Altered cell metabolism in tissues of the knee joint in a rabbit model of Botulinum toxin A-induced quadriceps muscle weakness.

Quadriceps muscle weakness is frequently associated with knee injuries in sports. The influence of quadriceps weakness on knee joint homeostasis remains undefined. We hypothesized that quadriceps weakness will lead to tissue-specific alterations in the cell metabolism of tissues of the knee. Quadriceps weakness was induced with repetitive injections of Botulinum toxin A in six 1-year-old New Zealand White rabbits for 6 months. Five additional animals served as controls with injections of saline/dextrose. Muscle weakness was assessed by muscle wet mass, isometric knee extensor torque, and histological morphology analysis. Cell metabolism was assessed for patellar tendon, medial and lateral collateral ligament, and medial and lateral meniscus by measuring the total RNA levels and specific mRNA levels for collagen I, collagen III, MMP-1, MMP-3, MMP-13, TGF-ß, biglycan, IL-1, and bFGF by reverse transcription and polymerase chain reaction. While the total RNA levels did not change, tissue-specific mRNA levels were lower for relevant anabolic and catabolic molecules, indicating potential changes in tissue mechanical set points. Quadriceps weakness may lead to adaptations in knee joint tissue cell metabolism by altering a subset of anabolic and catabolic mRNA levels corresponding to a new functional and metabolic set point for the knee that may contribute to the high injury rate of athletes with muscle weakness.

The StarClose Vascular Closure System: interventional results from the CLIP study.

BACKGROUND: The StarClose Vascular Closure System is a femoral access site closure technology that uses a flexible nitinol clip to complete a circumferential, extravascular arteriotomy close. The Clip CLosure In Percutaneous Procedures study was initiated to study the safety and efficacy of the StarClose device in subjects undergoing diagnostic and interventional catheterization procedures. METHODS: A total of 17 U.S. sites enrolled 596 subjects, with 483 subjects randomized at a 2:1 ratio to receive StarClose or standard compression of the arteriotomy after the percutaneous procedure. The study included roll-in (n = 113), diagnostic (n = 208), and interventional (n = 275) arms with a primary safety endpoint of major vascular complications through 30 days and a primary efficacy endpoint of postprocedure time to hemostasis. RESULTS: The results of the diagnostic StarClose cohort have been reported separately. Results for the interventional arm revealed major vascular complications occurring in 1.1% of StarClose subjects (2/184) and 1.1% in manual compression subjects (1/91; P = 1.00). No infections were seen in either cohort. Minor complications in the StarClose interventional group occurred at a rate of 4.3% (8/184) and with compression at 9.9% (9/91; P = 0.107). Pseudoaneurysm or arteriovenous fistula was not seen with StarClose. With StarClose, procedural success was 100% (136/136) for the diagnostic group and 98.9% (181/183) in the interventional group. Device success for the treatment group was 86.8%. In the interventional cohort, 87.3% (158/181) of StarClose subjects reported a pain scale of 0-3 compared with 93.3% (84/90) in the compression group, which was not statistically different. CONCLUSIONS: The clinical results of this study demonstrate that the StarClose Vascular Closure System is noninferior to manual compression with respect to the primary safety endpoint of major vascular events in subjects who undergo percutaneous interventional procedures. StarClose significantly reduced time to hemostasis, ambulation, and dischargeability when compared with compression.

Rotational atherectomy or balloon angioplasty in the treatment of intra-stent restenosis: BARASTER multicenter registry.

The BARASTER registry was formed to evaluate the initial success and long-term results of rotational atherectomy in the management of in-stent restenosis. Rotational atherectomy was used in 197 cases of in-stent restenosis: 46 with stand-alone rotational atherectomy or at most 1 atmosphere of balloon inflation (Rota strategy), and 151 with rotational atherectomy and adjunctive balloon angioplasty <1 atmosphere (Combination strategy). These were compared with 107 episodes of in-stent restenosis treated with balloon angioplasty alone. In this observational study, the use of Combination therapy was associated with a slightly higher initial success rate (95% vs. 87% with the Rota strategy and 89% with Balloons, P = 0.08). There was a reduction in one year clinical outcomes (death, myocardial infarction or target lesion revascularization) in the combination group (38% vs. 60% with Rota and 52% with balloons, P = 0.02). These data support a benefit of the strategy of debulking with rotational atherectomy followed by adjunctive balloon angioplasty, in the management of in-stent restenosis.

