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Tay MRJ, Sangha H, Mittal N, Farag J. Sinus tarsi ganglion in a figure skater: An unusual cause of ankle pain. PM R 2024; 16:297-299. [PMID: 37289030 DOI: 10.1002/pmrj.13008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Matthew Rong Jie Tay
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Harpreet Sangha
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
| | - Nimish Mittal
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
| | - Jordan Farag
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
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Tackey C, Slepian PM, Clarke H, Mittal N. Post-Viral Pain, Fatigue, and Sleep Disturbance Syndromes: Current Knowledge and Future Directions. Can J Pain 2024; 7:2272999. [PMID: 38239826 PMCID: PMC10795785 DOI: 10.1080/24740527.2023.2272999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/16/2023] [Indexed: 01/22/2024]
Abstract
Background Post-viral pain syndrome, also known as post-viral syndrome, is a complex condition characterized by persistent pain, fatigue, musculoskeletal pain, neuropathic pain, neurocognitive difficulties, and sleep disturbances that can occur after an individual has recovered from a viral infection. Aims This narrative review provides a summary of the sequelae of post-viral syndromes, viral agents that cause it, and the pathophysiology, treatment, and future considerations for research and targeted therapies. Methods Medline, PubMed, and Embase databases were used to search for studies on viruses associated with post-viral syndrome. Conclusion Much remains unknown regarding the pathophysiology of post-viral syndromes, and few studies have provided a comprehensive summary of the condition, agents that cause it, and successful treatment modalities. With the COVID-19 pandemic continuing to affect millions of people worldwide, the need for an understanding of the etiology of post-viral illness and how to help individuals cope with the sequalae is paramount.
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Affiliation(s)
- Caleb Tackey
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Maxwell Slepian
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Nimish Mittal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
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Khattignavong E, Neshatian M, Vaez M, Guillermin A, Tauer JT, Odlyha M, Mittal N, Komarova SV, Zahouani H, Bozec L. Development of a facile method to compute collagen network pathological anisotropy using AFM imaging. Sci Rep 2023; 13:20173. [PMID: 37978303 PMCID: PMC10656449 DOI: 10.1038/s41598-023-47350-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 11/12/2023] [Indexed: 11/19/2023] Open
Abstract
Type I collagen, a fundamental extracellular matrix (ECM) component, is pivotal in maintaining tissue integrity and strength. It is also the most prevalent fibrous biopolymer within the ECM, ubiquitous in mammalian organisms. This structural protein provides essential mechanical stability and resilience to various tissues, including tendons, ligaments, skin, bone, and dentin. Collagen has been structurally investigated for several decades, and variation to its ultrastructure by histology has been associated with several pathological conditions. The current study addresses a critical challenge in the field of collagen research by providing a novel method for studying collagen fibril morphology at the nanoscale. It offers a computational approach to quantifying collagen properties, enabling a deeper understanding of how collagen type I can be affected by pathological conditions. The application of Fast Fourier Transform (FFT) coupled with Atomic Force Microscope (AFM) imaging distinguishes not only healthy and diseased skin but also holds potential for automated diagnosis of connective tissue disorders (CTDs), contributing to both clinical diagnostics and fundamental research in this area. Here we studied the changes in the structural parameters of collagen fibrils in Ehlers Danlos Syndrome (EDS). We have used skin extracted from genetically mutant mice that exhibit EDS phenotype as our model system (Col1a1Jrt/+ mice). The collagen fibrils were analyzed by AFM based descriptive-structural parameters, coupled with a 2D Fast Fourier Transform(2D-FFT) approach that automated the analysis of AFM images. In addition, each sample was characterized based on its FFT and power spectral density. Our qualitative data showed morphological differences in collagen fibril clarity (clearness of the collagen fibril edge with their neighbouring fibri), D-banding, orientation, and linearity. We have also demonstrated that FFT could be a new tool for distinguishing healthy from tissues with CTDs by measuring the disorganization of fibrils in the matrix. We have also employed FFT to reveal the orientations of the collagen fibrils, providing clinically relevant phenotypic information on their organization and anisotropy. The result of this study can be used to develop a new automated tool for better diagnosis of CTDs.
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Affiliation(s)
- Emilie Khattignavong
- Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, M5G 1G6, Canada
- UMR 5513, Laboratoire de Tribologie et Dynamique Des Systémes, École Centrale de Lyon-École Nationale d'Ingénieurs de Saint, Université de Lyon, Étienne, France
| | - Mehrnoosh Neshatian
- Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, M5G 1G6, Canada
| | - Mina Vaez
- Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, M5G 1G6, Canada
| | - Amaury Guillermin
- UMR 5513, Laboratoire de Tribologie et Dynamique Des Systémes, École Centrale de Lyon-École Nationale d'Ingénieurs de Saint, Université de Lyon, Étienne, France
| | - Josephine T Tauer
- Shriners Hospital for Children, Montreal, QC, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada
| | - Marianne Odlyha
- School of Biological Science, Birkbeck College, University of London, London, UK
| | - Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Svetlana V Komarova
- Shriners Hospital for Children, Montreal, QC, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada
| | - Hassan Zahouani
- UMR 5513, Laboratoire de Tribologie et Dynamique Des Systémes, École Centrale de Lyon-École Nationale d'Ingénieurs de Saint, Université de Lyon, Étienne, France
| | - Laurent Bozec
- Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, M5G 1G6, Canada.
