Telehealth-Enabled In-Home Elbow Rehabilitation for Brachial Plexus Injuries Using Deep-Reinforcement-Learning-Assisted Telepresence Robots

Due to damage to the network of nerves that regulate the muscles and feeling in the shoulder, arm, and forearm, brachial plexus injuries (BPIs) are known to significantly reduce the function and quality of life of affected persons. According to the World Health Organization (WHO), a considerable share of global disability-adjusted life years (DALYs) is attributable to upper limb injuries, including BPIs. Telehealth can improve access concerns for patients with BPIs, particularly in lower-middle-income nations. This study used deep reinforcement learning (DRL)-assisted telepresence robots, specifically the deep deterministic policy gradient (DDPG) algorithm, to provide in-home elbow rehabilitation with elbow flexion exercises for BPI patients. The telepresence robots were used for a six-month deployment period, and DDPG drove the DRL architecture to maximize patient-centric exercises with its robotic arm. Compared to conventional rehabilitation techniques, patients demonstrated an average increase of 4.7% in force exertion and a 5.2% improvement in range of motion (ROM) with the assistance of the telepresence robot arm. According to the findings of this study, telepresence robots are a valuable and practical method for BPI patients' at-home rehabilitation. This technology paves the way for further research and development in telerehabilitation and can be crucial in addressing broader physical rehabilitation challenges.

Progressive Dysregulation of Tau Phosphorylation in an Animal Model of Temporal Lobe Epilepsy

Tau is an intracellular protein known to undergo hyperphosphorylation and subsequent neuro-toxic aggregation in Alzheimer's disease (AD). Here, tau expression and phosphorylation at three canonical loci known to be hyperphosphorylated in AD (S202/T205, T181, and T231) were studied in the rat pilocarpine status epilepticus (SE) model of temporal lobe epilepsy (TLE). We measured tau expression at two time points of chronic epilepsy: two months and four months post-SE. Both time points parallel human TLE of at least several years. In the whole hippocampal formation at two months post-SE, we observed modestly reduced total tau levels compared to naïve controls, but no significant reduction of S202/T205 phosphorylation levels. In the whole hippocampal formation from four month post-SE rats, total tau expression had reverted to normal, but there was a significant reduction in S202/T205 tau phosphorylation levels that was also seen in CA1 and CA3. No change in phosphorylation was seen at the T181 and T231 tau loci. In somatosensory cortex, outside of the seizure onset zone, no changes in tau expression or phosphorylation were seen at the later time point. We conclude that total tau expression and phosphorylation in an animal model of TLE studied do not show hyperphosphorylation at the three AD canonical tau loci. Instead, the S202/T205 locus showed progressive dephosphorylation. This suggests that changes in tau expression may play a different role in epilepsy than in AD. Further study is needed to understand how these changes in tau may impact neuronal excitability in chronic epilepsy.

Molecular based identification and phylogenetic relationship by using cytochrome b gene of Pangasius pangasius

Molecular appraoch for identification of unknown species by using Cytochrome b gene is an effective and reliable as compared with morphological based identification. For DNA barcoding universal molecular genes were used to identify the species. Cytochrome b is a specific gene used for identification purpose. DNA barcoding is a reliable and effective method compared to the different traditional morphological methods of specie identification. So,in the present study which was conducted to identify the species, a total of 50 fish samples were collected from five different sites. DNA was extracted by using the Phenol Chloroform method from muscle tissue. Five sequences were sequenced (one from each site), analyzed, and identified specific species as Pangasius pangasius. Identified sequences were variable in length from 369 bp (Site 1), 364 bp (Site 2), 364 bp (Site 3), 352 bp (Site 4), and 334 bp (Site 5). Identity matches on the NCBI database confirmed the specific specie as P. pangasius. A distancing tree was drawn to show maximum likelihood among the same and different species. Yet, in many cases fishes on diverse development stages are difficult to identify by morphological characters. DNA-based identification methods offer an analytically powerful addition or even an alternative tool for species identification and phylogenetic study. This work intends to provide an updated and extensive overview on the DNA based methods for fish species identification by using Cytochrome b gene as targeted markers for identification purpose.

A Deadly Herbicide 'Paraquat Poisoning' and Miserable Death of a 19 Years Boy

Poisoning by paraquat herbicide now a days is a major medical problem in many parts of Asia as well as in Bangladesh. Already it has been banned in the European Union and some other countries for several years. Paraquat is highly toxic if ingested, with clinical features including oral burns, sore throat, vomiting and diarrhoea, progressing to pneumonitis, pulmonary fibrosis and multi-organ failure. Recently we dealt with many cases of paraquat poisoning in Mymensingh Medical College Hospital and here we report one case. A 19 years old student intentionally ingested 10 ml of paraquat herbicide and presented with multi organ failure. His renal function was supported with 4 session's hemodialysis and regain normal renal function. But he also developed Acute Lung Injury (ALI) and liver dysfunction, was supported with ionotropic and invasive ventilation and couldn't save. On 14th day of poisoning he died.

Exogenous melatonin-mediated regulation of K+ /Na+ transport, H+ -ATPase activity and enzymatic antioxidative defence operate through endogenous hydrogen sulphide signalling in NaCl-stressed tomato seedling roots

Melatonin (Mel) and hydrogen sulphide (H₂ S) have emerged as potential regulators of plant metabolism during abiotic stress. Presence of excess NaCl in the soil is one of the main causes of reduced crop productivity worldwide. The present investigation examines the role of exogenous Mel and endogenous H₂ S in tomato seedlings grown under NaCl stress. Effect of 30 µm Mel on endogenous synthesis of H₂ S was examined in roots of NaCl-stressed (200 mm) tomato seedlings. Also, the impact of treatments on the oxidative stress markers, transport of K⁺ and Na⁺ , and activity of H⁺ -ATPase and antioxidant enzymes was assessed. Results show that NaCl-stressed seedlings supplemented with 30 µm Mel had increased levels of endogenous H₂ S through enhanced L-cysteine desulfhydrase activity. Mel in association with H₂ S overcame the deleterious effect of NaCl and induced retention of K⁺ that maintained a higher K⁺ /Na⁺ ratio. Use of plasma membrane inhibitors and an H₂ S scavenger revealed that Mel-induced regulation of K⁺ /Na⁺ homeostasis in NaCl-stressed seedling roots operates through endogenous H₂ S signalling. Synergistic effects of Mel and H₂ S also reduced the generation of ROS and oxidative destruction through the enhanced activity of antioxidant enzymes. Thus, it is suggested that the protective function of Mel against NaCl stress operates through an endogenous H₂ S-dependent pathway, wherein H⁺ -ATPase-energized secondary active transport regulates K⁺ /Na⁺ homeostasis.

