Efficacy of Extracorporeal Shockwave Therapy on Cervical Myofascial Pain Following Neck Dissection Surgery: A Randomized Controlled Trial

Objective@#To investigate the efficacy of extracorporeal shockwave therapy (ESWT) on cervical myofascial pain following neck dissection in reducing pain and improving cervical range of motion (ROM). @*Methods@#Forty-six patients with cervical myofascial pain following neck dissection surgery were recruited and subdivided at random into two equal groups. The ESWT group received ESWT once a week for 4 weeks (0.25 mL/mm2, 1,000 shocks) and a topical non-steroidal anti-inflammatory drug (3 times/day for 4 weeks). The control group received only topical NSAID. The pain assessment was done by using the visual analog scale (VAS) and pressure algometry. A cervical ROM device was used for the assessment of the lateral flexion and rotation of the neck ROM on both sides. All measurements were collected at baseline, 2 weeks, and 4 weeks. @*Results@#The ESWT group revealed a significant improvement in all parameters at post I and post II than did the control group (p>0.001), that revealed a statistical decrease only in the VAS score at post I without any statistical difference in the pain threshold and neck ROM. However, there were statistical differences in all parameters at post II compared to those at pre-treatment and post I (p<0.001). @*Conclusion@#As a confirmation of the efficacy of ESWT in cervical myofascial pain control following neck dissection, we observed better results with no side effects in the ESWT group (Clinical Trial Registry No. PACTR202002648274347).

Expression of cytotoxic T-lymphocyte-associated antigen-4 [CTLA-4; CD152] on peripheral blood T lymphocytes in systemic lupus erythematosus children

Background: CTLA-4 [CD152] encodes cytotoxic T lymphocyte-associated antigen-4, a cell-surface molecule providing a negative signal for T-cell activation. CTLA-4/B7 is the most important costimulation-signaling pathway that regulates T cell responses and plays a critical role in maintenance and breakdown of selftolerance, and hence in susceptibility to autoimmune diseases

Objective: The aim of this study was to investigate and evaluate the expression of CTLA-4 on peripheral blood T-lymphocytes [PBTL] in children with systemic lupus erythematosus [SLE] in relation to clinical features; disease activity and severity

Methods: From December 2006 to August 2007, 32 pediatric patients [30 girls, 2 boys] fulfilled at least four of the 1997 revised criteria for the classification of SLE were enrolled in this study. Expression of CTLA-4 on freshly isolated PBTL was assayed by flow cytometry in all SLE patients during activity and remission in addition to 32 age- and sex-matched children serving as controls. Results were expressed as percentage of PBTL cells expressing surface CTLA-4 molecule in comparison to isotype-matched controls. CTLA-4+PBTL% were correlated with some SLE disease activity and severity variables

Results: CTLA-4 expression on freshly isolated PBTL was significantly higher in SLE patients during disease activity [median = 12; mean +/- SD = 10.45 +/- 8.3%] than controls [median = 4; mean +/- SD = 3.34 +/- 3.1%; p < 0.0001]. The patients' values were statistically comparable during quiescence [median = 14; mean +/- SD = 15.02 +/- 7.1%; p > 0.05] and activity. Among SLE patients, the median and mean +/- SD of CTLA-4+PBTL % of children with lupus nephritis was significantly higher than those without nephritis [15; 13.56 +/- 10.4% versus 10; 9.51 +/- 9.1%; p < 0.01]. CTLA-4 expression could be related to lupus severity but there was no correlation with disease activity. A positive correlation could be elicited between CTLA-4+PBTL% during lupus activity and the corresponding values during remission. CTLA-4+PBTL% correlated positively with the anti-dsDNA autoantibodies titers, serum creatinine, and 24 hours urinary protein excretion. On the other side, the percentages correlated inversely with the estimated creatinine clearance and serum C3 and C4 levels. CTLA-4 expression did not vary according to therapy

Conclusion: CTLA-4 surface expression on PBTL in SLE children was up regulated irrespective of lupus activity. The over expression was related to lupus severity and might have a significant role in the pathogenesis of lupus nephritis and cerebritis