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Sabo A, Mittal N, Deshpande A, Clarke H, Taati B. Automated, Vision-Based Goniometry and Range of Motion Calculation in Individuals With Suspected Ehlers-Danlos Syndromes/Generalized Hypermobility Spectrum Disorders: A Comparison of Pose-Estimation Libraries to Goniometric Measurements. IEEE J Transl Eng Health Med 2023; 12:140-150. [PMID: 38088992 PMCID: PMC10712662 DOI: 10.1109/jtehm.2023.3327691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 09/28/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023]
Abstract
Generalized joint hypermobility (GJH) often leads clinicians to suspect a diagnosis of Ehlers Danlos Syndrome (EDS), but it can be difficult to objectively assess. Video-based goniometry has been proposed to objectively estimate joint range of motion in hyperextended joints. As part of an exam of joint hypermobility at a specialized EDS clinic, a mobile phone was used to record short videos of 97 adults (89 female, 35.0 ± 9.9 years old) undergoing assessment of the elbows, knees, shoulders, ankles, and fifth fingers. Five body keypoint pose-estimation libraries (AlphaPose, Detectron, MediaPipe-Body, MoveNet - Thunder, OpenPose) and two hand keypoint pose-estimation libraries (AlphaPose, MediaPipe-Hands) were used to geometrically calculate the maximum angle of hyperextension or hyperflexion of each joint. A custom domain-specific model with a MobileNet-v2 backbone finetuned on data collected as part of this study was also evaluated for the fifth finger movement. Spearman's correlation was used to analyze the angles calculated from the tracked joint positions, the angles calculated from manually annotated keypoints, and the angles measured using a goniometer. Moderate correlations between the angles estimated using pose-tracked keypoints and the goniometer measurements were identified for the elbow (rho =.722; Detectron), knee (rho =.608; MoveNet - Thunder), shoulder (rho =.632; MoveNet - Thunder), and fifth finger (rho =.786; custom model) movements. The angles estimated from keypoints predicted by open-source libraries at the ankles were not significantly correlated with the goniometer measurements. Manually annotated angles at the elbows, knees, shoulders, and fifth fingers were moderately to strongly correlated to goniometer measurements but were weakly correlated for the ankles. There was not one pose-estimation library which performed best across all joints, so the library of choice must be selected separately for each joint of interest. This work evaluates several pose-estimation models as part of a vision-based system for estimating joint angles in individuals with suspected joint hypermobility. Future applications of the proposed system could facilitate objective assessment and screening of individuals referred to specialized EDS clinics.
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Affiliation(s)
- Andrea Sabo
- KITE Research Institute, Toronto Rehabilitation Institute--University Health NetworkTorontoONM5G 2A2Canada
| | - Nimish Mittal
- KITE Research Institute, Toronto Rehabilitation Institute--University Health NetworkTorontoONM5G 2A2Canada
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of MedicineUniversity of TorontoTorontoONM5S 1A1Canada
- Department of Anesthesia and Pain MedicineUniversity of TorontoTorontoONM5S 1A1Canada
- Faculty of Kinesiology and Physical EducationUniversity of TorontoTorontoONM5S 1A1Canada
| | - Amol Deshpande
- Faculty of MedicineUniversity of TorontoTorontoONM5S 1A1Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoONM5S 1A1Canada
- Canada Transitional Pain ServiceToronto General Hospital—University Health NetworkTorontoONM5T 1V4Canada
- Canada Transitional Pain ServiceToronto General HospitalTorontoONM5G 2C4Canada
| | - Babak Taati
- KITE Research Institute, Toronto Rehabilitation Institute--University Health NetworkTorontoONM5G 2A2Canada
- Department of Computer ScienceUniversity of TorontoTorontoONM5S 1A1Canada
- Institute of Biomedical Engineering, University of TorontoTorontoONM5S 1A1Canada
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Ricci V, Mezian K, Chang KV, Mittal N, Kara M, Naňka O, Özçakar L. Ultrasound-guided injection of the elbow: Cadaveric description for the proximal to distal approach. PM R 2023; 15:1431-1435. [PMID: 36864563 DOI: 10.1002/pmrj.12966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Ultrasound (US) guided intra-articular elbow injections are commonly performed in clinical practice. OBJECTIVE To describe a proximal to distal approach for US-guided intra-articular elbow injection. DESIGN Cadaveric study. SETTINGS Academic institution. METHODS Both elbows of a single cadaver were injected with green-colored water-diluted latex dye using the US-guided proximal to distal approach. In the left elbow, the needle was kept in situ; in the right elbow, the needle was removed. Subsequently, a layer-by-layer anatomical dissection was performed in both elbows. MAIN OUTCOME MEASURES Presence and distribution of the latex dye and location of the needle tip within the elbow joint capsule. RESULTS Anatomical dissection of both elbows confirmed the correct intra-articular position of the needle tip in the left elbow as well as correct placement of the latex dye bilaterally. During layer-by-layer dissection of the left elbow, the position of the radial nerve was observed anterior to the needle. CONCLUSIONS This cadaveric observation demonstrated that the US-guided proximal to distal approach is a convenient technique to access the elbow joint. Compared to the previously described techniques, the in-plane, proximal to distal approach may provide excellent needle visibility during the entire procedure, precisely targeting the articular space. The preliminary data need to be validated in additional clinical studies.
