Hepatitis B and C coinfection in a real-life setting: viral interactions and treatment issues.

BACKGROUND: Only limited data concerning hepatitis B (HBV) and C viruses (HCV) coinfection are available. Direct-acting antivirals (DAAs) may be more effective for HCV clearance than interferon (IFN)-based regimens with a risk of HBV reactivation. METHODS: We retrospectively enrolled 40 HBV/HCV-coinfected patients to evaluate their clinical profile and treatment outcomes. RESULTS: Chronic dual infection was present in 25/40 (62.5%) patients, acute HCV superinfection in 5/40 (12.5%) patients and acute HBV superinfection in 10/40 (25%). Twenty-five patients (62.5%) were treated: 16/25 (64%) with IFN, 4/25 (16%) with nucleot(s)ide analogs (NUCs) and 5/25 (20%) with DAAs. Of the 16 patients treated with IFN-based therapy, 6 (37.5%) achieved both sustained virological response (SVR) and HBsAg clearance. Of the 4 patients treated with NUCs, one (25%) achieved both SVR and HBsAg clearance. All five patients treated with DAAs (100%) achieved SVR, while one case of HBV reactivation was recorded. Fifteen of the 40 patients (37.5%) did not receive any treatment. Eight of them (53.5%) presented with acute HBV superinfection: spontaneous HCV clearance was recorded in 5/8 (62.5%), while HBsAg clearance occurred in 6/8 (75%). Three of them (20%) presented with acute HCV superinfection; spontaneous HCV clearance was recorded in one of the three (33.5%). The other four patients (26.5%) presented with dual HBV/HCV infection. CONCLUSIONS: A significant proportion of patients presented with active HBV replication. Treatment with DAAs seems to be efficacious for HCV eradication. However, clinicians should be aware of HBV reactivation. HBV superinfection may lead to both HBsAg and HCV clearance.

Ischemia-Reperfusion Injury of Sciatic Nerve in Rats: Protective Role of Combination of Vitamin C with E and Tissue Plasminogen Activator.

An ischemia/reperfusion injury of rat's sciatic nerve was experimentally developed. In this model, we measured the in vivo production of superoxide radical, as a marker of oxidative stress and the occludin expression as an indicator of blood-nerve barrier function and we examined potential protective innervations against these abnormalities. Right sciatic nerves of the animals underwent 3 h of ischemia followed by 7 days of reperfusion and were divided into three groups: ischemic, pretreated with vitamin C in conjunction with vitamin E and treated with tissue plasminogen activator. Compared to measurements from left sciatic nerves used as sham, the ischemic group showed significantly increased superoxide radical and reduced expression of occludin in western blot and immunohistochemistry. No such differences were detected between sham and nerves in the vitamin or tissue plasminogen activator groups. It is suggested that the experimental ischemia/reperfusion model was suitable for studying the relationship between oxidative state and blood-nerve barrier. The reversion of abnormalities by the applied neuroprotective agents might prove to be a clinically important finding in view of the implication of vascular supply derangement in various neuropathies in humans.

Parenteral MCT/ω-3 Polyunsaturated Fatty Acid-Enriched Intravenous Fat Emulsion Is Associated With Cytokine and Fatty Acid Profiles Consistent With Attenuated Inflammatory Response in Preterm Neonates: A Randomized, Double-Blind Clinical Trial.

BACKGROUND: Soybean oil-based intravenous fat emulsion (IVFE) administered to preterm neonates can induce oxidative stress and inflammatory response, which are associated with severe complications of prematurity. This study aimed to test the hypothesis that administration of medium-chain triglyceride (MCT)/ω-3 polyunsaturated fatty acid (PUFA)-enriched IVFE in preterm neonates is associated with a cytokine and fatty acid (FA) profile consistent with attenuated inflammatory response. PATIENTS/METHODS: In a double-blind randomized study, 60 preterm neonates (gestational age 26-32 weeks) were randomized to receive either MCT/ω-3 PUFA-enriched IVFE (intervention group) or soybean oil-based IVFE (control group). Serum biochemistry, tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-8, α-tocopherol, and FAs were assessed at baseline, on day of life 15, and day of life 30 or at the end of intervention. RESULTS: All cytokine levels changed significantly across the 3 time points, whereas the type of IVFE had a significant effect on final IL-6 and IL-8 levels, which were lower in the intervention group. The difference in final IL-6 and IL-8 levels remained significant after controlling for bronchopulmonary dysplasia and/or infection. α-Tocopherol and FA values changed significantly over time. MCT/ω-3 PUFA-enriched IVFE administration was associated with significantly higher α-tocopherol, eicosapentaenoic acid, docosahexaenoic acid, and ω-3 PUFAs and lower linolenic acid, total PUFA, and ω-6/ω-3 PUFA values compared with soybean oil-based IVFE. Both IVFEs were well tolerated. CONCLUSION: Compared with the soybean oil-based IVFE, the MCT/ω-3 PUFA-enriched IVFE is associated with a more favorable cytokine and FA profile consistent with attenuated inflammatory response in preterm neonates.