Resuscitation therapy in systemic sepsis: evidence-based

The septic syndrome is associated with persistent high mortality, mostly due to the late diagnosis of this disease entity, and its inappropriate management. Therapies used for management of criticatly-ill patients in general, have been recently tested in systemic sepsis The present article spots light on available literature including systematic reviews and meta-analysis to explore evidence-based guidelines for resuscitation therapy in the septic syndrome. The American Society of Anesthesiologists defines practice guidelines as "systematically developed recommendations that describe a basic management strategy or a range of basic management strategies for patient care". This is because absence of proof does not mean that proof is absent. The "early" use of both global-and splanchnic oriented haemodynamic therapy, together with repeated clinical interpretations form an important cornerstone for treatment of patients with systemic sepsis. Central venous, pulmonary artery, and peripheral arterial catheters, should be placed as early as possible for diagnostic and therapeutic purposes. Fluid resuscitation by crystalloids, colloids and haemoglobin transfusion aim to therapeutically drive oxygen delivery and oxygen consumption to global and regional goals with myocardial performance being the end-point of resuscitation. Fluid challenge should be administered, and repeated based on response [increased arterial blood pressure and urine output] and tolerance [evidence of intravascular volume overload]. Norepinephrine and dopamine are the vasopressors of choice for treatment of systemic sepsis. They aim to maintain blood pressure, both during and following adequate fluid therapy. Phenylephrine and epinephrine are not recommended as first line agents for therapy. Dobutamine is recommended as the agent of choice to increase cardiac output, but if used with low mean arterial pressure, it should be combined with a vasopressor while the cardiac output is being measured. Low-dose dopamine should not be used for renal protection as part of treatment of severe sepsis. Continuous venovenous haemofiltration offers easy management of fluid balance in haemodynamically unstable septic patients. In the absence of haemodynamic instability, haemofiltration is equivalent to intermittent haemodialysis. Tight glycemic control by insulin is recommended in the septic patient. However, this should be combined with a nutritional protocol. Bicarbonate therapy is not recommended for improving haemodynamics or in reducing vasopressor requirements in the presence of lactic acidosis and PH >/= 7.15. Activated Protein-C therapy and selective digestive decontamination strategy would play important roles in the management of systemic sepsis in the near future

Plasma macrophage-derived chemokine [CCL22] and its receptor CCR4 on peripheral blood T lymphocytes of asthmatic children

Background: the macrophage-derived chemokine [MDC/CCL22] acts on CC chemokine receptor-4 [CCR4] to direct trafficking and recruitment of T helper-2 [TH2] cells into sites of allergic inflammation. It was previously found overexpressed in lesional samples from adult asthmatics

Objective: this study is aimed to investigate the participation of CCR4/MDC axis in the development of TH2-dominated allergen-induced childhood asthma in relation to disease activity, attack severity, and response to therapy, and to outline its value in differentiating atopic asthma from infection-associated airway reactivity

Methods: proportion of CCR4-expressing peripheral blood T lymphocytes [CCR4+PBTL%] were purified and quantitated by negative selection from peripheral blood mononuclear cells by flow cytometry, and the concentration of MDC in plasma was measured by ELISA in 32 children with atopic asthma [during exacerbation and remission], as well as in 12 children with acute lower respiratory tract infections [ALRTI], and 20 healthy children serving as controls

Results: the mean plasma MDC level [925 +/- 471.5 pg/ml] and CCR4+PBTL% [55.3 +/- 23.6%] were significantly higher in asthmatic children during acute attacks in comparison to children with ALRTI [109 +/- 27.3 pg/ml and 27.6 +/- 7.5%] and healthy controls [99.6 +/- 25.6 pg/ml and 24.2 +/- 4.1%]. Both values decreased significantly after subsidence of attacks [502 +/- 284.3 pg/ml and 32.5 +/- 10.5%] although remained higher than the other 2 groups which were actually comparable in terms of MDC and CCR4%. MDC and CCR4% values were higher among children with acute severe than mild or moderate asthma exacerbations, and in persistent than intermittent cases during stability. Positive correlations could be elicited between both markers during exacerbation or stability, and between the exacerbation level of each and its corresponding value during remission. Corticosteroid-treated patients had the highest expression of both markers when relation to therapy was studied