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Affiliation(s)
- Vincenzo Ricci
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taiwan
| | - Nimish Mittal
- Temerty Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Murat Kara
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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Mezian K, Ricci V, Mittal N, Novotný T, Chang KV, Özçakar L, Naňka O. Ultrasound-guided injection of the hip: Cadaveric description for the lateral approach. PM R 2023; 15:1150-1155. [PMID: 36515662 DOI: 10.1002/pmrj.12932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/09/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ultrasound (US)-guided intraarticular hip joint injections are commonly performed using an in-plane anterior approach, which has several limitations. OBJECTIVE To describe and report a "lateral" (lateral to medial) approach for US-guided intraarticular hip injection. DESIGN Cadaveric investigation. SETTING Academic institution, department of anatomy. PARTICIPANTS One cadaveric specimen. METHODS Both hips of a single cadaver were injected using the US-guided lateral approach. In the left hip, the needle was inserted and kept in situ. The right hip was injected with white-colored water-diluted latex dye. Subsequently, a layer-by-layer anatomical dissection was performed. MAIN OUTCOME MEASURES Presence and distribution of latex dye and location of needle tip within the joint capsule of the hip. RESULTS Anatomical dissection of the left and right hips confirmed the correct intraarticular position of the needle tip and the placement of the latex dye, respectively. During layer-by-layer dissection of the left hip, positions of the lateral cutaneous nerve and the lateral circumflex femoral artery were observed anterior to the needle, 30 mm for the nerve and 8 mm for the artery. CONCLUSIONS This preliminary study demonstrated that the US-guided lateral approach is a convenient technique to access the hip joint in a cadaveric specimen. Compared with the "classical" anterior technique, the lateral approach may provide several advantages, including improved needle visibility, theoretically decreased risk of vascular injury, and less risk of needle contamination. Because injury to the lateral epiphyseal arteries is possible when lateral approach is used, caution is required, especially in children. These preliminary conclusions will need to be validated in future/larger clinical studies.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vincenzo Ricci
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Tomáš Novotný
- Department of Orthopaedics, University J.E. Purkinje, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
- National Taiwan University College of Medicine, Taipei, Taiwan
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
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D’hondt N, Marcial KM, Mittal N, Costanzi M, Hoydonckx Y, Kumar P, Englesakis MF, Burns A, Bhatia A. A Scoping Review of Epidural Spinal Cord Stimulation for Improving Motor and Voiding Function Following Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2023; 29:12-30. [PMID: 37235192 PMCID: PMC10208259 DOI: 10.46292/sci22-00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Objectives To identify and synthesize the existing evidence on the effectiveness and safety of epidural spinal cord stimulation (SCS) for improving motor and voiding function and reducing spasticity following spinal cord injury (SCI). Methods This scoping review was performed according to the framework of Arksey and O'Malley. Comprehensive serial searches in multiple databases (MEDLINE, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, LILACS, PubMed, Web of Science, and Scopus) were performed to identify relevant publications that focused on epidural SCS for improving motor function, including spasticity, and voiding deficits in individuals with SCI. Results Data from 13 case series including 88 individuals with complete or incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] grade A to D) were included. In 12 studies of individuals with SCI, the majority (83 out of 88) demonstrated a variable degree of improvement in volitional motor function with epidural SCS. Two studies, incorporating 27 participants, demonstrated a significant reduction in spasticity with SCS. Two small studies consisting of five and two participants, respectively, demonstrated improved supraspinal control of volitional micturition with SCS. Conclusion Epidural SCS can enhance central pattern generator activity and lower motor neuron excitability in individuals with SCI. The observed effects of epidural SCS following SCI suggest that the preservation of supraspinal transmission is sufficient for the recovery of volitional motor and voiding function, even in patients with complete SCI. Further research is warranted to evaluate and optimize the parameters for epidural SCS and their impact on individuals with differing degrees of severity of SCI.
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Affiliation(s)
- Nina D’hondt
- Department of Pain Medicine, Multidisciplinary Pain Center, VITAZ, Sint-Niklaas, Belgium
| | - Karmi Margaret Marcial
- Department of Anesthesiology, Philippine General Hospital, University of Philippines, Philippines
| | - Nimish Mittal
- Department of Physical Medicine and Rehabilitation, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matteo Costanzi
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Yasmine Hoydonckx
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pranab Kumar
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marina F. Englesakis
- MLIS Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Anthony Burns
- Department of Physical Medicine and Rehabilitation, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anuj Bhatia