The PARAGON stent study: a randomized trial of a new martensitic nitinol stent versus the Palmaz-Schatz stent for treatment of complex native coronary arterial lesions.

A new martensitic nitinol stent with improved flexibility and radiopacity was tested to evaluate whether these differences improve initial or long-term outcome. Patients who underwent percutaneous revascularization of a discrete native coronary lesion were randomly assigned to the new stent (PARAGON, n = 349) or to the first-generation Palmaz-Schatz (PS) stent (n = 339). The primary end point was target vessel failure at 6 months (a composite of cardiac or noncardiac death, any infarction in the distribution of the treated vessel, or clinically indicated target vessel revascularization). Secondary end points were, among others, device and procedural success and angiographic restenosis. Mean age was 62 years; diabetes was present in 21% of patients, prior bypass surgery in 6%, and recent infarction in 22% (p = NS for comparison between the 2 randomized arms). The PARAGON stent group had smaller reference vessels (2.97 vs 3.05 mm, p = 0.05), more prior restenosis (8.0% vs 4.5%, p = 0.07), and a longer average stent length (21.3 vs 19.4 mm, p < 0.05). Device success was significantly higher in the PARAGON arm (99.1% vs 94.3%, p < 0.05). Death and infarction at 6-month follow-up were infrequent in both groups. There was no significant difference in death (2.0% vs 1.2%, p = 0.546), but a higher rate of infarction for the PARAGON cohort (9.2% vs 4.7%, p = 0.025). Although target vessel failure (20.3% vs 12.4%, p = 0.005) and target lesion revascularization (12.0% vs 5.9%, p = 0.005) were higher in the PARAGON group, there was no significant difference in 6-month follow-up in in-stent minimal lumen diameter or in the rate of binary angiographic restenosis. Both PARAGON and PS stents are safe and associated with infrequent adverse events. The PARAGON stent can be delivered more frequently than the first-generation PS stent. Although there was no significant difference in in-stent minimal lumen diameter or the frequency of angiographic restenosis, clinical restenosis was more frequent in the PARAGON group.

[The manual lifting of patients: the results of an assessment of exposure to the specific risk and of a clinical study in a rehabilitative institute]. / Movimentazione manuale pazienti: risultati della valutazione dell'espozione al rischio specifico e dell'indagine clinica in un istituto riabilitativo.

An investigation was carried out in a rehabilitation centre in the Province of Milan in order to quantify exposure to patient handling and assess impairment of the spine induced by this risk factor. Altogether 5 departments were analyzed, with different rehabilitation aims (cardiological, respiratory and neurological); 97 of the 104 exposed staff underwent physical examination by an occupational health physician. Both exposure assessment and identification of impairment were performed using the methods proposed by the EPM Research Group. The exposure indices (MAPO Index) were high in 4 departments (5.6, 6.75, 8.81 and 13.8) and only one department had an index of 2.95 which is considered low-medium. The prevalences of impairment of the lumbar region of the spine were also higher in this group of workers compared to those found in other hospitals. In particular, the disorders of the lumbar spine reported were 45.4% in the males and 62.6% in the females. Of these 13% showed a third grade SAP. About 11% of the workers who underwent physical examination reported episodes of acute low back pain in the previous 12 months with a frequency 4 times higher than that found in group of unexposed workers. Analysis of the rehabilitation centre drew attention to the need for improvement measures that took into account the particular nature of the care services involved as in some cases it is not always possible to use equipment and aids to assist certain manual handling. In these cases the solutions involve the organization aspects especially. The results of this study were used by the rehabilitation centre management in order to plan the interventions for improvement. On the whole it was shown that analysis of this risk factor and health surveillance of exposed workers in such particular structures as rehabilitation centres is of considerable importance.

Reoperation for Hirschsprung's disease.