Explicating genetic diversity based on ITS characterization and determination of antioxidant potential in sea buckthorn (Hippophae spp.)

BACKGROUND

Sea buckthorn (Hippophae) is in the focus of interest mainly for its positive effects on health of both human and animal organisms. Due to the similarities in vegetative morphology, Hippophae species are often misidentified. Therefore, current study was focused on ITS based sequence characterization of sea buckthorn species and comparative biochemical evaluation for its antioxidant properties.

METHODS AND RESULTS

DNA was extracted from leaf samples. Primer pairs K-Lab-SeaBukRhm-ITS1F1- K-Lab-SeaBukRhm-ITS1R1 and K-LabSeaBukTib- ITSF1- K-LabSeaBukTib-ITSR1 were used for PCR amplification. The purified PCR products were outsourced for sequencing. Phylogenetic tree was constructed based on neighbor-joining (NJ) method. Moreover, comparison of antioxidant potential of leaves of two sea buckthorn species (Hippophae rhamnoides and Hippophae tibetana) collected from different regions of Ladakh viz., Stakna, Nubra, DRDO Leh and Zanskar was determined by 2,2-diphenyl-1-picrylhydrazyl (DPPH), 2,2-azino-bis (3- ethylbenzothiazoline-6-sulphonic acid) diammonium salt (ABTS), and Total antioxidant capacity (TAC) by phosphomolybdenum assays. The present investigation led to the differentiation of two sea buckthorn species viz., H. rhamnoides and H. tibetana based on Internal Transcribed Spacer (ITS) region. Moreover, significant variation was observed in antioxidant potential of leaf extracts collected from different regions.

CONCLUSIONS

Primary ITS sequence analysis was found to be powerful tool for identification and genetic diversity studies in sea buckthorn. Leaves of sea buckthorn have pronounced antioxidant properties and can be used in food, neutraceuticals and pharmaceutical industries etc. The current study will pave the way to discover small bioactive molecules responsible for antioxidant and anticancer properties in sea buckthorn.

Is selective late sodium current inhibition different from class I/B antiarrhythmic action? Comparison of the effects of GS967 to mexiletine in canine ventricular myocardium

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): National Research, Development and Innovation Office New National Excellence Programme

Enhancement of the late Na+ current (INa,late) increases arrhythmia propensity in the heart, while suppression of the current is antiarrhythmic. GS-458967 (GS) is an agent considered to be a selective blocker of INa,late. In the present study, effects of GS967 on INa,late, on L-type calcium current (ICaL), and on action potential (AP) morphology were studied in canine ventricular myocytes by using conventional voltage clamp, action potential voltage clamp and sharp microelectrode techniques. These effects of GS were compared to tetrodotoxin (TTX) and to the class I/B antiarrhythmic compound mexiletine.

GS (1 μM), mexiletine (40 μM) and TTX (10 μM) dissected largely similarly shaped inward currents under action potential voltage clamp conditions. In case of GS and mexiletine, the amplitude and integral of this inward current was significantly smaller when measured in the presence of 1 μM nisoldipine, while no difference was observed in case of TTX. Under conventional voltage clamp conditions, INa,late was significantly reduced by 1 μM GS and 40 μM mexiletine (about 79% and 63% reduction of current integrals, respectively). The integral of ICa,L was moderately but significantly decreased by both drugs (reduction of 9% and 14%, respectively). These changes were associated with a faster inactivation of ICa,L.

Drug effects on early Na+ current (INa,early) were assessed by analyzing the maximal rate of depolarization (V + max) in multicellular preparations. Both GS and mexiletine showed fast onset and offset kinetics: 110 ms and 289 ms offset time constants, respectively, as determined from V + max measurements in right ventricular papillary muscles, while the onset kinetics was characterized by 5.3 AP and 2.6 AP lengths, respectively, at 2.5 Hz.

Effects on beat-to-beat variability of AP duration (APD) was studied in isolated myocytes. Short-term variability was significantly decreased by both GS and mexiletine (average reduction of 42% and 24%, respectively) while they caused similar shortening of the APD.

The electrophysiological effects of GS are similar to those of mexiletine, but with a somewhat faster offset kinetics of V + max block. However, since GS reduced V+ max and INa,late in the same concentration, the currently accepted view that GS that selectively blocks INa,late has to be questioned and it is suggested that GS should be classified as a class I/B (or I/B + IV) antiarrhythmic agent.

Fabrication of Nanostructured Cadmium Selenide Thin Films for Optoelectronics Applications

There is lot of research work at enhancing the performance of energy conversion and energy storage devices such as solar cells, supercapacitors, and batteries. In this regard, the low bandgap and a high absorption coefficient of CdSe thin films in the visible region, as well as, the low electrical resistivity make them ideal for the next generation of chalcogenide-based photovoltaic and electrochemical energy storage devices. Here, we present the properties of CdSe thin films synthesized at temperatures (below 100°C using readily available precursors) that are reproducible, efficient and economical. The samples were characterized using XRD, FTIR, RBS, UV-vis spectroscopy. Annealed samples showed crystalline cubic structure along (111) preferential direction with the grain size of the nanostructures increasing from 2.23 to 4.13 nm with increasing annealing temperatures. The optical properties of the samples indicate a small shift in the bandgap energy, from 2.20 to 2.12 eV with a decreasing deposition temperature. The band gap is suitably located in the visible solar energy region, which make these CdSe thin films ideal for solar energy harvesting. It also has potential to be used in electrochemical energy storage applications.