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Rozenberg D, Al Kaabi N, Camacho Perez E, Nourouzpour S, Lopez-Hernandez L, McGillis L, Goligher E, Reid WD, Chow CW, Ryan CM, Kumbhare D, Huszti E, Champagne K, Raj S, Mak S, Santa Mina D, Clarke H, Mittal N. Evaluation and Management of Dyspnea in Hypermobile Ehlers-Danlos Syndrome and Generalized Hypermobility Spectrum Disorder: Protocol for a Pilot and Feasibility Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e44832. [PMID: 36939815 PMCID: PMC10131980 DOI: 10.2196/44832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Dyspnea is a prevalent symptom in individuals with hypermobile Ehlers-Danlos Syndrome (hEDS) and generalized hypermobility spectrum disorder (G-HSD), yet its contributors have not been identified. One known contributor to dyspnea is respiratory muscle weakness. The feasibility and effectiveness of inspiratory muscle training (IMT) in combination with standard-of-care rehabilitation (aerobic, resistance, neuromuscular stabilization, and balance and proprioception exercises) in improving respiratory muscle strength and patient-reported outcomes in patients with hEDS or G-HSD have not been evaluated. OBJECTIVE This study aims to evaluate dyspnea, respiratory muscle strength, and patient-reported outcome measures (PROMs) in hEDS or G-HSD compared with healthy controls and to assess the feasibility of a randomized controlled trial of IMT and standard-of-care rehabilitation for improving respiratory muscle strength, exercise capacity, and PROMs compared with standard-of-care rehabilitation in hEDS and G-HSD. METHODS The study will include 34 participants with hEDS or G-HSD and 17 healthy, age- and sex-matched controls to compare respiratory muscle structure and function and PROMs. After baseline assessments, participants with hEDS or G-HSD will be randomized into the intervention group and provided IMT combined with Ehlers-Danlos Syndrome standard-of-care rehabilitation or into the usual care group, and provided only standard-of-care rehabilitation for 8 weeks. The intervention group will be prescribed IMT in their home environment using the POWERbreathe K5 IMT device (POWERbreathe International Ltd). IMT will comprise 2 daily sessions of 30 breaths for 5 days per week, with IMT progressing from 20% to 60% of the baseline maximal inspiratory pressure (MIP) over an 8-week period. Feasibility will be assessed through rates of recruitment, attrition, adherence, adverse events, and participant satisfaction. The primary pilot outcome is MIP change over an 8-week period in hEDS or G-HSD. Secondary outcomes will include the evaluation of dyspnea using Medical Research Council Scale and 18-point qualitative dyspnea descriptors; diaphragmatic thickening fraction using ultrasound; respiratory muscle endurance; pulmonary function; prefrontal cortical activity using functional near-infrared spectroscopy; aerobic capacity during cardiopulmonary exercise testing; quality of life using Short Form-36; and scores from the Depression, Anxiety, and Stress scale-21. These measures will also be performed once in healthy controls to compare normative values. Multivariable regression will be used to assess the contributors to dyspnea. Paired 2-tailed t tests will be used to assess the changes in MIP and secondary measures after 8 weeks of IMT. RESULTS Study recruitment began in August 2021 and, with several disruptions owing to COVID-19, is expected to be completed by December 2023. CONCLUSIONS This study will provide a better understanding of the factors associated with dyspnea and the feasibility and effectiveness of IMT combined with standard-of-care rehabilitation. IMT may be a novel therapeutic strategy for improving respiratory muscle function and patient-reported outcomes in individuals with hEDS or G-HSD. TRIAL REGISTRATION ClinicalTrials.gov NCT04972565; https://clinicaltrials.gov/ct2/show/NCT04972565. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44832.
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Affiliation(s)
- Dmitry Rozenberg
- Respirology and Lung Transplantation, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Noor Al Kaabi
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Encarna Camacho Perez
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Sahar Nourouzpour
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Ewan Goligher
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - W Darlene Reid
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Chung-Wai Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Clodagh M Ryan
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
| | - Dinesh Kumbhare
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | | | - Satish Raj
- Department of Cardiac Sciences, Cumming School of Medicine, Calgary, AB, Canada
| | - Susanna Mak
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Daniel Santa Mina
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Nimish Mittal
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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Mittal N, Sabo A, Deshpande A, Clarke H, Taati B. Feasibility of video-based joint hypermobility assessment in individuals with suspected Ehlers-Danlos syndromes/generalised hypermobility spectrum disorders: a single-site observational study protocol. BMJ Open 2022; 12:e068098. [PMID: 36526308 PMCID: PMC9764649 DOI: 10.1136/bmjopen-2022-068098] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Ehlers-Danlos syndromes (EDS)/generalised hypermobility spectrum disorders (G-HSD) affect the connective tissue of the body and present with a heterogeneous set of symptoms that pose a challenge for diagnosis. One of the main diagnostic criteria of EDS/G-HSD is generalised joint hypermobility, which is currently assessed by clinicians during a physical exam. However, the practice for measuring joint hypermobility is inconsistent between clinicians, leading to high inter-rater variability. Often patients are misdiagnosed with EDS/G-HSD based on an incorrect hypermobility assessment, leading to increased referral rates and resource utilisation at specialised EDS clinics that results in unnecessary emotional distress for patients. An objective, validated and scalable method for assessing hypermobility might mitigate these issues and result in improved EDS/G-HSD patient care. METHODS AND ANALYSIS This study will examine the use of videos obtained using a smartphone camera to assess the range of motion (ROM) and hypermobility of the joints assessed in Beighton score and more (spine, shoulders, elbows, knees, ankles, thumbs and fifth fingers) in individuals with suspected EDS/G-HSD. Short videos of participants will be captured as they undergo a formal assessment of joint hypermobility at the GoodHope EDS Clinic at Toronto General Hospital. Clinicians will measure the ROM at each joint using a clinical-grade goniometer to establish ground truth measurements. Open-source human pose-estimation libraries will be used to extract the locations of key joints from the videos. Deterministic and machine learning systems will be developed and evaluated for estimating the ROM at each joint. Results will be analysed separately for each joint and human pose-estimation library. ETHICS AND DISSEMINATION This study was approved by the Research Ethics Board of the University Health Network in Toronto on 26 April 2022. Participants will provide written informed consent. Findings from this study will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER NCT05366114.
