChR-MG patients were grouped as IS-positive and -negative and compared with age- and sex-matched healthy controls. Peripheral blood mononuclear cells were used for ex vivo intracellular cytokine production, and subsets of CD4(+) T cells and circulating follicular helper T (cTfh) cells were detected phenotypically by the expression of the chemokine and the costimulatory receptors. Thymocytes obtained from patients who had thymectomy were also analyzed. IL-21, IL-4, IL-10, and IL-17A productions in CD4(+) T cells were increased in AChR-MG compared to those in healthy controls. IS treatment enhanced IL-10 and reduced IFN-gamma production in AChR-MG patients compared to those in IS-negative patients. Increased IL-21 and IL-4 productions were also demonstrated in SN-MG patients. Among CD4(+) T cells, Th17 cells were increased in both disease subgroups. Treatment induced higher proportions of Th2 cells in AChR-MG patients. Both CXCR5(+) and CXCR5(-) CD4(+) T cells expressed higher programmed cell death protein 1 (PD-1) and inducible costimulatory (ICOS) in AChR-MG and SN-MG groups, mostly irrespective of the treatment. Based on chemokine receptors on CXCR5(+)PD-1(+) in CD4(+) T (cTfh) cells, in AChR-MG patients without treatment, the proportions of Tfh17 cells were higher than those in the treated group, whereas the Tfh1 cells were decreased compared with those in the controls. The relevance of CXCR5 and PD-1 in the pathogenesis of AChR-MG was also suggested by the increased presence of these molecules on mature CD4 single-positive thymocytes from the thymic samples. The study provides further evidence for the importance of IL-21, IL-17A, IL-4, and IL-10 in AChR-MG. Disease-related CD4(+)T cells are identified mainly as PD-1(+) or ICOS+ with or without CXCR5, resembling cTfh cells in the circulation or probably in the thymus. AChR-MG and SN-MG seem to have some similar characteristics. IS treatment has distinctive effects on cytokine expression.Istanbul Universit

Tarsal tunnel syndrome masked by painful diabetic polyneuropathy

WOS: 000362378900028PubMed ID: 26333036INTRODUCTION: Various causes influence the etiology of tarsal tunnel syndrome including systemic diseases with progressive neuropathy, such as diabetes. PRESENTATION OF CASE: We describe a 52-year-old male patient with complaints of numbness, burning sensation and pain in both feet. The laboratory results showed that the patient had uncontrolled diabetes, and the EMG showed distal symmetrical sensory-motor neuropathy and nerve entrapment at the right. Ultrasonography and MRI showed the cyst in relation to medial plantar nerve, and edema- moderate atrophy were observed at the distal muscles of the foot. DISCUSSION: Foot neuropathy in diabetic patients is a complex process. So, in planning the initial treatment, medical or surgical therapy is selected based on the location and type of the pathology. Foot deformities can be corrected with resting, anti-inflammatory treatment, appropriate shoes, orthesis and socks, and if required, ankle stabilization can be attempted. If the patient is still unresponsive, surgical treatment may be applied. CONCLUSION: It is essential to investigate more localized reasons like tarsal tunnel syndrome that may mimic diabetic neuropathy, should be treated primarily

Peroneal nöropatisi olan hastalarda etiyolojik faktörlerin ve elektrofizyolojik bulguların değerlendirilmesi