The spectrum of HBV/HCV coinfection: epidemiology, clinical characteristics, viralinteractions and management.

Monoinfection with either hepatitis B (HBV) or C virus (HCV) represents one of the major causes of chronic liver disease globally. However, in endemic areas a substantial number of patients are infected with both viruses mainly as a result of the common routes of transmission. Numerous studies have demonstrated that dually infected patients carry a greater risk of advanced liver disease, cirrhosis and hepatocellular carcinoma compared with monoinfected patients. The choice of treatment is based on the virological profile of each patient taking into account the dominant virus pattern. In predominant HCV, standard combination treatment with pegylated interferon and ribavirin has proven equally effective in HBV/HCV-coinfected patients as well as in HCV-monoinfected patients. Strikingly, approximately 60% of patients with inactive HBV infection before HCV treatment may present HBV reactivation while others experience hepatitis B surface antigen seroconversion after clearing HCV, demonstrating the complexity of the interaction between the two viruses during the follow up. The therapeutic strategies for the predominant HBV dually infected patients are more vague, although high genetic barrier nucleos(t)ide analogues play an indisputable role. Finally, the recently approved combination treatments for chronic hepatitis C containing direct-acting antivirals may definitely change the treatment protocols in the future although there is no experience with these drugs in dually infected patients until today.

Oxygen-plasma-modified biomimetic nanofibrous scaffolds for enhanced compatibility of cardiovascular implants.

Electrospun nanofibrous scaffolds have been extensively used in several biomedical applications for tissue engineering due to their morphological resemblance to the extracellular matrix (ECM). Especially, there is a need for the cardiovascular implants to exhibit a nanostructured surface that mimics the native endothelium in order to promote endothelialization and to reduce the complications of thrombosis and implant failure. Thus, we herein fabricated poly-ε-caprolactone (PCL) electrospun nanofibrous scaffolds, to serve as coatings for cardiovascular implants and guide tissue regeneration. Oxygen plasma treatment was applied in order to modify the surface chemistry of the scaffold and its effect on cell attachment and growth was evaluated. The conditions of the surface modification were properly adjusted in order to define those conditions of the treatment that result in surfaces favorable for cell growth, while maintaining morphological integrity and mechanical behavior. Goniometry (contact angle measurements), scanning electron microscopy (SEM), atomic force microscopy (AFM), and X-ray photoelectron spectroscopy (XPS) measurements were used to evaluate the morphological and chemical changes induced by the plasma treatment. Moreover, depth-sensing nanoindentation was performed to study the resistance of the plasma-treated scaffolds to plastic deformation. Lastly, the cell studies indicated that all scaffolds were cytocompatible, with the plasma-treated ones expressing a more pronounced cell viability and adhesion. All the above findings demonstrate the great potential of these biomimetic tissue-engineering constructs as efficient coatings for enhanced compatibility of cardiovascular implants.

Occludin dislocation in brain capillary endothelium of rats with bile duct ligation induced cholestasis.

The present study used a rat model with bile duct ligation to examine the effect of cholestasis, to the localization of occludin in brain capillary endothelium by means of electronic microscopy. The results demonstrated a dislocation of occludin away from the tight junction sites of brain endothelial cells. A significant increase of the occludin-interendothelial cleft distance was demonstrated in the midbrain and the cerebellum samples but not in the frontal cortex, compared to the control group samples. These findings imply a brain region selective derangement of occludin in response to liver disease.