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Affiliation(s)
- Nimish Mittal
- Department of Medicine, Division of Physical Medicine and Rehabiitation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
| | - Andrea Sabo
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
| | | | - Hance Clarke
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- Pain Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Babak Taati
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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10
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McDougall A, Sangha H, Mittal N, Farag J. Suprascapular Neuropathy Secondary to Compressive Paralabral Cyst at the Spinoglenoid Notch. Am J Phys Med Rehabil 2022; 101:e128-e129. [PMID: 35213395 DOI: 10.1097/phm.0000000000001995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Alexandre McDougall
- From the University of Toronto, Toronto Rehabilitation Institute, Toronto, Ontario, Canada
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11
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Hunt C, Provenzano DA, Eshraghi Y, Mittal N, Souza D, Buchheit T. Should intra-articular hyaluronic acid be used routinely for knee osteoarthritis pain? PM R 2022; 14:879-885. [PMID: 34837674 PMCID: PMC9970143 DOI: 10.1002/pmrj.12740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/13/2021] [Accepted: 11/11/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Christine Hunt
- Department of Pain Medicine, Mayo Clinic, Jacksonville, FL, USA 32224
| | | | - Yashar Eshraghi
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA 70112,Department of Anesthesia, Interventional Pain Management, Ochsner Health System, University of Queensland Ochsner Clinical School, New Orleans, Louisiana, USA 70115
| | - Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA 44233
| | - Thomas Buchheit
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA 27710,Anesthesiology Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA 27705
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12
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Mun KJ, Bhatia A, Flannery J, Rampersaud R, Mittal N. Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: What Is the Clinical Effectiveness of Transforaminal Epidural Steroid Injections Versus Surgical Microdiscectomy in Patients With Radicular Pain Secondary to Herniated Lumbar Disc? Am J Phys Med Rehabil 2022; 101:e50-e53. [PMID: 34711712 DOI: 10.1097/phm.0000000000001921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kyung Joon Mun
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (KJM); Department of Anesthesia and Pain Medicine, University Health Network-Toronto Western Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada (AB, NM); Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (JF, NM); Division of Orthopaedic Surgery, Toronto Western Hospital, Schroeder Arthritis Institute, Krembil Research Institute University Health Network (UHN), Toronto, Ontario, Canada (RR); and University of Toronto, Toronto, Ontario, Canada (RR)
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13
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Singh P, Arora S, Goyal A, Mittal N, Singh A, Sharma S, Shanthaiah D, Dardi I. INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS. Acta Endocrinol (Buchar) 2022; 18:174-180. [PMID: 36212268 PMCID: PMC9512378 DOI: 10.4183/aeb.2022.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide. AIMS The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus. METHODS We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications. RESULTS The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED. CONCLUSION Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.
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Affiliation(s)
- P. Singh
- Dayanand Medical College and Hospital, Dept. of Endocrinology
| | - S. Arora
- Dayanand Medical College and Hospital, Dept. of Endocrinology
| | - A. Goyal
- Dayanand Medical College and Hospital, Dept. of Urology
| | - N. Mittal
- Dayanand Medical College and Hospital, Dept. of Endocrinology
| | - A. Singh
- Dayanand Medical College and Hospital, Dept. of Endocrinology
| | - S. Sharma
- Dayanand Medical College and Hospital, Dept. of social and preventive medicine, Ludhiana, Punjab
| | - D.M. Shanthaiah
- Institute of Medical Sciences, Dept. of Endocrinology and Metabolism, Banaras Hindu University, Varanasi, Uttar Pradesh
| | - I.K. Dardi
- Columbia Asia Hospital, Patiala, Punjab, India
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14
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Mittal N, Santa Mina D, Buryk-Iggers S, Lopez-Hernandez L, Hussey L, Franzese A, Katz J, Laflamme C, McGillis L, McLean L, Rachinsky M, Rozenberg D, Slepian M, Weinrib A, Clarke H. The GoodHope Exercise and Rehabilitation (GEAR) Program for People With Ehlers-Danlos Syndromes and Generalized Hypermobility Spectrum Disorders. Front Rehabilit Sci 2021; 2:769792. [PMID: 36188836 PMCID: PMC9397788 DOI: 10.3389/fresc.2021.769792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022]
Abstract
Introduction: The Ehlers-Danlos Syndromes (EDS) and Generalized Hypermobility Spectrum Disorders (G-HSD) comprise a heterogeneous group of genetic disorders of abnormal synthesis and/or maturation of collagen and other matricellular proteins. EDS is commonly characterized by manifestations such as multi joint hypermobility that can lead to musculoskeletal pains, subluxations and dislocations, fragile skin, organ dysfunction, and chronic significant diffuse pain with fatigue, deconditioning eventuating to poor quality of life. Evidence suggests exercise and rehabilitation interventions may ameliorate symptoms of unstable joints, recurrent subluxations/dislocations, and chronic widespread musculoskeletal pain. To date, there have only been a few reports describing exercise and rehabilitation care strategies for people with EDS. Methods: In this manuscript, we describe the GoodHope Exercise and Rehabilitation (GEAR) program, its overarching principles, as well as the program development and delivery model. The GEAR program aims to decrease functional impairment, reduce pain, increase confidence in symptom self-management, and provide a community of support for people with EDS/G-HSD. To achieve these goals, we detail the model of care that includes exercise and rehabilitation therapy, education for self-management, and support accessing relevant community resources. Strengths and Limitations of the Study: GEAR represents a novel exercise and rehabilitation care model for people with G-HSD and various clinical EDS subtypes, beyond the commonly included hEDS subtype. Systematic collection of data via validated measurements is ongoing and will guide the refinement of GEAR and support the development of emerging exercise and rehabilitation programs for people with EDS.