HCN Channel Phosphorylation Sites Mapped by Mass Spectrometry in Human Epilepsy Patients and in an Animal Model of Temporal Lobe Epilepsy

Because hyperpolarization-activated cyclic nucleotide-gated (HCN) ion channels modulate the excitability of cortical and hippocampal principal neurons, these channels play a key role in the hyperexcitability that occurs during the development of epilepsy after a brain insult, or epileptogenesis. In epileptic rats generated by pilocarpine-induced status epilepticus, HCN channel activity is downregulated by two main mechanisms: a hyperpolarizing shift in gating and a decrease in amplitude of the current mediated by HCN channels, I_h. Because these mechanisms are modulated by various phosphorylation signaling pathways, we hypothesized that phosphorylation changes occur at individual HCN channel amino acid residues (phosphosites) during epileptogenesis. We collected CA1 hippocampal tissue from male Sprague Dawley rats made epileptic by pilocarpine-induced status epilepticus, and age-matched naïve controls. We also included resected human brain tissue containing epileptogenic zones (EZs) where seizures arise for comparison to our chronically epileptic rats. After enrichment for HCN1 and HCN2 isoforms by immunoprecipitation and trypsin in-gel digestion, the samples were analyzed by mass spectrometry. We identified numerous phosphosites from HCN1 and HCN2 channels, representing a novel survey of phosphorylation sites within HCN channels. We found high levels of HCN channel phosphosite homology between humans and rats. We also identified a novel HCN1 channel phosphosite S791, which underwent significantly increased phosphorylation during the chronic epilepsy stage. Heterologous expression of a phosphomimetic mutant, S791D, replicated a hyperpolarizing shift in I_h gating seen in neurons from chronically epileptic rats. These results show that HCN1 channel phosphorylation is altered in epilepsy and may be of pathogenic importance.

Inhibition of microbial growth by silver nanoparticles synthesized from Fraxinus xanthoxyloides leaf extract

AIMS

Conventional antibiotics have been failed to treat infectious diseases due to emergence of multidrug resistance (MDR) in some common pathogens. The current study aimed to formulate new antimicrobials from greener sources. In the midst of these efforts, nanotechnology is a newly emerged field, in which the synthesis of new nanoparticles through novel and efficient means is on the rise.

METHODS AND RESULTS

The current work has been carried out to assess the potential of Fraxinus xanthoxyloides (FX) leaf extract in biosynthesis of silver nanoparticles (FX-AgNPs). This method is economical and simple one-step approach to synthesize AgNPs. Characterization of FX-AgNPs has been done by UV-Visible spectroscopy, scanning electron microscope (SEM), X-ray diffraction (XRD), transmission electronic microscope (TEM) and Fourier transforms infrared spectroscopy (FT-IR). The formation of FX-AgNPs has confirmed through UV-Visible spectroscopy (at 430 nm) by change of colour owing to surface Plasmon resonance. Based on the XRD pattern, the crystalline property of FX-AgNPs has established. Functional groups existing in F. xanthoxyloides leaf extract are confirmed by FT-IR spectrum. SEM and TEM authenticated morphology of the AgNPs. The newly synthesized nanoparticles were evaluated for their antimicrobial potential. Minimum inhibitory concentration was determined against Escherichia coli, methicillin-resistant Staphylococcus aureus (MRSA) strains, Pseudomonas aeruginosa and Candida albicans by microtiter plate assay. The lowest inhibition (69%) observed against MRSA was at a concentration of 50 ppm FX-AgNPs and maximum inhibition (81%) observed was against P. aeruginosa. The biosynthesized AgNPs triggered up to 68·6% reduction of the P. aeruginosa biofilm when compared to the control.

CONCLUSION

It can be concluded that nanoparticles could be a better alternative of antibiotics with greater efficacies and represent a valuable milestone to fight against infections caused by MDR pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study imparts a useful insight into the development of a new antimicrobial agent from a novel source.

Selective hyperactivation of JNK2 in an animal model of temporal lobe epilepsy

c-Jun N-terminal kinases (JNKs) are members of the mitogen-activated protein kinase (MAPK) family and are derived from three genes, Jnk1-3. These kinases are involved in cellular responses to homeostatic insults, such as inflammation and apoptosis. Furthermore, increased JNK expression and activation are associated with debilitating neurodegenerative diseases, including Alzheimer’s and Parkinson’s. We previously reported elevated levels of phosphorylated JNK (pJNK), indicative of JNK hyperactivation, in the CA1 hippocampus of chronically epileptic rats. We also showed that pharmacological inhibition of JNK activity reduced seizure frequency in a dose-dependent fashion (Tai TY et al., Neuroscience, 2017). Building on these observations, the objectives of this current study were to investigate the timeline of JNK activation during epileptogenesis, and to identify the JNK isoform(s) that undergo hyperactivation in the chronic epilepsy stage. Western blotting analysis of CA1 hippocampal homogenates showed JNK hyperactivation only during the chronic phase of epilepsy (6–9 weeks post-status epilepticus), and not in earlier stages of epileptogenesis (1 h, 1 day, and 1 week post-status epilepticus). After enrichment for pJNK by immunoprecipitation, we identified JNK2 as the only significantly hyperactivated JNK isoform, with expression of the 54 kDa pJNK2 variant elevated to a greater extent than the 46 kDa pJNK2 variant. Expression of the total amounts of both JNK2 variants (phosphorylated plus non-phosphorylated) was reduced in epilepsy, however, suggesting that activation of upstream phosphorylation pathways was responsible for JNK2 hyperactivation. Since our prior work demonstrated that pharmacological inhibition of JNK activation had an antiepileptic effect, JNK2 hyperactivation is therefore likely a pathological event that promotes seizure occurrences. This investigation provides evidence that JNK2 is selectively hyperactivated in epilepsy and thus may be a novel and selective antiepileptic target.

Brachial Plexus Schwannoma: A Case Report with Emphasis on Imaging

Brachial plexus tumors are rare. Schwannomas are benign nerve sheath tumors and only about 5% arise from brachial plexus. Diagnosis of these tumors are challenging for radiologists as well as clinicians as they are rare and the anatomy of the neck is complex. We report a case of a middle aged woman who was admitted in Mymensingh Medical College in Neurosurgery Department on 15th December 2017 with right supraclavicular swelling; based on the clinical findings was provisionally diagnosed as supraclavicular lymphadenopathy; Ultrasonography and Magnetic Resonance Imaging suggested schwannoma. Complete excision of the mass through supraclavicular approach showed the origin of it from the brachial plexus, which subsequently was confirmed to be a schwannoma with histopathology.