Cholestasis, bronchopulmonary dysplasia, and lipid profile in preterm infants receiving MCT/ω-3-PUFA-containing or soybean-based lipid emulsions.

BACKGROUND: This study aimed to compare the effect of 2 lipid emulsions (LEs), a medium-chain triglyceride (MCT)/ω-3-polyunsaturated fatty acid (PUFA)-containing LE and a soybean-based LE, on the incidence of neonatal cholestasis, bronchopulmonary dysplasia (BPD), and lipid profile of preterm infants. Patients and METHODS: In this prospective, observational study, 2 groups of preterm neonates, the very low birth weight (VLBW) (n = 129) and the low birth weight (LBW) groups (n = 153), which received parenteral LEs for at least 7 days, were included. Infants received either MCT/ω-3-PUFA-containing LE (SMOFlipid, subgroup I) or soybean-based LE (Intralipid, subgroup II) according to the attending neonatologist's preference and availability. Full biochemical assessment was performed on days of life 15, 30, and 45 and on discharge. RESULTS: Of the VLBW infants, 7.4% and 13.3% of infants in subgroups I and II, respectively, developed cholestasis (P = .39; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.15-1.76). The duration of LE administration was independently associated with cholestasis (P < .001; OR, 0.925; 95% CI, 0.888-0.963). The maximum amounts of lipids administered ranged between 1.6 and 3.6 g/kg/d in both VLBW subgroups. The VLBW subgroup I had lower incidence of BPD, lower alkaline phosphatase and phosphate, higher high-density lipoprotein (HDL), and lower cholesterol-to-HDL ratio on discharge than the VLBW subgroup II. The type of LE was independently associated with BPD and alkaline phosphatase. In the LBW group, the type of LE was not associated with clinical and biochemical parameters. CONCLUSION: In VLBW infants, the MCT/ω-3-PUFA-containing LE administration is associated with decreased BPD and more favorable lipoprotein profile. Although a trend toward a lower incidence of cholestasis was observed, a preventive effect of MCT/ω-3-PUFA-containing LE on parenteral nutrition-associated cholestasis is not supported.

Mutational analysis for biotinidase deficiency of a Greek patients' cohort ascertained through expanded newborn screening.

Late-onset multiple carboxylase deficiency, also known as biotinidase (BTD) deficiency, is an autosomal recessively inherited disorder of biotin metabolism. Its early diagnosis and treatment seems that it can even fully prevent its various clinical manifestations. Mutations in the BTD gene scattered throughout its coding region have been detected in patients ascertained either through newborn screening or clinically. From March 2010 up to June 2011, 18 954 Greek neonates were subjected to biochemical determination of BTD activity through a semiquantitative fluoroimmunoassay. Subsequently, the first cohort of our 'suspected' samples was further tested for the presence of aberrations associated either with partial or profound BTD deficiency through sequencing of the coding region of the BTD gene, including splice-site junctions. On the basis of the molecular data derived from the study of our first cohort of 'suspected' samples, a panel of four mutations, most frequently encountered in the Greek population, was created, and a rapid, reliable and cost-effective real-time-based genotyping assay for the detection of these mutations was developed. This is the first report about the BTD mutational spectrum in Greece, and it could be a beneficial utility in the differential clinical diagnosis of BTD deficiency.

Association of reduced zinc status with angiographically severe coronary atherosclerosis: a pilot study.

In vitro studies attribute antiatherogenic and insulin-like properties to zinc (Zn). However, only a few conflicting clinical data exist concerning the relationship between Zn and coronary artery disease (CAD) as well as glycemic indices. We studied 72 patients without prior history of myocardial infarction or revascularization procedures, who underwent coronary angiography for evaluation of chest pain. Coronary artery disease severity was estimated using 3 angiographic scores. Zn in serum and 24-hour urine, as well as serum Zn/24-hour urine Zn ratio were determined. Serum Zn was not associated with CAD prevalence and severity. However, urinary Zn loss was significantly higher among patients with CAD and showed a positive association with CAD severity. Serum Zn/24-hour urine Zn ratio was inversely associated with CAD, as well as with diabetes mellitus prevalence, fasting glucose, and glycated hemoglobin levels. Low serum Zn/24-hour urine Zn ratio is associated with angiographically severe atherosclerosis and impaired glucose homeostasis.