BACKGROUND/PURPOSE: Reoperation for Hirschsprung's disease traditionally has been used for patients with anastomotic leaks or stricture or with severe constipation from retained aganglionic segment or neuronal dysplasia, but there is little information regarding its use for other complications and the long-term outcome in these patients. METHODS: In a 23-year period, 107 infants and children underwent Soave (68 patients) or Duhamel (39 patients) pull-through procedures. The age at operation was newborn to 6 years (mean, 10 months). Eighty percent had aganglionosis limited to the rectosigmoid colon. Follow-up was by office visit or telephone (mean, 8.5 years). RESULTS: Twenty-three of the 68 patients with Soave pull-through (34%) underwent reoperation for intractable enterocolitis (10 patients, all 10 cured); anastomotic stenosis (four patients, three cured, one continued diversion); anastomotic leak (four patients, four cured); retained aganglionic segment (three patients, three cured); one necrosis of pull-through converted to Duhamel and cured; and one rectal prolapse that was diverted. Fifteen of the 39 patients with Duhamel procedure (38%) underwent reoperation for severe constipation (seven patients, six cured, one diverted); persistent rectal septum (four patients, 4 cured); and intractable enterocolitis (four patients, three cured, one diverted). Overall, 21 of 23 patients (91%) with reoperation after Soave procedures were cured, whereas 13 of 15 patients (87%) who underwent reoperation after Duhamel procedure were cured, and four patients remain diverted. CONCLUSIONS: These data show that aggressive reoperation can result in a high cure rate in Hirschsprung's disease. Although there is no significant difference in the rate of reoperation after Duhamel and Soave procedures, the patients with Soave pull-through required more complex reoperations, with several requiring more than one procedure. An aggressive approach to reoperation in patients with Hirschsprung's disease clearly is justified.

Heart transplantation among 233 infants during the first six months of life: the Loma Linda experience. Loma Linda Pediatric Heart TransplantGroup.

Two hundred thirty-three heart transplantations were performed in infants during their first 6 months of life at Loma Linda University between November, 1985 and June, 1999. Survival has now exceeded 13 years. Nearly 70% of infants are expected to live at least 10 years. Those transplanted during the first 30 days of life have about a 15% survival advantage at 10 years. Scarcity of donors continues to limit the transplantation effort. While acute rejection is the most common cause of late mortality, posttransplant coronary artery disease (PTCAD) is the leading cause of graft loss affecting 22 recipients (9.5%). The majority of patients are asymptomatic prior to diagnosis of PTCAD and are either retransplanted or dead within 6 months. Retransplantation (9 of 11 retransplantations for PTCAD) has been highly successful, with 10 year actuarial survival of 91%. Posttransplant lymphoproliferative disease (PTLD) has been found in only 7 patients (3%), most commonly in lymph nodes. Causes of late mortality include acute rejection (n = 16), PTCAD (n = 9), infection (n = 7), PTLD (n = 2), chronic graft dysfunction (n = 2), arrhythmia (n = 1), recurrent pulmonary vein stenosis (n = 1), and other noncardiac causes (n = 4). Infant psychomotor development is mildly delayed although cognitive development is normal. School-age children are performing at the level of their peers with average achievement and low average intelligence testing. Heart transplantation is durable therapy for newborns and infants with structurally incurable and end-stage myopathic heart disease.

Molecular characterization of FRAXE-positive subjects with mental impairement in two unrelated Italian families.

The FRAXE fragile site, 600 Kb distal to the more common FRAXA, has been reported to be expressed in subjects with mild nonsyndromal mental retardation. Amplification of more than 200 GCC repeats associated with methylation of the adjacent CpG island at Xq28 is responsible for FRAXE fragility. We describe two unrelated, mentally retarded males identified during a screening for fragile X syndrome. Both index cases underwent FRAXE molecular analysis, following cytogenetic expression of the fra X site and negative FRAXA test. In family 1, we were able to investigate other 13 subjects over three generations, identifying two additional FRAXE-positive males, one with a fully mutated allele and one with a mosaic genotype. Detailed evaluation of physical traits and psychometric tests was performed on three retarded males from family 1 and the propositus from family 2. All of them were found to lack a definite phenotype, and showed different degrees of mental retardation. Slight mental retardation was evident in the mosaic male, suggesting that methylation might be an important determinant of mental impairment.