Lateralized microstructural changes in early-stage Parkinson's disease in anterior olfactory structures, but not in substantia nigra

Parkinson's disease (PD) is a progressive neurological disorder characterized by motor symptoms as well as severe deficits in olfactory function and microstructural changes in olfactory brain regions. Because of the evidence of asymmetric neuropathological features in early-stage PD, we examined whether lateralized microstructural changes occur in olfactory brain regions and the substantia nigra in a group of early-stage PD patients. Using diffusion tensor imaging (DTI) and the University of Pennsylvania Smell Identification Test (UPSIT), we assessed 24 early-stage PD patients (Hoehn and Yahr stage 1 or 2) and 26 healthy controls (HC). We used DTI and a region of interest (ROI) approach to study the microstructure of the left and right anterior olfactory structures (AOS; comprising the olfactory bulbs and anterior end of the olfactory tracts) and the substantia nigra (SN). PD patients had reduced UPSIT scores relative to HC and showed increased mean diffusivity (MD) in the SN, with no lateralized differences. Significant group differences in fractional anisotropy (FA) and MD were seen in the AOS, but these differences were restricted to the right side and were not associated with the primary side of motor symptoms amongst PD patients. No associations were observed between lateralized motor impairment and lateralized microstructural changes in AOS. Impaired olfaction and microstructural changes in AOS are useful for early identification of PD but asymmetries in AOS microstructure seem unrelated to the laterality of PD motor symptoms.

High-grade glioma management and response assessment-recent advances and current challenges

The management of high-grade gliomas (hggs) is complex and ever-evolving. The standard of care for the treatment of hggs consists of surgery, chemotherapy, and radiotherapy. However, treatment options are influenced by multiple factors such as patient age and performance status, extent of tumour resection, biomarker profile, and tumour histology and grade. Follow-up cranial magnetic resonance imaging (mri) to differentiate treatment response from treatment effect can be challenging and affects clinical decision-making. An assortment of advanced radiologic techniques-including perfusion imaging with dynamic susceptibility contrast mri, dynamic contrast-enhanced mri, diffusion-weighted imaging, proton spectroscopy, mri subtraction imaging, and amino acid radiotracer imaging-can now incorporate novel physiologic data, providing new methods to help characterize tumour progression, pseudoprogression, and pseudoresponse. In the present review, we provide an overview of current treatment options for hgg and summarize recent advances and challenges in imaging technology.

Osteopetrosis

A 15 years old Bangladeshi boy presented with hepatosplenomegaly, anaemia, multiple fractures (symptomatic and asymptomatic) without jaundice was investigated. Laboratory findings revealed leukoerythroblastic blood picture with reduced haemoglobin (7.7 gm/dl). Skeletal survey showed generalized increased bone density, sclerosed medulary space, Rugger-Jersey spine and diploic space filled with dense materials. Overlapping clinical features of both intermediate autosomal recessive and adult autosomal dominant variety of osteopetrosis were found in this patient but diagnosis were made on the basis of typical radiological finding which was mostly consistent with the adult autosomal dominant variety. The patient was treated conservatively and specialist consultation was taken in managing bony abnormalities. This patient was discharged with advised of subsequent follow-up.

Primary disseminated MDR-TB in a Bangladeshi man: a silent and emerging clinical problem for clinicians

A 26 years old Bangladeshi man experienced sudden gross haematuria for 10 days when he was working in Italy in June'07 that was resolved spontaneously. Six months' later he again developed haematuria and was admitted into an Italian hospital for its evaluation and management. In the mean time, he developed low grade fever, cough, back pain, spinal angulations, walking difficulty. His X-ray chest postero-anterior view revealed cavitary lesions in upper zones of both lung fields. Intravenous Urography (IVU) was done which revealed hydronephrosis and hydroureter of left kidney. Magnetic Resonance Imaging (MRI) of dorso-lumber spine revealed collapse of D10-12 and L4-5 vertebral bodies with perivertebral and epidural abscess. Sputum and urine smear for Acid-Fast-Bacilli (AFB) demonstrated the organisms on Z-N stain and AFB culture and sensitivity demonstrated that it was resistant to isoniazide, Rifampicin and streptomycin and diagnosed as primary disseminated multi-drug Resistant tuberculosis (MDR-TB). Second-line drugs were started in Italy on 15th January'08 and were continued thereafter in National Institute of Diseases of the Chest and Hospital (NIDCH). A ureteric stent which was given in Italy to get relief of hydro-ureter was removed in Dhaka. A neurosurgery (costo-transversectomy with decompression of spine) was done in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and patient get relief of back pain paresthesia. Lastly, his sputum and urine AFB smear and AFB culture became negative. So, primary disseminated MDR-TB with renal, spinal and pulmonary involvement was diagnosed in this Bangladeshi man who had a sputum AFB culture and sensitivity during his initial diagnostic work-up in Italy. It's an alarming case that demonstrated necessity of sputum AFB culture and sensitivity during initial diagnostic work-up.

Distribution of ABO and Rh D blood groups in the population of Poonch District, Azad Jammu and Kashmir

We evaluated the distribution of ABO and Rhesus (Rh) D blood groups in the population of Poonch district in Azad Jammu and Kashmir. The blood group phenotypes were detected by the classic slide method. The ABO blood group system in the total sample showed the same trend of prevalence as for the general Indian subcontinent (B > or = O > A > AB). The same trend was found among males, but among females the order of prevalence was different (O B > A > AB). However, the allelic frequencies in both sexes were in the order of O > B > A. The Rh positive and negative distribution trend in both sexes was also similar.

High density polyethylene/boron carbide composites for neutron shielding

Composites of high density polyethylene with three different amounts of modified boron carbide namely: 7 phr (parts per hundred parts of resin), 15 phr and 24 phr have been prepared. These composites show excellent thermal neutron shielding properties which increase with the increase of boron content in the composites matrix. Moreover, the effects of boron carbide on the mechanical properties, the effect of thermal oxidative aging on mechanical properties and swelling of composites in different solvents have also been studied in these composites.

Urgent cholecystectomy for acute cholecystitis in a district general hospital - is it feasible?

INTRODUCTION

Laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gall stone disease. However, its place remains controversial in the management of acute cholecystitis due to a high reported incidence of bile leaks and conversion rate. Tertiary referral centres have reported good results. We present a series of cases after the introduction of an urgent cholecystectomy pathway in a district general hospital.

PATIENTS AND METHODS

A practice of urgent cholecystectomy for acute cholecystitis was introduced by three consultant general surgeons. All prospective patients having an urgent laparoscopic cholecystectomy for acute cholecystitis, over an 8-month period were entered into a database. A dedicated ultrasound service was instituted to provide prompt diagnosis in these patients. Their demographic details, operative findings, laboratory results were recorded in a prospective database. Timing of ERCP, postoperative complications and conversion rate and hospital stay were also noted.