Metabolic syndrome and angiographic coronary artery disease prevalence in association with the Framingham risk score.

BACKGROUND: The association of metabolic syndrome with coronary artery disease (CAD) has been studied extensively. However, little is known about the effect of Framingham risk score (FRS) and metabolic syndrome components on the association of metabolic syndrome with angiographically significant CAD. Our aim was to investigate whether that relationship is influenced by individual's 10-year CAD risk profile as assessed by FRS. Furthermore, we sought to elucidate whether metabolic syndrome is associated with angiographically significant CAD independently of its individual components. METHODS: We studied a consecutive sample of 150 patients undergoing coronary angiography for the evaluation of chest pain. Metabolic syndrome was defined according to the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria, and the 10-year CAD risk was estimated by the FRS. RESULTS: Metabolic syndrome patients had a 2-fold higher CAD prevalence compared to those without metabolic syndrome [odds ratio (OR), 2.004; 95% confidence interval (CI), 1.029-3.905] but this finding was attenuated after adjustment for FRS (OR, 1.770; 95% CI, 0.872-3.594). Stratification of patients into three groups according to FRS revealed that metabolic syndrome predictive ability was confined in those being at <10% 10-year CAD risk. Including metabolic syndrome and its individual components into the same logistic regression model, only the glucose criterion was an independent predictor of angiographically significant CAD (OR, 4.137; 95% CI, 1.477-11.583). CONCLUSIONS: Metabolic syndrome is an independent determinant of angiographically significant CAD only among those individuals at low 10-year risk for future coronary events. Individual components of the syndrome, such as impaired fasting glucose, have a stronger association with CAD than the syndrome as a whole.

Altered occludin expression in brain capillaries induced by obstructive jaundice in rats.

The development of increased oxidative stress in the context of obstructive cholestasis has been proven in various rats' organs including the brain. The present study aimed to detect alterations of tight junction-associated occludin in rat brain capillaries after bile duct ligation (BDL). In experiment 1, occludin expression was evaluated by Western blot analysis in 5 animals 10 days after BDL and compared with 5 sham-operated ones. In experiment 2, groups of 9 animals each were used to assess occludin levels on the 1st, 5th, and 10th days after BDL and to associate these measurements with the in vivo superoxide radical production measured by means of an ultrasensitive fluorescent assay. The results indicated that occludin expression in BDL animals, as opposed to sham-operated, was significantly reduced at every time point studied, being lowest in the rats remaining on BDL condition for 10 days. Moreover, it was demonstrated that the time-dependent downregulation of occludin expression in the brain endothelial was significantly correlated with the time-dependent increase of brain superoxide radical level, implying a relationship between these two abnormalities. In conclusion, the evidence presented herein suggests the implication of occludin and, therefore, of blood-brain barrier in the pathophysiology of extrahepatic cholestasis.

Metabolism of polyamines and oxidative stress in the brain of cholestatic rats.

In a recently published article in "Amino Acids" it was shown that obstructive jaundice of 9 days' duration in rats induces significant alterations of polyamines' metabolism in the brain, which might play an important pathogenetic role in cholestatic brain injury. The authors proposed that alterations of polyamines in cholestatic brain might induce neuronal toxicity through a mechanism that implicates the production of reactive oxygen species and oxidative stress, although this parameter was not evaluated in their study. This hypothesis is supported by our recent findings on brain oxidative status in rats with obstructive jaundice of 10 days' duration. Potential interrelations of the two studies' findings are discussed in this commentary.

Time-related alterations of superoxide radical levels in diverse organs of bile duct-ligated rats.

The time-related alterations of superoxide radical measured in vivo by employing an ultrasensitive fluorescent assay in the liver, intestine, kidney and brain of rats with experimentally induced obstructive jaundice was investigated. Eighteen rats were randomly divided into Group A, rats subjected to sham operation, and Group B, rats subjected to bile duct ligation (BDL). Three rats from each group were subsequently killed at different time points post-operatively (1, 5 and 10 days). As compared to sham-operated, BDL rats showed a gradual increase with time of superoxide radical in the intestine, liver, kidney and brain: for animals sacrificed on the 1(st), 5(th) and 10(th) day the increase was 45%, 50% and 96% in the liver, 76%, 81% and 118% in the intestine, 64%, 71% and 110% in the kidney and 76%, 95% and 142% in the brain, respectively. This study provides direct evidence of an early appearance of oxidative stress in diverse organs, implying a uniform systemic response to biliary obstruction and emphasizing the need of early bile flow restoration.