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Affiliation(s)
- Nimish Mittal
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- *Correspondence: Nimish Mittal
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stephanie Buryk-Iggers
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Laura Hussey
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Alyssa Franzese
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Joel Katz
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Psychology, Faculty of Health, York University, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Camille Laflamme
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Lianne McLean
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Dmitry Rozenberg
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Respirology, Temerty Faculty of Medicine, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Maxwell Slepian
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Aliza Weinrib
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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15
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Mittal N, Mina DS, McGillis L, Weinrib A, Slepian PM, Rachinsky M, Buryk-Iggers S, Laflamme C, Lopez-Hernandez L, Hussey L, Katz J, McLean L, Rozenberg D, Liu L, Tse Y, Parker C, Adler A, Charames G, Bleakney R, Veillette C, Nielson CJ, Tavares S, Varriano S, Guzman J, Faghfoury H, Clarke H. The GoodHope Ehlers Danlos Syndrome Clinic: development and implementation of the first interdisciplinary program for multi-system issues in connective tissue disorders at the Toronto General Hospital. Orphanet J Rare Dis 2021; 16:357. [PMID: 34376220 PMCID: PMC8353438 DOI: 10.1186/s13023-021-01962-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 07/18/2021] [Indexed: 11/22/2022] Open
Abstract
Ehlers-Danlos Syndrome (EDS) are a heterogeneous group of genetic connective tissue disorders, and typically manifests as weak joints that subluxate/dislocate, stretchy and/or fragile skin, organ/systems dysfunction, and significant widespread pain. Historically, this syndrome has been poorly understood and often overlooked. As a result, people living with EDS had difficulty obtaining an accurate diagnosis and appropriate treatment, leading to untold personal suffering as well as ineffective health care utilization. The GoodHope EDS clinic addresses systemic gaps in the diagnosis and treatment of EDS. This paper describes a leap forward—from lack of awareness, diagnosis, and treatment—to expert care that is tailored to meet the specific needs of patients with EDS. The GoodHope EDS clinic consists of experts from various medical specialties who work together to provide comprehensive care that addresses the multi-systemic nature of the syndrome. In addition, EDS-specific self-management programs have been developed that draw on exercise science, rehabilitation, and health psychology to improve physical and psychosocial wellbeing and overall quality of life. Embedded into the program are research initiatives to shed light on the clinical presentation, underlying mechanisms of pathophysiology, and syndrome management. We also lead regular educational activities for community health care providers to increase awareness and competence in the interprofessional management of EDS beyond our doors and throughout the province and country.
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Affiliation(s)
- Nimish Mittal
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. .,Temerty Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada. .,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada. .,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Aliza Weinrib
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada
| | - P Maxwell Slepian
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Psychology, York University, Toronto, ON, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada
| | - Stephanie Buryk-Iggers
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Camille Laflamme
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Laura Hussey
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Joel Katz
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada.,University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| | - Lianne McLean
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Dmitry Rozenberg
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Temerty Faculty of Medicine, Division of Respirology, Ajmera Transplant Program, Toronto General Hospital Research Institute, UHN, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yvonne Tse
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Colleen Parker
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Arnon Adler
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - George Charames
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Robert Bleakney
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Christian Veillette
- Department of Surgery, Division of Orthopedics, University of Toronto, Toronto, ON, Canada
| | - Christopher J Nielson
- Department of Surgery, Division of Orthopedics, University of Toronto, Toronto, ON, Canada
| | - Sandra Tavares
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Stephanie Varriano
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Juan Guzman
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Hanna Faghfoury
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Temerty Faculty of Medicine, Division of Medical Genetics, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
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Chohan K, Mittal N, McGillis L, Lopez-Hernandez L, Camacho E, Rachinsky M, Mina DS, Reid WD, Ryan CM, Champagne KA, Orchanian-Cheff A, Clarke H, Rozenberg D. A review of respiratory manifestations and their management in Ehlers-Danlos syndromes and hypermobility spectrum disorders. Chron Respir Dis 2021; 18:14799731211025313. [PMID: 34291699 PMCID: PMC8312172 DOI: 10.1177/14799731211025313] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) are a heterogeneous group of heritable genetic connective tissue disorders with multiple characteristics including joint hypermobility, tissue fragility, and multiple organ dysfunction. Respiratory manifestations have been described in EDS patients, but have not been systematically characterized. A narrative review was undertaken to describe the respiratory presentations and management strategies of individuals with EDS and HSD. METHODS A broad literature search of Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL was undertaken from inception to November 2020 of all study types, evaluating EDS/ HSD and pulmonary conditions. This narrative review was limited to adult patients and publications in English. RESULTS Respiratory manifestations have generally been described in hypermobile EDS (hEDS), classical and vascular EDS subtypes. Depending on EDS subtype, they may include but are not limited to dyspnea, dysphonia, asthma, sleep apnea, and reduced respiratory muscle function, with hemothorax and pneumothorax often observed with vascular EDS. Respiratory manifestations in HSD have been less frequently characterized in the literature, but exertional dyspnea is the more common symptom described. Respiratory symptoms in EDS can have an adverse impact on quality of life. The respiratory management of EDS patients has followed standard approaches with thoracotomy tubes and pleurodesis for pleural manifestations, vocal cord strengthening exercises, continuous positive pressure support for sleep apnea, and exercise training. Reduced respiratory muscle function in hEDS patients responds to inspiratory muscle training. CONCLUSION Respiratory symptoms and manifestations are described in EDS and HSD, and have generally been managed using conservative non-surgical strategies. Research into the prevalence, incidence and specific respiratory management strategies in EDS and HSD is needed to mitigate some of the associated morbidity.