RESULTS

There were 64 patients in the study with a median age of 51 years (range, 21-84 years). There were 21 males and 43 females. All patients underwent laparoscopic cholecystectomy during the index admission. Eleven patients had pre-operative ERCP and 12 patients had on-table cholangiogram. There were no conversions. Postoperative ERCP was required in six patients. The median time interval between admission and operation was 3 days (range, 2-7 days). There were two bile leaks but no common bile duct injury. There were two cases of superficial wound infection. One patient required re-operation for small bowel obstruction secondary to a port site hernia.

CONCLUSIONS

Urgent laparoscopic cholecystectomy for acute cholecystitis is a feasible treatment option in a district general hospital. A safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-delivered service. Urgent cholecystectomy service can be provided safely in a district general hospital with outcomes comparable to previously published literature.

Determinants influencing prevalence of louse infestations on layers of district Faisalabad (Pakistan)

1. This paper describes the influence of some epidemiological determinants on the prevalence of louse infestation on layers in Faisalabad (Pakistan). 2. Seventy layer farms were screened to determine the prevalence of louse infestation and its determinants including age of the bird, availability of space per bird and frequency of litter change. Prevalence of Lipeurus caponis was highest (53.2%), followed by Menacanthus stramineus (22.16%), Goniodes dissimilis (12.37%) and Goniodes gallinae (12.37%). 3. Older birds (36 to 74 weeks of age) were found with a significantly higher prevalence of louse infestation than younger birds. 4. Month-wise prevalence of louse infestation was higher during the summer months (from April to August) and at older age. 5. Birds kept at floor area allowances ranging from 0.43 to 0.55 m(2) were highly infested with lice as compared to those provided with a space of 0.61 m(2) or higher per bird. 6. Litter change frequency after every 8 weeks resulted in a reduced chance of louse infestation as compared to less frequent litter changing practice. 7. It was concluded from the study that the louse infestation is a menace for the poultry production industry in Pakistan and age, space per bird and litter change frequency are the influencing determinants. 8. Further research on the chemotherapeutic trials and resistance in poultry should be continued for an effective lice control program.

Blood and body fluid splashes during surgery--the need for eye protection and masks

INTRODUCTION

While most surgeons make an effort to avoid needlestick injury, some can pay little attention to reduce the potential route of infection occurring when body fluids splash into the eye. It has been shown that transmission of HIV, hepatitis B or C can occur across any mucous membrane. This study aims to quantify how frequently body fluids splash the mask and lens of wrap around protective glasses thus potentially exposing the surgeon to infection.

PATIENTS AND METHODS

A prospective study was carried out by a single surgeon on all cases performed over a 1-year period. Protective mask and glasses were examined before and after operations.

RESULTS

A total of 384 operations were performed with 174 (45%) showing blood or body fluid splash on the lens. A high incidence of splashes was found in vascular surgical procedures (79%). All amputations showed splash on the protective lens. Interestingly, 50% of laparoscopic cases resulted in blood or body fluid splash on the protective lens.

CONCLUSIONS

This study has shown a high incidence (45%) of blood and body fluid splashes found on protective glasses and masks. There was a very high incidence (79%) during vascular surgical procedures. With the prevalence of HIV and hepatitis increasing, it seems prudent to protect oneself against possible routes of transmission.

Are routine peritoneal fluid cultures during appendicectomy justified?

BACKGROUND

To determine the impact of obtaining routine peritoneal fluid cultures during appendicectomy, on the treatment and the clinical outcomes.

METHODS

The case notes of 137 consecutive patients having appendicectomy, selected from the microbiology database over a period of 1 year were reviewed. The microorganisms in peritoneal cultures, selection of antibiotics and clinical outcomes were recorded. Patients were subdivided into two groups; group I: uncomplicated appendicitis and group II: complicated appendicitis.

RESULTS

The study included 137 patients with a median age of 19 years. Cultures were obtained from 79.5% of patients (group I: 67/84, group II: 42/53). Cultures were positive in 28.3% (19/67) patients in group I and 69% (29/ 42) in group II. Wound infection (5.6%), prolonged ileus (7.5%) and intra-abdominal abscess (3.7%) were the recorded complications in group II. Antibiotics were modified in 3 out of 109 patients.

CONCLUSION

Intra-operative peritoneal cultures during appendicectomy do not significantly contribute towards patient management.

Atrichia with papular lesions resulting from a novel insertion mutation in the human hairless gene

BACKGROUND

Congenital atrichia with papular lesions is a rare, recessively inherited condition of total alopecia, characterized clinically by complete and irreversible hair loss, which begins shortly after birth with the development of the papular lesions of keratin-filled cysts over an extensive area of the body. Mutations in the human hairless (HR) gene have been implicated in the pathogenesis of this disorder.

OBJECTIVE

To search for a mutation in human HR in a family with congenital atrichia.

METHODS

Linkage analysis was carried out using genotyping markers closely linked to congenital atrichia locus on chromosome 8p12. Subsequently, human HR was sequenced to identify a disease-causing mutation.

RESULTS

A novel 11 bp insertion mutation, G202 (InsCTTCCCCCAGG), in exon 2 of the hairless gene was identified in a Pakistani consanguineous family affected by congenital atrichia. The insertion results in the expansion of 11 bp tandem repeat, which introduces a translational frameshift leading to downstream premature termination codon.

CONCLUSIONS

This mutation is the first insertion mutation identified in the coding sequence of human HR. This extends our knowledge of mutations in HR that define the pathogenic basis of this disease.

Bovine hypodermosis: prevalence and economic significance in southern Punjab, Pakistan

Prevalence and economic losses of warble fly infestation (WFI) in cattle and buffaloes were recorded in Dera Ghazi Khan and Rajan Pur districts of southern Punjab (Pakistan). A total of 18,000 cattle and 9000 buffaloes were examined in the field and slaughter house. Only one species of Hypoderma, i.e. Hypoderma lineatum was recorded from this area. The prevalence of WFI was higher in slaughter house versus field, cattle versus buffaloes, males versus females, and young versus old animals in both the districts. The highest month-wise prevalence was recorded in December and the lowest in July. Organ-wise prevalence of WFI was highest in oesophagus followed in order by rumen and spleen. The economic losses based on the value of warbled and warble-free hides were estimated as Rs. 22.8 million per annum (currency exchange rate is Rs. 57.5=US 1 dollar).