Superoxide radical formation in diverse organs of rats with experimentally induced obstructive jaundice.

Oxidative stress seems to be a cardinal feature of cholestasis, implicated in the pathophysiology of organ injury not only in the liver, but also in several extrahepatic tissues. The present study was designed to assess directly oxidative stress in vital organs of experimentally jaundiced rats by measuring the key oxidative stress marker superoxide radical (O2(*-)). Twelve male Wistar rats underwent laparotomy and were divided into two groups - group I (n = 6) sham operated, and group II (n = 6) bile-duct ligated. Ten days later, the O2(*-) formation rate was quantified in liver, intestine, kidney and heart of all animals. These measurements were done by application of a new ultrasensitive fluorescent assay for the in vivo quantification of O2(*-), which is based on the 1:1 molar stoichiometric reaction of O2(*-) with dihydroethidine (DHE, an O2(*-) trap) that results in the formation of the specific product 2-OH-ethidium. 2-OH-Ethidium was measured by fluorescence in rats' organs and its formation rate was converted to O2(*-) production rate. As compared to sham-operated rats, in jaundiced rats there was a significant increase of O2(*-) in the intestine (136%, P < 0.01), liver (104%, P < 0.01), and kidney (95%, P < 0.01), whereas there was no significant difference in heart O2(*-) levels. Superoxide radical may play an important role in the pathophysiology of cholestatic liver injury, intestinal barrier failure and renal failure, associated with postoperative morbidity and mortality in obstructive jaundice. On the contrary, O2(*-) and oxidative stress are possibly not implicated in the pathophysiology of hepatic cardiomyopathy.

Quantification of superoxide radical in the brain of rats with experimentally induced obstructive jaundice.

The study aimed to directly measure in vivo superoxide radical (O*2) a direct indicator of oxidative stress, in the brain of rats with experimentally induced obstructive jaundice by employing a new quantitative ultrasensitive fluorescent assay requiring minimum sample. O*2 anion is specific for dihydroethidine (DHE) and upon reaction gives a characteristic product, namely 2-OH-ethidium. Ten male rats underwent laparotomy and were divided into two groups: I, sham operated and II bile duct ligation. Ten days later, following injection with DHE (a O*2 trap), all animals were killed and samples from cerebral cortex, midbrain and cerebellum were removed for analysis. It was shown that compared to group I, in group II the O*2 was increased by 67% in the cerebral cortex and by 37% in the midbrain as a consequence of experimental obstructive jaundice, while its levels were unaffected in the cerebellum. The data in this experimental obstructive jaundice model imply a region-specific increase of O*2 formation rate, being higher in cerebral cortex, less so in the midbrain and not at all in cerebellum.

Effect of N-acetylcysteine, allopurinol and vitamin E on jaundice-induced brain oxidative stress in rats.

We examined the possible protective effect of certain antioxidants (N-acetylcysteine, allopurinol and vitamin E) against the oxidative stress of brain tissue induced by experimental obstructive jaundice in rats. Thirty-six male Wistar rats were randomly divided into six groups; group I control, group II sham operated, group III bile duct ligated and groups IV, V, and VI in which the rats, after bile duct ligation, were given every day an intraperitoneal injection with N-acetylcysteine, allopurinol and Vit-E respectively. All rats were sacrificed on the tenth day by exsanguination and the oxidative state in samples from cortex, midbrain and cerebellum was assessed by measuring the thiol redox state and lipid peroxidation quantified by MDA measurements. The main finding was that all three antioxidants decrease lipid peroxidation in the three brain areas. Cysteine levels increased and protein thiol levels were reserved only in the group treated with N-acetylcysteine, whereas oxidized glutathione increased dramatically in the group treated with allopurinol, suggesting that each antioxidant agent had a certain influence profile on the different antioxidant defense systems. The observed effects of the antioxidants in this experimental model could also provide insight into some aspects of jaundice-induced hepatic encephalopathy in humans.

Brain oxidative stress induced by obstructive jaundice in rats.