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Affiliation(s)
- Karan Chohan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nimish Mittal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Encarna Camacho
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - W Darlene Reid
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh Mai Ryan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | | | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Hance Clarke
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Respirology, University Health Network, Toronto, Ontario, Canada
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Tran J, Peng P, Agur A, Mittal N. Diagnostic block and radiofrequency ablation of the acromial branches of the lateral pectoral and suprascapular nerves for shoulder pain: a 3D cadaveric study. Reg Anesth Pain Med 2021; 46:305-312. [PMID: 33574156 DOI: 10.1136/rapm-2020-102300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Acromial branches of the lateral pectoral and suprascapular nerves have been proposed as targets for diagnostic block and radiofrequency ablation to treat superior shoulder pain; however, the nerve capture rates of these procedures have not been investigated. The objectives of this study were to use dissection and 3D modeling technology to determine the course of these acromial branches, relative to anatomical landmarks, and to evaluate nerve capture rates using ultrasound-guided dye injection and lesion simulation. METHODS Ultrasound-guided dye injections, targeting the superior surface of coracoid process and floor of supraspinous fossa, were performed (n=5). Furthermore, needles targeting the superior and posterior surfaces of the coracoid process were placed under ultrasound guidance to simulate needle electrode position (n=5). Specimens were dissected, digitized, and modeled to determine capture rates of acromial branches of lateral pectoral and suprascapular nerves. RESULTS The course of acromial branches of lateral pectoral and suprascapular nerves were documented. Dye spread capture rates: acromial branches of lateral pectoral and suprascapular nerves were captured in all specimens. Lesion simulation capture rates: (1) when targeting superior surface of coracoid process, the entire acromial branch of lateral pectoral nerve was captured in all specimens and (2) when targeting posterior surface of coracoid process, the acromioclavicular and bursal branches of acromial branch of suprascapular nerve were captured in all specimens; coracoclavicular branch was captured in 3/5 specimens. CONCLUSIONS This study supports the anatomical feasibility of ultrasound-guided targeting of the acromial branches of lateral pectoral and suprascapular nerves. Further clinical investigation is required.
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Affiliation(s)
- John Tran
- Division of Anatomy, Department of Surgery, University of Toronto Faculty of Medicine, Toronto, Canada
| | - Philip Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, Canada
| | - Anne Agur
- Division of Anatomy, Department of Surgery, University of Toronto Faculty of Medicine, Toronto, Canada
| | - Nimish Mittal
- Physical Medicine and Rehabilitation, University Health Network, Toronto, Canada
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Pushparaj H, Hoydonckx Y, Mittal N, Peng P, Cohen SP, Cao X, Bhatia A. A systematic review and meta-analysis of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain. Eur J Pain 2021; 25:986-1011. [PMID: 33471393 DOI: 10.1002/ejp.1735] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/16/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Studies have reported relief of chronic shoulder pain with non-ablative pulsed neuromodulatory (pRF) or ablative radiofrequency (aRF) procedures on innervation of the shoulder joint but interpretation of these reports is hampered by inconsistent indications, anatomic targets and follow-up. This systematic review was conducted to synthesize the existing literature on procedures employing pRF or aRF for treating chronic shoulder pain. DATABASES AND DATA TREATMENT MEDLINE and other medical literature databases were reviewed up to 31 December 2019 for publications on pRF or aRF procedures on shoulder joint innervation to relieve chronic pain. Data on analgesic and functional outcomes measured at any time point following the interventions were extracted. Existing knowledge on innervation of the shoulder joint with relevance to RF procedures was also synthesized. RESULTS In all, 42 publications, 7 randomized controlled trials (RCTs) and 35 observational studies, case series or reports were identified. Thirty-six of these publications were on pRF procedure and 29 of these reported procedures exclusively targeting the suprascapular nerve. A meta-analysis of the seven RCTs evaluating pRF indicated no analgesic benefit or functional improvement with this treatment over conventional medical management. Case series and reports on aRF indicate a potential for analgesic benefit but the quality of this evidence was low. CONCLUSIONS RF treatments targeting the sensory innervation of the shoulder joint affected by degenerative conditions have the potential to reduce pain but the current evidence does not suggest analgesic or functional benefit (GRADE certainty of evidence-low). Studies of high methodological quality are required to further investigate the role of these interventions. SIGNIFICANCE This is a comprehensive review of literature on pulsed (non-ablative) and ablative radiofrequency (RF) procedures for chronic shoulder pain. The systematic review and meta-analysis of 7 trials found that pulsed RF for chronic shoulder pain provided similar analgesia and functional improvement as conservative medical management at three months after the procedures. The case series and reports on ablative RF for shoulder pain indicate possible analgesic benefit but their quality was low. This review highlights the need for studies of a high quality on ablative RF treatments for chronic shoulder pain.
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Affiliation(s)
- Hemkumar Pushparaj
- Department of Anesthesia and Pain Management, University Health Network-Toronto Western Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yasmine Hoydonckx
- Department of Anesthesia and Pain Management, University Health Network-Toronto Western Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nimish Mittal
- Department of Physical Medicine and Rehabilitation, University Health Network-Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada
| | - Philip Peng
- Department of Anesthesia and Pain Management, University Health Network-Toronto Western Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Steven P Cohen
- Departments of Anesthesiology and Critical Care Medicine & Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Departments of Anesthesiology & Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Xingshan Cao
- Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anuj Bhatia
- Department of Anesthesia and Pain Management, University Health Network-Toronto Western Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Catapano M, Catapano J, Borschel G, Alavinia SM, Robinson LR, Mittal N. Effectiveness of Platelet-Rich Plasma Injections for Nonsurgical Management of Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arch Phys Med Rehabil 2020; 101:897-906. [DOI: 10.1016/j.apmr.2019.10.193] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/20/2019] [Accepted: 10/22/2019] [Indexed: 12/13/2022]
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20
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McGillis L, Mittal N, Santa Mina D, So J, Soowamber M, Weinrib A, Soever L, Rozenberg D, Liu L, Tse Y, Katz J, Charames GS, Murphy K, Vadas P, Slepian MP, Walsh S, Wilson L, Adler A, Franzese A, Hussey L, Nevay DL, Guzman J, Clarke H. Utilization of the 2017 diagnostic criteria for hEDS by the Toronto GoodHope Ehlers-Danlos syndrome clinic: A retrospective review. Am J Med Genet A 2019; 182:484-492. [PMID: 31840928 DOI: 10.1002/ajmg.a.61459] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/11/2019] [Accepted: 12/02/2019] [Indexed: 01/31/2023]
Abstract
The new 2017 diagnostic criteria for hypermobile Ehlers-Danlos Syndrome (hEDS) provide a framework for diagnosing hEDS but are more stringent than the previous Villefranche criteria. Our clinical experience at the GoodHope EDS clinic was that the 2017 criteria left many highly symptomatic patients without a diagnosis of hEDS. We conducted a retrospective cohort study to confirm our clinic experience and assess the accuracy of the 2017 diagnostic criteria for hEDS in patients who had a previous hEDS diagnosis based on the Villefranche criteria. Our study found that 15% (n = 20 of 131) of patients with a prior diagnosis of hEDS met the 2017 diagnostic criteria, and many of the traits used to distinguish hEDS were not significantly more frequent in patients who met 2017 criteria versus those who did not. In both groups objective systemic manifestations were found less frequently than subjective systemic manifestations. Beighton score (BS) as assessed by primary care practitioner was found to be higher than assessment by EDS practitioner in 81% (n = 74 of 91) of cases. Generalized joint hypermobility was confirmed in only 46% (n = 51 of 111) of patients who had a previous diagnosis of hEDS. Higher BS did not correlate with increased number of systemic manifestations in our cohort. Common comorbidities of hEDS were found with similar frequency in those who met 2017 criteria and those who did not. Based on our cohort, the 2017 hEDS diagnostic criteria require refinement to improve its diagnostic accuracy.