Objective: Peroneal neuropathy is the most common entrapment mononeuropathy in the lower extremity. The common site of injury is around the fibular head where the nerve becomes superficial. Compressive pathologies are the most frequently seen etiologies. The treatment plan is designed according to the etiology. Electrophysiologic investigations are accepted as the gold standard for the diagnosis of peroneal neuropathy. In this study, we aimed to evaluate the etiologic factors and electrodiagnostic findings in peroneal neuropathy. Method: We retrospectively analyzed the etiological and electrodiagnostic test findings of patients with clinical features compatible with peroneal neuropathy, who presented to the Electromyography Laboratory of İstanbul Medipol University Hospital between January 2016 and December 2019. Patients with polyneuropathy or a disease that may cause polyneuropathy such as diabetes mellitus, those with lumbosacral radiculopathy or plexopathy, and those with neurodegenerative diseases were excluded. Results: A total of 30 patients with clinical features compatible with peroneal neuropathy (19 males, 11 females, median age 30 years; range 21 to 66) were enrolled in the study. Four (13.3%) patients had a comorbid disease. The median duration (minimum-maximum) of the symptoms was 20.5 (2-140) weeks. The affected side of the peroneal nerve was 43.3% right, 43.3% left, and 13.3% bilateral. The common cause of peroneal nerve injuries was due to compression (40%). Potential causes of compression in five out of 12 cases were iatrogenic. Weight loss was found in 10% of patients and one patient (3.3%) had a history of a recurrent ganglion cyst. Approximately 23% of lesions were due to traction injury and 23% of cases were idiopathic. According to electrophysiologic investigations, 16 cases were predominantly demyelinating without axonal injury. The axonal injury was detected in the remaining 14 cases (%46.6) and half of the cases with axonal injury were accompanied by demyelinating injury. Six cases had mild, 3 cases had severe, and 5 cases had a total axonal injury. Conclusion: Compression is the most commonly seen etiological factor in peroneal neuropathy. Electrophysiologic investigations play a significant role in the differential diagnosis, prognosis, management plan, and follow-up of recovery. Further detailed studies are needed to clarify the relationship between electrophysiologic findings and prognosis to form an algorithm for the treatment and follow-up.Amaç: Peroneal nöropati, alt ekstremitede en sık görülen tuzak mononöropatidir. Yaygın yaralanma bölgesi, sinirin yüzeysel olduğu fibula başındadır. En sık görülen etiyolojiler kompresif patolojilerdir. Tedavi planı etiyolojiye göre tasarlanır. Elektrofizyolojik incelemeler peroneal nöropati tanısında altın standart olarak kabul edilmektedir. Bu çalışmada peroneal nöropatide etiyolojik faktörleri ve elektrodiagnostik bulguları değerlendirmeyi amaçladık. Yöntem: İstanbul Medipol Üniversite Hastanesi Elektromiyografi Laboratuvarı’na Ocak 2016-Aralık 2019 tarihleri arasında başvuran peroneal nöropati ile uyumlu klinik özellikleri olan hastaların etiyolojik ve elektrodiagnostik test bulgularını retrospektif olarak inceledik. Polinöropatili veya diabetes mellitus gibi polinöropatiye neden olabilecek bir hastalığı olan hastalar, lumbosakral radikülopati veya pleksopatisi olanlar ve nörodejeneratif hastalığı olanlar çalışma dışı bırakıldı. Bulgular: Çalışmaya peroneal nöropati ile uyumlu klinik özelliklere sahip 30 hasta (19 erkek, 11 kadın, medyan yaş 30 yıl, 21-66 aralıkta) alındı. Dört (%13,3) hastada ek hastalık vardı. Medyan (minimum-maksimum) semptom süresi 20,5 (2-140) haftaydı. Peroneal sinirin etkilenen tarafı %43,3 sağ, %43,3 sol ve %13,3 bilateral idi. Peroneal sinir yaralanmalarının en sık nedeni kompresyona bağlıydı (%40). On iki olgudan beşinin olası kompresyon nedenleri iyatrojenikti. Hastaların %10’unda kilo kaybı saptandı ve bir hastada (%3,3) tekrarlayan ganglion kisti öyküsü vardı. Lezyonların yaklaşık %23’ü traksiyon yaralanmasına bağlıydı ve olguların %23’ü idiyopatikti. Elektrofizyolojik incelemelere göre, 16 olgu ağırlıklı olarak aksonal yaralanma olmaksızın demiyelinizan idi. Kalan 14 olguda (%46,6) aksonal yaralanma saptandı ve aksonal yaralanmalı olguların yarısına demiyelinizan yaralanma eşlik etti. Altı olguda hafif, 3 olguda ağır ve 5 olguda total aksonal yaralanma vardı. Sonuç: Kompresyon, peroneal nöropatide en sık görülen etiyolojik faktördür. Elektrofizyolojik araştırmalar ayırıcı tanıda, prognoz, tedavi planı ve iyileşmenin takibinde anahtar rol oynar. Tedavi ve takip için bir algoritma oluşturmak için elektrofizyolojik bulgular ile prognoz arasındaki ilişkiyi netleştiren daha detaylı çalışmalara ihtiyaç vardır