Conclusion: our findings reinforce the concept that up regulation of CCR4/MDC axis is implicated in the pathogenesis of pediatric atopic asthma and may represent a useful biomarker of monitoring allergic inflammation and response to therapy. Neutralization and manipulation of CCR4-expressing T cells, as well as MDC antagonism, may represent an adjuvant in the treatment of severe allergic disorders

Serum mucosa-associated epithelial chemokine [MEC/CCL28] in atopic dermatitis: a specific marker for severity

Background: mucosa-associated epithelial chemokine [MEC; CCL28] is considered pivotal in mediating migration of CCR3 and CCR10-expressing skin-homing memory CLA+ T cells. CCL28 is selectively and continuously expressed by epidermal keratinocytes, but highly upregulated in inflammatory skin diseases such as atopic dermatitis [AD]

Objective: this controlled longitudinal study was designed to evaluate the expression of CCL28 serum levels in childhood AD and bronchial asthma [BA], and its possible relations to disease severity and activity

Methods: serum CCL28 levels were measured in 36 children with AD, 23 with BA, and 14 who had both conditions as well as in 21 healthy age and sex-matched subjects serving as controls. Sixteen patients in the AD group were followed up and re-sampled for serum CCL28 after clinical remission. Serum CCL28 levels were correlated with some AD disease activity and severity variables

Results: serum CCL28 levels in AD whether during flare [median = 1530; mean +/- SD = 1590.4 +/- 724.3 pg/ml] or quiescence [median = 1477, mean +/- SD = 1575.2 +/- 522.1 pg/ml] were significantly higher than the healthy children values [median = 301; mean +/- SD = 189.6 +/- 92.8 pg/ml]. However, the levels during flare and quiescence were statistically comparable. The serum levels in BA [median = 340; mean +/- SD = 201.6 +/- 109.5 pg/ml] were significantly lower than the AD group and comparable to the healthy control values. Serum CCL28 levels in severe AD were significantly higher as compared to mild and moderate cases and correlated positively to the calculated severity scores [LSS and SCORAD]. CCL28 levels during exacerbation of AD could be positively correlated to the corresponding values during remission, the peripheral absolute eosinophil counts and serum lactate dehydrogenase levels. Serum CCL28 did not vary with the serum total IgE values in AD

Conclusion: our data reinforce the concept that CCL28 might share in the pathogenesis of AD probably through selective migration and infiltration of effector/memory Th2 cells into the skin. It may also represent an objective prognostic marker for disease severity. Further studies may pave way for CCL28 antagonism among the adjuvant therapeutic strategies

Seromuscular vascularized ileal loop patch for the repair of radiation induced vesico-vaginal fistula after radical hysterectomy for cervical carcinoma

The use of Vascularized pedicled seromuscular Heal loop patch as a well Vascularized interposition tissue flap, between bladder and vaginal walls for repair of radiation induced vesico-vaginal fistula -was studied on nine patients from the period of April 2000 till January 2003 in the national cancer institute. Those patients were referred to the surgical department with adiagnosed vesico-vaginal fistula, that developed after completion of an external beam and intracavitary radiotherapy post hysterectomy for cervical carcinoma. Through transabdominal, Transvesical approach, with stinting of the ureters during dissection of the fistulous tract, an ileal loop flap is mobilized with its mesenteric blood supply to become technically amenable for enforcement of the repair or reconstruction of the deficient vesical wall after excision of the scarred fistulous tract simulating cystoplasty technique. The outcome of this approach and flap technique showed successful healing of all fistulae in all patients, without complications either post operatively or during follow up. This study recommended the use of seromascular Vascularized Heal loop patch for the repair of radiation induced vesico-vaginal fistula after radical hysterectomies

Malignant otitis externa in upper Egypt: why do not all diabetics have malignant otitis externa?