The role of white cell count and C-reactive protein in the diagnosis of acute appendicitis

BACKGROUND

Despite recent advances in diagnostic medicine, the diagnosis of appendicitis is still doubtful in a number of cases. Majority of the clinicians rely on their clinical examination strengthened by the laboratory tests. This study was carried out to find out the specificity and sensitivity of white cell count (WCC) and C-Reactive Protein (CRP) in diagnosing appendicitis in patients presenting with right iliac fossa pain.

METHODS

A total of 259 patients were included in this study that presented in the hospital with acute right iliac fossa pain and later on operated and had appendicectomy. The histopathology data was collected to find out the frequency of negative appendicectomy. According to the histopathology reports these patients were grouped into three sub-groups as normal appendix, inflamed appendix or perforated/gangrenous appendix. A record was kept of the WCC and CRP levels of these patients on admission.

RESULTS

A total of 259 patients were included in this study and out of them 37 had a normal appendix giving an over all negative appendicectomy rate of 14.3%. Out of these 11 were male and 26 were female, male to female ratio being 1:2.3. The age range was 12-73 with a median age of 24. Among the 222 patients who had appendicitis, 96 had a ruptured/perforated appendix and 126 had an inflamed appendix. Over all the WCC was elevated in 185 patients and CRP was elevated in 168 cases. The cut off value for white cell count was 11 x 10(6)/L. The C reactive protein levels were calculated by immunoturbidimetric test and the cut off value was taken as 1.7 mg/dl. The sensitivity and specificity of WCC in this study was 83% and 62.1% and that for CRP was 75.6% and 83.7 %.

CONCLUSION

Both the inflammatory markers i.e. WCC and C-reactive protein can be helpful in the diagnosis, when measured together as this increases their positive predictive value.

Cardiac acceleration as a marker of vagal withdrawal in heart rate control during exercise in humans

OBJECTIVE

To investigate whether the time rate of change in heart rate i.e. cardiac acceleration, during aerobic exercise in human subjects could be used to differentiate vagal withdrawal from sympathetic stimulation.

METHODS

Fifteen male subjects exercised on a bicycle ergometer at 50 Watts (Step 1), then 100 Watts (Step 2), for 2 minutes each.

RESULTS

Heart rate (HR) was monitored from a resting value (mean +/- SD) of 80.3 +/- 12.9 to 113.8 +/- 13.6 beats min-1 in Step 1. In Step 2 exercise, HR increased from 113.8 +/- 13.6 to 145 +/- 20 beats min-1. At the initiation of Step 1, a rapid acceleration of HR was observed in the form of an overshoot response. In contrast to Step 1, a small overshoot response of cardiac acceleration was observed during Step 2. The difference between the mean cardiac acceleration at 10 seconds in Steps 1 and 2 was significant (2.40 +/- 0.19 and 0.71 +/- 0.12 beats min-1 sec-1, p<0.0001).

CONCLUSION

The initial vagal withdrawal of exercise-induced tachycardia, as a frontline adaptive mechanism, can be indirectly identified from HR transients using cardiac acceleration as a new marker.

Neuronal loss in familial frontotemporal dementia with ubiquitin-positive, tau-negative inclusions

The neuronal density in the frontal, temporal, and parietal lobes was determined in nine cases of familial frontotemporal dementia with ubiquitin-positive, tau-negative inclusions (FTDU). The mean age at onset was 56.9 +/- 2.2 years and the duration of disease was 6.7 +/- 0.5 years. The mean age at death was 63.6 +/- 2.2 years. There was substantial loss (34%) of brain weight (877 +/- 73 g) in the familial cases in comparison with 10 normal aged controls (1326 +/- 50 g, P < 0.001). All of the familial FTDU cases showed atrophy of the frontal, temporal, and parietal lobes; neuronal loss; vacuolation in superficial laminae; reactive astrocytosis; and ubiquitin-positive, tau-negative intracytoplasmic and intranuclear inclusions and dystrophic neurites in varying sites and numbers. Neuronal loss was estimated in nine cases of familial FTDU and in 10 aged controls using a stereological probe, the optical "disector," and a computerized stereology system (CAST-Grid, Olympus, Denmark). There was a significant reduction in neuronal density in the frontal lobe (22.3 +/- 3.8 x 10(3)/mm(3)) of familial FTDU in comparison to aged controls (33.1 +/- 1.7 x 10(3) per mm(3), P < 0.05). An estimate of the relative numbers of neurons was calculated by multiplying the numerical density by the cortical thickness, which showed a striking loss of neurons of 56% in the frontal lobe, 52% loss in the temporal lobe, and a 49% loss in the parietal lobe of familial FTDU when compared to controls. This study shows that familial FTDU has profound focal neuronal loss in multiple association areas that relate to the clinical symptoms characteristic of the disease.

Male breast cancer

OBJECTIVE

To review cases of male breast cancer.

SETTINGS

Histopathology Section, Department of Pathology, The Aga Khan University, Karachi.

METHOD

Fifty one cases of male breast cancer specimens, received during a period of 10 years, routinely processed and stained with Haematoxylin and Eosin were analyzed. Special stains and Immunohistochemistry were used in difficult cases.

RESULTS

Male breast cancer affected individuals in the sixth and seventh decades of life with a mean age of 56.2 years. Infiltrating ductal carcinoma (IDC) was the predominant type. Skin involvement was seen in 27.45% of the cases. Breast lump was the most common presenting symptom followed by skin ulceration. At the time of presentation 43.13% patients had a tumour size of more than 3 cm.

CONCLUSION

Male breast cancer is a rare disease. Most of our findings correspond to the published local and international data.

Analysis of tau haplotypes in Pick's disease

Pick's disease (PiD) is characterized by the deposition of tau protein as three-repeat tau Pick bodies, whereas progressive supranuclear palsy (PSP) involves the deposition of four-repeat tau neurofibrillary tangles. PSP is associated with the tau H1 haplotype. The authors investigated a possible association between PiD and the tau H1 or H2 haplotype. There was no difference between the tau H2 haplotype or H2H2 genotype frequency in PiD cases and control subjects. No tau mutations were identified in pathologically typical cases of PiD, with antibody 12-E8-negative Pick bodies.

Left ventricular diastolic dysfunction in congenital chronic anaemias during childhood as determined by comprehensive echocardiographic imaging including acoustic quantification

AIMS

To evaluate prospectively the left ventricular performance in thalassaemia major and sickle cell disease using comprehensive echocardiographic imaging including acoustic quantification during early childhood.