Evaluation of biceps brachii muscle oxygenation and differences in oxygenation during exercise and resting states with multichannel fNIRS

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Upper and middle third auricular reconstruction with a peninsular conchal flap

Background: Traumatic or iatrogenic full thickness auricular defects can be reconstructed in many ways. The defects exceeding 2 cm require challenging reconstruction techniques. The reconstruction options for those should include an- terior and posterior skin envelope repair with cartilaginous content. Providing color and texture match, while maintaining anatomic landmarks, should be considered. The outcomes of patients in which we used a peninsular conchal axial pattern flap (PCF) to reconstruct the composite defects of the auricle were outlined in this case series. Materials and Methods: Five patients with different etiologies were evaluated and operated with PCF between March 2012 and January 2015. The ages of the patients ranged from 21 to 91 years with a median age of 80. The mean follow-up period was 16.8 months. In PCF, the conchal subpart of the auricle was elevated as an axial pattern composite flap relied on the anastomotic connections between the superficial temporal artery and the posterior auricular artery. Donor sites were left to secondary healing. The statistical assessment was carried out with the Mann-Whitney U test. Results: The median age of the patients was 80 (21-91) years. The median percentage of flap survival was 100,00. The median operation duration was 92,00 minutes. Donor site epithelialization was 21 and 20 days in the first two patients, with a median of 20,5 days. In the latter three patients, a silver-containing dressing material was used prophylactically to suppress contamination by skin bacteria, which led to a decrease of the length of healing time to a median of 11,00 days, with a range of 3,00. Conclusion: PCF offers a one-stage procedure and can be used in the reconstruction of defects of the auricle exceeding 2 cm. The use of axial pattern peninsular conchal flap is recommended to all of our colleagues. [Arch Clin Exp Surg 2016; 5(1.000): 1-6

Difüzyon manyetik rezonans görüntüleme bulguları ışığında creutzfeldt-jakob hastalığı

WOS: 000362665700008Fifty-seven year old male patient came to us with forgetfulness, sleepiness, hand tremor, sluggish movements and withdrawn mood. The patient’s place, time and people orientation was disrupted in his neurological examination. There was postural tremor in the bilateral upper extremities. There was no pathological reflex. Routine biochemistry, hemogram, sedimentation, vitamin B12, thyroid function tests, cranial magnetic resonance imaging (MRI) and electroencephalography (EEG) were assessed as normal. He scored 13/30 points in Mini-mental state evaluation. While the second cranial MRI at the 45th day was normal, the diffusion restrictions in the frontal pole, anterior interhemispheric fissure and bilateral insular cortex seen in the diffusion-weighted imaging (DWI) attracted attention (Figures 1, 2). There was a widespread sluggishness in the EEG.Elli yedi yaşında erkek hasta, dört aydır unutkanlık, aşırı uyku hali, ellerde titreme, hareketlerde yavaşlama, içine kapanma şikayetleri ile başvurdu. Nörolojik muayenesinde hastanın yer, zaman ve kişi oryantasyonu bozuktu. Bilateral üst ekstremitelerde postüral tremoru vardı. Patolojik refleksi yoktu. Rutin biyokimya, hemogram, sedimantasyon, vitamin B12, tiroid fonksiyon testleri, ilk yapılan kranyal manyetik rezonans görüntüleme (MRG) ve elektroensefalografi (EEG) normal olarak değerlendirildi. Mini-mental durum değerlendirme testinden 13/30 puan aldı. Kırk beş gün sonra yapılan ikinci kranyal MRG’de rutin sekanslar inceleme normalken, difüzyon ağırlıklı görüntülerde (DAG) frontal pol, anterior interhemisferik fissür, bilateral insulada sadece kortekste izlenen difüzyon kısıtlaması dikkati çekti (Şekil 1, 2). EEG’de hafif yaygın yavaşlama vardı. Subakut başlangıçlı demans etiyolojisine yönelik periferik kanda ve beyin-omurilik sıvısında bakılan enfeksiyon, otoimmün ve paraneoplastik belirteçler negatifti. Beyin-omurilik sıvısında; hücre yoktu, biyokimya testleri normaldi, 14-3-3 proteini pozitif, tau proteini ve nöron spesifik enolaz değerleri normaldi