Eighteen diabetic patients [7 men and 11 women, with an age ranged between 50 and 75 years] among 1730 cases of malignant otitis externa in the ENT Clinic at Assiut University Hospitals were studied and treated in this work. This group consisted of seven men and eleven women. Diabetes was long-standing in all patients and uncontrolled, except in one. Laboratory investigations in the form of high and low-density lipids, ESR, creatinine and blood sugar curves were done to all patients. Biopsy for histopathological examination was taken from the granulation tissues or aural polyp. Computerized tomography of the temporal bones and radioisotope bone scan using technetium 99 MDP was done to all patients in the Nuclear Medicine Unit in Assiut University Hospitals. The clinical features and presentation were summarized. The strategy of the diagnosis and treatment was discussed. The combination of antibiotic and drugs that improve microcirculation was found to be essential in treatment of malignant otitis externa. Liporegulation drugs are also valuable in controlling high levels of LDL. ESR is a useful tool to monitor patients with MOE during treatment and in the follow up

Effect of partial tenonectomy during trabeculectomy on success rate of glaucoma surgery

This study evaluates the. effect of partial tenonectomy at the time of trabeculectomy. Of 49 eyes, 23 were randomly assigned to partial tenonectomy during trabeculectomy and 26 trabeculectomy without tenonectomy. There was no statistically significant difference in the success rate between the two groups using an upper limit of intraocular pressure [I.O.P.] of 18 mmHg as the criterion for success [P = 0.59]. There was no difference in the need for further postoperative surgical intervention or medications between the two groups. Although certain advantages exist with each technique, these findings suggest that equivalent results can be anticipated with either method. There are different opinions concerning the question of if and what manner the Tenon capsule should be removed at the time of filtering surgery. In this study the effect of partial tenonectomy at the time of trabeculectomy was evaluated

Study of platelet functions in healthy cigarette smokers

The present work was done on 35 clinically free men, 25 of them are heavy smokers, smoking more than 20 cigarettes per day, their ages ranged from 22-87 years; and ten of them are non smokers as a control group; their ages from 25 to 85 years. Ranged There were significant increase of ADP and collagen induced platelet aggregation percent, significant increase of platelet adhesiveness percent, insignificant decrease in platelet aggregation ratio and insignificant increase of platelet count in smokers than non smokers after an over night fasting. We found a significant increase of ADP induced platelet aggregation percent and a significant decrease of PAK 20 mm. after acute cigarette smoking in both groups. So the acute effect of cigarette smoking increases platelet sensitivity, especially aggregation, to smoking which was marked 20 min. after cigarette smoking

effect of halothane anaesthesia on blood and plasma volumes in bilharzial hepatosplenomegaly

Ten male patients with bilharzial hepatosplenomegaly were the subject of this study. Another ten male patients of nearly the same age and body weight were taken as control. The plasma and blood volumes were estimated before and 30 minutes after 2% halothane anaesthesia without any surgical interference. The plasma volume was determined by Evens blue dye method and the total blood volume was calculated from the haematocrit value. There was no significant difference between the mean blood volumes of the two groups before the administration of halothane. The 2% halothane administration for 30 minutes, significantly increased the mean total blood volumes in both groups, although the difference between the mean percent increases was not significant. The mean haematocit values of both groups did not display any significant change before or following the exposure to halothane. Patients with bilharzial hepatosplenomegaly developed more hypervolaemia during halothane anaesthesia, possibly mainly due to an increase in the plasma volume. The effect of halothane anaesthesia on the blood volume was the subject of conflicting reports. Some authors [Payne and colleagues, 1959, and Grable and associates, 1962] reported an increase in blood volume, while other [Morse and colleagues, 1963] could not detect any change in blood volume following the administration of halothane. Hepatosplenic bilharziasis is a disease associated with changes in haemodynamic pattern [Mousa, 1967] and these changes can be modified by the action of various drugs especially the vasoactive ones. The purpose of this study is to report the effect of halothane anaesthesia on the plasma and blood volumes in hepatosplenic bilharziasis