METHODS AND RESULTS

Twenty-three patients with thalassaemia and 26 patients with sickle cell disease underwent echocardiographic examination including M-mode, 2-D, Doppler and acoustic quantification. All patients were matched for age, sex, weight and height with 20 normal controls. All patients were below 13 years of age. Thalassaemia and sickle cell disease patients were significantly anaemic when compared with normals (P<0.0001). All patients had normal left ventricular systolic parameters. Acoustic quantification-derived left ventricular volumes, filling rates, and emptying rates were not different in thalassaemia patients from controls. Left ventricular volumes, however, were larger in sickle cell disease patients than in controls. In contrast, by Doppler technique, left ventricular filling occurs mainly in early diastole (E wave) in thalassaemia patients and mainly in late diastole (A wave) in sickle cell disease patients, (P=0.03 and 0.01 respectively). E/A ratio was lower and diastolic filling period was shorter than normal in sickle cell disease but not in thalassaemia patients. Patients in both groups had left ventricular mass (determined by M-mode) significantly higher than normal (P<0.0001).

CONCLUSION

The left ventricular systolic performance is well preserved in patients with chronic anaemia due to thalassaemia major and sickle cell disease during early childhood. In both diseases, however, there is left ventricular hypertrophy and measurable abnormalities in the diastolic filling detected by Doppler. Such changes do not fit a specific cardiomyopathic pattern due to diastolic dysfunction i.e. restrictive physiology vs delayed relaxation. Acoustic quantification of left ventricular diastolic parameters (filling rates) was less sensitive than Doppler in detecting these early diastolic abnormalities in both diseases.

Neuropathologic variation in frontotemporal dementia due to the intronic tau 10(+16) mutation

BACKGROUND

An increasing number of recently described tau mutations show considerable clinical heterogeneity. The assessment of this phenotypic variation is of vital importance in the differential diagnosis of neurodegenerative diseases.

OBJECTIVE

To assess the neuropathologic heterogeneity in a comprehensive study of 12 brains with a tau mutation at exon 10(+16) (C-to-T) splice site from 9 families.

METHODS

A comprehensive neuropathologic examination has been carried out, using a wide range of tau antibodies.

RESULTS

All brains showed frontotemporal atrophy of varying severity and pallor of the pigmented nuclei of the brainstem. The histologic changes were more extensive to include other cortical areas, the deep gray matter, and the white matter. The hallmark histologic lesions were the tau-positive neuronal and glial inclusions. In neurons, these ranged from typical neurofibrillary tangles through well-circumscribed inclusions to diffuse cytoplasmic staining. This tau pathology was complemented by the presence of large, abnormal achromatic neurons, neuronal loss, astrocytosis, and superficial status spongiosus.

CONCLUSION

The distribution, type, and severity of these histologic abnormalities varied not only from case to case but also within the same brain. These brains with a common tau mutation raise important differential diagnostic problems: cases in the past might have been misdiagnosed as corticobasal degeneration or even atypical Pick disease, disorders with similar, if not identical, phenotypic manifestations.

Clinical features of frontotemporal dementia due to the intronic tau 10(+16) mutation

OBJECTIVE

To describe the clinical features of nine British families with neuropathologically verified frontotemporal dementia (FTD) due to the intronic tau exon 10(+16) mutation.

METHODS

Retrospective chart reviews of family members with FTD belonging to nine tau 10(+16) mutation pedigrees in whom neuropathologic examination had been carried out. APOE genotype was determined for those patients for whom DNA was available.

RESULTS

The median age at onset was 50 years (range 37 to 59 years; n = 30). The median age at death was 61 years (range 42 to 72 years; n = 33). The median duration of the disease was 11 years (range 3 to 22 years; n = 25) for those who have died and is 17 years (range 15 to 23 years; n = 3) for those living. The most common presenting symptom was disinhibition (n = 23). A minority presented with frontal dysexecutive symptoms, apathy, impairment of episodic memory, or depression. All of these patients subsequently developed personality and behavioral change. Memory impairment, language deficits, ritualistic behavior, hyperphagia, and hyperorality were frequent symptoms. Parkinsonism, neuroleptic sensitivity, or primitive reflexes were present in half of the patients, where these data were available. The clinical features of ALS were absent. Neuropathologic examination of 12 patients demonstrated the hallmark tau-positive neuronal and glial inclusions. APOE genotype did not account for the considerable variation in age at onset, age at death, duration of disease, or severity of estimated brain atrophy.

CONCLUSIONS

All cases fulfilled the clinical criteria for a diagnosis of FTD. Despite similar clinical phenotypes, there was considerable variation in age at onset and duration of disease both between and within families, suggesting the presence of an effect due to other genetic or environmental factors.

The genetic and pathological classification of familial frontotemporal dementia

BACKGROUND

Frontotemporal dementia (FTD) is an important cause of neurodegenerative dementia, particularly in younger patients. TAU has been identified as the gene responsible for FTD linked to chromosome 17, but it is likely that there is pathological and genetic heterogeneity among families with FTD.

OBJECTIVE

To explore the genetic and pathological basis of familial FTD.

DESIGN

Clinical case series with genetic analysis of each family, and pathological confirmation of diagnosis where possible.

SETTING

Specialist dementia research group, particularly recruiting patients with young-onset dementia.

PATIENTS

Twenty-two families with an index member with FTD, meeting Lund-Manchester criteria, and a family history of other affected members with dementia were ascertained.

RESULTS

Half of the families had mutations in the TAU gene (TAU exon 10 +14, +16, and P301S), and pathological diagnoses were available in 17 of 22 families. Three main pathological diagnoses were made: FTD with neuronal and glial tau deposition, FTD with ubiquitin inclusions, and FTD with neuronal loss and spongiosis but without intracellular inclusions. No cases of familial Pick disease were identified. With the use of the pathological diagnoses, each family with FTD with neuronal and glial tau deposition had a TAU mutation, whereas TAU mutations were not identified in families in the other 2 diagnostic groups.

CONCLUSIONS

This study illustrates the value of TAU sequencing in FTD and suggests that around one half of individuals with familial FTD have TAU mutations and dementia with tau pathological findings. Furthermore, these data suggest that there are at least 2 additional genes to be identified among families with autosomal dominant FTD.