Final results of the Balloon vs Optimal Atherectomy Trial (BOAT)

BACKGROUND: Previous directional coronary atherectomy (DCA) trials have shown no significant reduction in angiographic restenosis, more in-hospital complications, and higher 1-year mortality than conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]). DCA, however, has subsequently evolved toward a more "optimal" technique (larger devices, more extensive tissue removal, and routine postdilation to obtain diameter stenosis <20%). METHODS AND RESULTS: The Balloon vs Optimal Atherectomy Trial (BOAT) was conducted to evaluate whether optimal DCA provides short- and long-term benefits compared with balloon angioplasty. One thousand patients with single de novo, native vessel lesions were randomized to either DCA or PTCA at 37 participating centers. Lesion success was obtained in 99% versus 97% (P=.02) of patients to a final residual diameter stenosis of 15% versus 28% (P<.0001) for DCA and PTCA, respectively, the latter including stents in 9.3% of the patients. There was no increase in major complications (death, Q-wave myocardial infarction, or emergent coronary artery bypass graft surgery [2.8% versus 3.3%]), although creatine kinase-MB >3X normal was more common with DCA (16% versus 6%; P<.0001). Angiographic restudy (in 79.6% of eligible patients at 7.2+/-2.6 [median, 6.9] months) showed a significant reduction in the prespecified primary end point of angiographic restenosis by DCA (31.4% versus 39.8%; P=.016). Clinical follow-up to 1 year showed nonsignificant 13% to 17% reductions in the DCA arm of the study for mortality rate (0.6% versus 1.6%; P=.14), target-vessel revascularization (17.1% versus 19.7%; P=.33), target-site revascularization (15.3% versus 18.3%; P=.23), and target-vessel failure (death, Q-wave myocardial infarction, or target-vessel revascularization, 21.1% versus 24.8%; P=.17). CONCLUSIONS: Optimal DCA provides significantly higher short-term success, lower residual stenosis, and lower angiographic restenosis than conventional PTCA, despite failing to reach statistical significance for reducing late clinical events compared with PTCA with stent backup.

Comparison of early and recent results with rotational atherectomy.

OBJECTIVES: We compared an early registry of rotational atherectomy with a recent registry to examine the evolution of patient profiles, lesion characteristics and procedural outcomes for patients treated with rotational atherectomy. BACKGROUND: With increased experience, the selection of patients and lesions treated with a device matures. This study documents the changes in the application of rotational atherectomy. METHODS: The patient characteristics and procedural outcomes from two multicenter patient registries-Registry I: 2,953 procedures, 3,717 lesions from 1988 to 1993; and Registry II: 200 procedures, 268 lesions from 1994-were analyzed and compared. RESULTS: There was an increase in the average age of the patients (63 vs. 65 years, p < 0.02) and the proportion of patients with unstable angina (42.9% vs. 56.5%, p < 0.01) or previous coronary artery bypass graft surgery (18.8% vs. 24.5%, p < 0.05) in Registry II. Registry II included fewer left anterior descending coronary lesions (46.5% vs. 32.8%, p < 0.01), more type B and C lesions (83.1% vs. 91.8%, p < 0.01), more eccentric lesions (69.0% vs. 79.5%, p < 0.01) and more calcified lesions (50.3% vs. 69.4%, p < 0.01). Complications, including urgent bypass surgery, Q and non-Q wave myocardial infarction, dissection, acute occlusion and perforation, were similar in the two groups. However, mortality increased from 1.0% to 3.0% (p < 0.05) in Registry II. CONCLUSIONS: Comparison of recent and early patients treated with rotational atherectomy revealed an increase in the complexity of patients and lesions. Although the rate of death was increased, the overall rate of major complications was not significantly changed (4.7% vs. 6.0%, p = NS).

Spherophakia associated with molybdenum cofactor deficiency.

Molybdenum cofactor deficiency is an autosomal recessive disorder characterized by lack of activity of the enzymes sulfite oxidase, aldehyde oxidase, and xanthine dehydrogenase or oxidase. The clinical manifestations are indistinguishable from those of isolated sulfite oxidase deficiency: craniofacial alterations, intractable neonatal convulsions, very severe mental retardation, lens dislocation, and death in the first decade of life. Lens dislocation is found in nearly all patients after neonatal age. In the present case it developed late (at the age of 8 years) and was preceded by bilateral spherophakia. We hypothesize that an abnormal relaxation of the zonular fibers is the cause of spherophakia in this disease; this causes lens dislocation eventually, after days, months, or years.

Critical analysis of the operative treatment of Hirschsprung's disease.