The effect of experimental obstructive jaundice on the oxidative status of brain tissues in rats was examined. Twenty-four male Wistar rats were divided into 4 groups: Group I was the control, group II was the sham operated, and groups III and IV were bile duct ligated and killed on the 5th and the 10th day, respectively. Oxidative stress was assessed by measuring the thiol redox state (protein and nonprotein components) and lipid peroxidation level variations in samples from the cerebral cortex, midbrain, and cerebellar tissue in all animals. Results indicated the presence of oxidative stress in the jaundiced animals that was more pronounced on the 10th day as indicated by a decrease in reduced glutathione and protein thiol and an increase in protein disulphide and lipid peroxidation. A dramatic elevation of the level of total nonprotein mixed disulphide level was found specifically in the midbrain in the 10th day group. This suggests an accumulation of nonprotein disulfides other than oxidized glutathione, which remained unchanged, in this particular brain area. This study showed a correlation between experimental obstructive jaundice and the oxidative stress in the rats' brain, implying that a similar pathogenetic mechanism may play a key role in cholestatic liver disease, resulting in hepatic encephalopathy in humans.

Computer assisted total parenteral nutrition for pre-term and sick term neonates.

INTRODUCTION: Over the past few years, the use of total parenteral nutrition (TPN) has been established for pre-term and sick term neonates. At 'IASO' Hospital, a series of protocols implemented through the use of a computer programme has been developed to assist in the time consuming task of prescribing and preparing TPN in neonates. The algorithms used for neonates of a different gestational age are based on the protocols created through screening of literature and personal experience. This is important because it heralds a uniformity of the prescription of TPN at IASO and other hospitals where these protocols have been implemented. OBJECTIVE: The objective is to determine the extent of error occurrence of the manual method as opposed to the new computerized procedure of TPN formulation, and to assess the immediate benefits stemming from the computer programme's use, in terms of personnel time reduction. Furthermore, the usefulness of the automated compounder in the computer driven process of TPN solution formulation was also assessed. SETTING: Gynaecology Hospital 'IASO'. METHOD: For a period of 6 months, sick and prematurely born babies were included in the study. Calculations regarding the composition of TPN solutions were conducted both by computer and manually. MAIN OUTCOME MEASURE: The time needed to complete the procedure and the results' accuracy were measured and compared. RESULTS: Implementation of the protocols into practice via this computer programme has been found to reduce the time spent by the physician and the pharmacist on TPN solution preparation, but the most important contribution is the virtual elimination (no errors in computerized calculation) of errors in the complex task of prescribing and formulating TPN solutions. For example, the average time taken to prepare the individual TPN solutions was 5.2 min while the computerized procedure took 15.4 min. CONCLUSION: Use of this system can optimize pharmacists' and physicians' work and help prevent prescription and preparation errors.

Klippel-Feil syndrome presenting with bilateral thoracic outlet syndrome.

STUDY DESIGN: This report aims, in the light of the recent literature, to describe the clinical features of bilateral thoracic outlet syndrome in a case of Klippel-Feil syndrome, the results of electrophysiologic evaluation, and the outcome after surgical intervention. OBJECTIVES: Cervical ribs in the context of Klippel-Feil syndrome as the cause of bilateral thoracic outlet syndrome is discussed. SUMMARY OF BACKGROUND DATA: In Klippel-Feil syndrome, congenital fusion of cervical vertebrae occurs and may also be associated with various anomalies, including musculoskeletal anomalies. The typical neurologic defects in this syndrome are caused by compression of the cervical cord and/or the corresponding roots. METHODS: A 25-year-old woman had experienced, for 3 years, sensory symptoms, mainly numbness and pain, in both arms and episodic color changes of the hands that were aggravated by certain activities. RESULTS: Radiologic examination revealed Klippel-Feil syndrome type I, accompanied by bilateral cervical ribs. Electrophysiologic evaluation demonstrated impairment of nerve conduction, as indicated by F wave changes, after the arms were raised. The patient underwent successful decompression of the neurovascular structures at the thoracic aperture. CONCLUSIONS: It is often difficult to diagnose thoracic outlet syndrome by conventional neurophysiology. Dynamic changes in F waves appear to be a useful finding. In the absence of symptoms of myeloradiculopathy, thoracic outlet syndrome could be the sole manifestation of Klippel-Feil syndrome.