Determination of trace amounts of copper(II) by using catalytic redox reaction between methylene blue and ascorbic acid

A sensitive and selective kinetic-spectrophotometric method is proposed for the determination of microg mL(-1) amounts of Cu2+ based on its catalytic effect on the oxidation of L-ascorbic acid by Methylene Blue in a strongly acidic medium. The reaction is monitored spectrophotometrically by measuring the decrease in color intensity of Methylene Blue at 665 nm. The analysis of Cu2+ ion is performed by a fixed-time method. At a given time of 2 min at pH 2.20 and 32 degrees C, the detection limit is 10 ng mL(-1) and the relative standard deviation for 0.4 microg mL(-1) Cu2+ is 3.60% (n = 6). The method is free from most of the interferences and the effect of diverse ions on the determination of Cu2+ is also reported. The proposed method is virtually specific to copper and has been satisfactorily applied to its determination in electric copper wire samples and pharmaceutical products. Results were also verified by the atomic absorption spectrometry technique (AAS).

Survival of Shigella dysenteriae type 1 on fomites

Studies have shown that various objects, such as utensils, toys, and clothes, can serve as vehicles for transmission of Shigella spp. Shigellae can become viable but non-culturable (VBNC) when exposed to various environmental conditions as shown in earlier studies. The present study was carried out to detect VBNC Shigella dysenteriae type 1 on various fomites by direct viable counting, polymerase chain reaction (PCR), and fluorescent antibody methods. S. dysenteriae type 1 was inoculated onto cloth, wood, plastic, aluminum, and glass objects. Results showed that 1.5-4.0 hours after inoculation, S. dysenteriae type 1 became non-culturable, and after five days, non-culturable but viable S. dysenteriae type 1 could be detected by both PCR and fluorescent antibody techniques. Fomites can be considered an important potential route of transmission of VBNC S. dysenteriae type 1 and a significant factor in the epidemiology of shigellosis.

Microbiological analysis of tube-well water in a rural area of Bangladesh

Five tube-wells in Matlab, Bangladesh, were selected for analysis of selected biophysicochemical parameters. The results showed that all tube-well water samples contained zooplankton and bacteria. Results for some of the parameters were outside the accepted limits recommended by the World Health Organization for drinking water. It is concluded that water from tube-wells should be treated if used as drinking water.

Corticobasal degeneration and progressive supranuclear palsy share a common tau haplotype

OBJECTIVE

To analyze the association of polymorphisms in the tau gene with pathologically confirmed corticobasal degeneration (CBD).

BACKGROUND

The authors previously described an extended tau haplotype (H1) that covers the human tau gene and is associated with the development of progressive supranuclear palsy (PSP). The authors now extend this analysis to CBD, a neurodegenerative condition with clinical and neuropathologic similarities to PSP. Like PSP, CBD is associated with accumulation of aggregates containing the 4-repeat isoforms of tau. Because of difficulty in diagnosis of CBD, the authors only analyzed cases with pathologically confirmed CBD.

METHODS

The authors collected 57 unrelated, neuropathologically confirmed cases of CBD. Tau sequencing in these cases failed to show the presence of pathogenic mutations. Polymorphisms that spanned the tau gene were analyzed in all CBD cases and controls.

RESULTS

Analyzing tau polymorphisms in CBD cases showed that the frequency of H1 and H1/H1 was significantly increased when analyzing all cases and when separating by country of origin. H1 frequency in all CBD cases was 0.921, compared with a control frequency of 0.766 (X(2) = 9.1, p = 0.00255 [1df], OR 3.56 [8.43 > CI 95% > 1.53]). The H1/H1 frequency was also significantly higher at 0.842 compared with 0.596 in age-matched controls (X(2) = 17.42, p = 0.00016, 2df), OR 3.61 [7.05 > CI 95% > 1.85]).

CONCLUSIONS

The CBD tau association described here suggests that PSP and CBD share a similar cause, although the pathogenic mechanism behind the two diseases leads to a different clinical and pathologic phenotype.

Retinoblastoma tells the story of our health care system

OBJECTIVE

To review cases of retinoblastoma.

SETTING

Department of Pathology Aga Khan University Hospital Karachi.

METHOD

Twenty-three specimens from cases of retinoblastoma received over a period of eight years were routinely processes and stained with haematoxylin and Eosin stain. Other stains were used for tuberculoses and melanin. Immunochemistry was resorted to in undifferentiated tumors.

RESULTS

Over 60% cases of retinoblastoma were diagnosed after 5 years and nine cases showed involvement of optinerve.

CONCLUSION

Late diagnosis of retinoblastoma effects the stage of the tumors and the prognosis.

Breast diseases in males--a morphological review of 150 cases

OBJECTIVE

This study was carried out to observe the prevalence breast diseases of males in our setup.

METHOD

All cases of male breast disease diagnosed from 1991-97.

RESULTS

One hundred and fifty (150) cases of male breast diseases were diagnosed. Age of the patients ranged from 4 to 90 years, with mean age 38.75 years (median = 33 years). Gynecomastia was the most common pathological abnormality of the male breast (58.66%). Most of the patients presented in the 3rd decade of life. Amongst the malignant conditions, infiltrating ductal carcinoma was most prevalent (82%). Most of the patients with malignancy presented in the 5th and 6th decades of life.

CONCLUSION

Gynecomastia was the most prevalent male breast disorder, followed by infiltrating ductal carcinoma. Our findings correspond with that of world literature.

Duplex venous imaging: role for a comprehensive lower extremity examination

Real-time compression ultrasound (CU) along with venous duplex imaging is the most commonly performed noninvasive vascular examination. It has become the definitive diagnostic test for most patients with deep venous thrombosis (DVT). Some practioners have recommended that CU alone of the common femoral vein (CFV) and of the popliteal vein (PV) are all that is required since a complete examination is time consuming and calf veins are difficult to visualize. However, if only the CFV and PV are examined, all patients with isolated superficial femoral vein (SFV) and calf DVT remain undiagnosed. The purpose of this study is to establish the value of a comprehensive venous duplex examination compared to CFV and PV compression alone for detecting both proximal and infrapopliteal DVT. From January 1996 through December 1997, the initial venous duplex examinations of 5767 extremities in 3067 patients were reviewed and results tabulated according to presence and location of clot. The ATL 3000 with a 7-14 mHz probe was utilized. Studies were interpreted as normal, proximal DVT (popliteal and above, with or without calf DVT), isolated calf, or isolated SFV deep venous thrombosis. If only the CFV and PV had been examined, 30.3% (isolated SFV + isolated calf vein DVT) of all DVT and 4.5% of proximal DVT would have been missed. A complete venous duplex examination altered the care in 288 (30.3%) of all patients examined who had DVT, and is therefore recommended as the standard noninvasive examination when evaluating patients for acute DVT.