OBJECTIVE: To critically analyze complications and long-term results of the operative treatment of Hirschsprung's disease. DESIGN: Medical records of patients with Hirschsprung's disease were reviewed retrospectively. Follow-up was obtained using a standardized telephone questionnaire. SETTING: Major pediatric referral center. PATIENTS: Eighty-two infants and children (68 boys, 14 girls) were treated for Hirschsprung's disease during a 20-year period (1975 to 1994). The age at diagnosis was younger than 30 days in 47 neonates (57%), 30 days to 1 year in 22 infants (27%), and older than 1 year in 13 children (16%). Aganglionosis was limited to the rectosigmoid region in 66 patients (81%). Fifty-five Soave (endorectal) and 27 Duhamel (retrorectal) primary pull-through operations were performed. MAIN OUTCOME MEASURES: Postoperative complications, reoperations, hospitalization, and current bowel habits. RESULTS: Eighteen children (67%) undergoing the Duhamel operation recovered uneventfully compared with 33 children (60%) undergoing the Soave operation. The complications following the Duhamel operation included enterocolitis in five cases (19%), rectal achalasia in four cases (15%), and persistent rectal septum in two cases (7%). Additional operations, which included myomectomy, rectal septum division, diverting enterostomy, and sphincterotomy, were required in seven patients (26%). Only one patient required more than one reoperation. In contrast, complications following the Soave operation included enterocolitis in 15 cases (27%), rectal stenosis in 12 (22%), anastomotic leak in four (7%), late perirectal fistula in three (5%), rectal prolapse in one (2%), and recurrent severe constipation in one (2%). Sixteen patients (29%) required additional operations, including diverting enterostomy, myomectomy, redo pull-through, sphincterotomy, fistulectomy, and revision of rectal prolapse. In this group nearly two reoperative procedures per patient were required. Telephone follow-up (mean, 89.3 months) after pull-through operations in 61 patients (74%) showed a mean of 2.8 stools per day, with 13 patients (21%) requiring daily medications. CONCLUSIONS: The most common operations (Soave and Duhamel) for Hirschsprung's disease result in an uneventful recovery in only 60% to 67% of patients. Although both Soave and Duhamel pull-through operations have nearly identical reoperation rates (26% vs 29%), complications after Soave pull-through operations often require multiple, more extensive procedures. Short-term total continence rates for both procedures are less than 50%, however, 100% became continent by 15 years after the pull-through procedure. Further refinement in operative technique and close follow-up are warranted.

Directional coronary atherectomy: experience in 310 patients.

This article describes the acute and long-term clinical outcomes of 310 consecutive patients who underwent directional coronary atherectomy (DCA) for treatment of coronary artery disease. An overall procedural success rate of 95% was noted with a total major complication rate of 5%. Analyses of minimal luminal diameter (MLD) were performed pre- and post-procedure for 160 patients. Clinical follow-up including treadmill testing and/or clinical symptoms was obtained on 293 patients. Results of angiographic analyses corresponded with the Kuntz model suggesting that larger MLDs are associated with lower restenosis rates. The overall target vessel revascularization rate was 27.6%, with a mean post-procedure percent diameter stenosis of 16%. These results indicate that DCA is associated with acceptable clinical restenosis rates, complications and long-term outcome.

Erythrocyte antioxidant system and serum ceruloplasmin levels in welders.

The erythrocyte antioxidant system (superoxide dismutase, catalase, glutathione peroxidase, reduced glutathione) and serum ceruloplasmin were studied in workers chronically exposed to welding fumes and gases, which are thought to be oxidant pollutants. Fifty-four healthy men using two electric arc welding processes (manual metal arc on stainless steel and mild steel, and metal inert gas on mild steel) were studied. The possible effects of cigarette smoking were also considered. The erythrocyte antioxidant system was in the normal range for all welders. Serum ceruloplasmin was significantly enhanced only in smoking welders and higher in manual metal arc than in metal inert gas welders, suggesting that the increase is related to the severity of the oxidant threat, which is more stressful for the workers using the manual metal arc technique because of the presence of stainless steel particles in the fumes. Although cigarette smoking alone did not increase serum ceruloplasmin levels, it affected the response to oxidant stress in welders.

Mitotic activity and DNA synthesis of rat islet cells following partial pancreatectomy.