Flexion-Induced Cervical Cord Compression: Hirayama Disease

WOS: 000467416800008PubMed ID: 30819416A 15-year-old man was presented with progressive weakness and amyotrophy of the right distal arm and hand muscles, which had been present for the last 3 months. The patient had no comorbid diseases and a history of cervical trauma. His family members had no neuromuscular disorders. A clinical examination showed weakness of the right interosseous muscles (grade 3/5 on the Medical Research Council scale), abduction of the right thumb, and extension of the right wrist and fingers II-V (Medical Research Council 4/5). On inspection, there was marked atrophy of the right first dorsal interosseous muscle and mild atrophy of the other intrinsic hand and flexion and extension muscles of the wrist. There was no fasciculation, sensory deficit, and pain, but tremulous movement of his fingers was observed

Hypergene Manganese Ores of Central Siberia

В зоне гипергенеза разведаны скопления оксидных и гидрооксидных марганцевых и железомарганцевых руд изменчивого качества. Среди них выделены остаточные образования, размеры и состав которых во многом определяются первичным карбонатным оруденением. Остаточно-инфильтрационные руды возникли вследствие выноса и перераспределения марганца и сопутствующих элементов при существовании первичных руд или марганценосных пород. Гидрогенное оруденение (в узком понимании) образовано в горизонтах грунтовых вод и зонах разгрузки межпластовых вод (месторождение «Сейбинское-1»). Инфильтрационные концентрации наименее масштабные и появляются в местах осаждения и замещения рудными минералами трещиноватых горных пород. В большинстве случаев гипергенное оруденение оценено в ранге проявлений, остаточные руды составляют ресурсы зоны окисления коренных месторождений Мазульского, Усинского и Николаевского, остаточно-инфильтрационные представлены средним по запасам Порожинским месторождением.The concentrations of oxide and hydroxide manganese and iron-manganese ores of variable quality are prospected in the area. The residual ores are specified, the dimention and quality of such deposits are mainly determined by primary carbonate mineralization. The residual-infiltration ores appeared as a result of evacuation and transition of manganese and assotiate elements, in case of existence of primary ores or manganese-bearing rocks. The hydrogenous mineralization (in the narrow sense) settle by underground water and sometime in the zones of interbedded water discharge (Sejbinsk-1 deposit). The infiltration genetic species of smaller scale are formed in deposition and replacement places of jointing rocks by ores minerals. In most cases the hypergene mineralization has been ranked as show of ores with the residual ores to form the resourses of oxidation zones of the Mazulsk, Usinsk and Nicolaevsk deposits. The residual-infiltration ores are presented by the middle-sized Porozhinsk deposit

Ulnar Nerve Compression at the Wrist: Diagnostic Role of Palmar Stimulation

Objective:Electrophysiological diagnosis of ulnar nerve entrapment at the wrist is sometimes difficult. The aim was to evaluate the diagnostic role of ulnar nerve stimulation above and below the Guyon channel in ulnar nerve entrapment at the wrist.Methods:Supramaximal ulnar nerve stimulation at the wrist and palm, in addition to the standard nerve conduction studies, in 10 patients with ulnar nerve entrapment at the wrist and 40 controls.Results:Motor latencies to the first dorsal interosseous muscle with wrist stimulation were prolonged unilaterally in six and bilaterally in four patients. Palmar stimulation showed partial conduction blocks on the more symptomatic side in all. In two bilateral cases, there were 28.8% and 44.3% amplitude loss on the less symptomatic side. Motor responses elicited with palm stimulation were also found to have prolonged latencies and decreased amplitudes.Conclusions:Stimulation of the deep branch of the ulnar nerve can expand the information about ulnar nerve entrapment at the wrist by providing evidence about its nature, prognosis, precise localization, and distal extent