The regenerative potential of the adult rat pancreas following a 50% pancreatectomy was investigated. Blood glucose values and body weight were unchanged by the procedure. The mitotic index (MI) of alpha, beta, and exocrine cells was examined in formalin-fixed sections of the pancreas stained for hormones and 5-bromo-2'-deoxyuridine (BrDU) after treating the animals with 2.5 mg/kg colchicine and/or 50 mg/kg BrDU prior to sacrifice. The MI was unchanged within the control group. For pancreatectomized versus control animals, in beta cells after 5 days the MI was 0.84% versus 0.41% (p less than 0.05), while 7 days postoperatively it was 1.04% versus 0.57% (p less than 0.01); in alpha cells, the MI was 0.32% versus 0.17% (p less than 0.05) at 5 days and 0.47% versus 0.24% (p less than 0.05) at 7 days. The MI of exocrine cells rose transiently on day 3 postoperatively to 0.74% in the pancreatectomized group but remained low at 0.15% (p less than 0.01) in the control group. The mean ratio of BrDU + ve beta cells was 1.19% in the pancreatectomy group and 0.45% in the control group on day 5 postoperatively (p = 0.01). A highly significant (r = 0.97; p less than 0.001) correlation existed between BrDU + ve and mitotic cells. There was no difference between the two groups in the area occupied by insulin-positive cells in pancreatic sections, nor in the number of beta cells per islet.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ambulatory electrocardiographic monitoring: a comparison of ischemic changes of the ST-segment and coronary cineangiography]. / Monitorização eletrocardiográfica ambulatorial: comparação entre alterações isquêmicas do segmento ST e a cinecoronariografia.

PURPOSE: To determine the usefulness of an ambulatory electrocardiographic monitoring system, in identifying atherosclerotic coronary artery disease among symptomatic and asymptomatic patients, through a comparison of ST-segment depression with angiographic findings. METHODS: Fifty patients, 48 men, with the mean age 49 +/- 13 years (range 20 to 73), presenting ST-segment depression, were submitted to coronary angiography, complemented by echocardiogram and exercise testing, when the angiography was considered normal. According to the symptoms patients were divided into three groups: I--asymptomatic (16-32%); II--atypical chest pain (15-30%); and III--angina (19-38%). The Cardiac Care Units (Compass TM) system was used for the ambulatory electrocardiographic monitoring. RESULTS: Twenty-four patients (48%) had significant atherosclerotic coronary artery disease documented angiographically. Twenty-six patients (52%) had normal coronary arteries by angiography: 18 (36%), presented some pathology demonstrated by echocardiographic studies (left ventricle hypertrophy, mitral valve prolapse, non-obstructive septal hypertrophy, dilated cardiomyopathy). Eight patients (16%) had normal echocardiograms, and in (6%) the exercise test was positive and in the other 5 (6%) negative. One of those patients (2%), with negative exercise test, had a myocardial bridge over the anterior descending branch of the left coronary artery, 2 patients (4%) presented symptomatic episodes of ST depression, and 2 other patients (4%) were asymptomatic. CONCLUSION: A comparison of the ST depression analysed in real time during ambulatory electrocardiographic monitoring with the cinecoronarographic findings showed a poor correlation of the two methods in identifying atherosclerotic coronary disease. The ischemic depressions of ST-segment were associated to obstructive lesions or slow flow in the coronary arteries in only 48% of the cases studied.

Seven cases of trisomy 3 mosaicism in chorionic villi.

This paper describes seven cases of confined chorionic mosaicism with trisomy 3. The chromosomally abnormal cell line in chorionic villi was revealed in three cases at diagnostic CVS and in four cases at the evacuation of the uterine cavity after a missed abortion had been diagnosed by ultrasound. In two of these cases, the abortion occurred after apparently normal development of the fetus during the second trimester of pregnancy. An evaluation of the effect of confined chorionic mosaicism with trisomy 3 on the viability of the conceptus has been attempted.

[Carpal tunnel syndrome in shoe hemmers]. / La sindrome del tunnel carpale nelle orlatrici calzaturiere.

The authors verified the working activity of patients observed at the Division of Orthopaedics and Traumatology, Porto San Giorgio Hospital between 1986 and 1987 for symptoms of median nerve compression at the wrist. Moreover, the pathogenetic relationship between repetitive movement and carpal tunnel syndrome were also studied. Out of a total of 267 cases, including 201 women and 66 men, 67 worked as shoe hemmers. Twenty-five percent of the total number of patients were shoe hemmers, and 33% of these were females. The Authors observed a thickened and fibrous carpal transverse ligament in these patients who were employed in hand-repetitive tasks. This swollen ligament probably compresses the median nerve at the wrist.