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Affiliation(s)
- Laura McGillis
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nimish Mittal
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Santa Mina
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Joyce So
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,The Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Medha Soowamber
- Department of Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Aliza Weinrib
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Leslie Soever
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Medicine, Respirology and Lung Transplant Program, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Louis Liu
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Division Of Gastroenterology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yvonne Tse
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Division Of Gastroenterology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Joel Katz
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - George S Charames
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Pathology and Lab Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Kieran Murphy
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Peter Vadas
- Division of Allergy and Clinical Immunology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Maxwell P Slepian
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Scott Walsh
- Department of Medicine, Division of Dermatology, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay Wilson
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Arnon Adler
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Alyssa Franzese
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Hussey
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Dayna-Lynn Nevay
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Juan Guzman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hance Clarke
- GoodHope EDS Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
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Talreja V, Patil V, Noronha V, Joshi A, Menon N, Chougule A, Menon M, Mittal N, Prabhash K. Molecular profiling and treatment patterns of advanced salivary gland cancers in head and neck region. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz428.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Catapano M, Zhang K, Mittal N, Sangha H, Onishi K, de Sa D. Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy: A Systematic Review. PM R 2019; 12:288-300. [PMID: 31642203 DOI: 10.1002/pmrj.12268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 10/04/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To systematically review and evaluate the efficacy and complication profile of prolotherapy using hyperosmolar dextrose solution injection for rotator cuff tendinopathy. LITERATURE SURVEY MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (from inception to 1 July, 2019). METHODOLOGY A comprehensive search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar dextrose solution for rotator cuff tendinopathy. Two reviewers independently screened the titles, abstracts, and full texts, and then extracted data from eligible studies. All reported outcome measures and complications were analyzed descriptively. SYNTHESIS Five studies satisfied inclusion criteria. Included studies analyzed a total of 272 participants with a final follow-up ranging from 6 weeks to 12 months. Prolotherapy differed greatly among studies. Two studies used a multisite enthesis injection protocol while the other three used ultrasound-guided protocols. Two of the studies used an intrasubstance supraspinatus injection and three used a supraspinatus enthesis injection. Control groups consisted of nonoperative rehabilitation including physical therapy and medical management in three studies, supraspinatus saline enthesis injection in one study, and corticosteroid injection in one study. There was statistically significant improvement in pain intensity with multisite injection protocols compared to physical therapy and medical management in both studies. Ultrasound-guided supraspinatus injection trials did not find any statistically significant difference in pain intensity, range of motion, strength, function, or ultrasound characteristics compared to controls of enthesis saline injection or corticosteroid. The complication rate was low, with only 6/272 participants experiencing adverse events consisting of transient increase in pain for 1 to 2 days postintervention. CONCLUSIONS Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.
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Affiliation(s)
- Michael Catapano
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kailia Zhang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nimish Mittal
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Harpreet Sangha
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Mittal N, Sangha H, Flannery J, Robinson LR, Agur A. Ultrasound‐Guided Incisionless Carpal Tunnel Release Using a Hook Knife: A Cadaveric Study. PM R 2019; 11:1101-1106. [DOI: 10.1002/pmrj.12118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 12/19/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Department of MedicineUniversity of Toronto Toronto Canada
- Department of Anesthesia and Pain Management, Toronto Western HospitalUniversity of Toronto Toronto Canada
| | - Harpreet Sangha
- Division of Physical Medicine and Rehabilitation, Department of MedicineUniversity of Toronto Toronto Canada
- Department of MedicineUniversity of Toronto Toronto Canada
| | - John Flannery
- Division of Physical Medicine and Rehabilitation, Department of MedicineUniversity of Toronto Toronto Canada
- Department of MedicineUniversity of Toronto Toronto Canada
| | - Lawrence R. Robinson
- Division of Physical Medicine and Rehabilitation, Department of MedicineUniversity of Toronto Toronto Canada
| | - Ann Agur
- Division of Physical Medicine and Rehabilitation, Department of MedicineUniversity of Toronto Toronto Canada
- ; and Division of Anatomy, Department of SurgeryUniversity of Toronto Toronto Canada
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24
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Rahman K, Mittal N, Gupta R, Kumar S, Gupta T, Gupta A, Nityanand S. Clinicopathological profile of paroxysmal nocturnal haemoglobinuria clone-positive aplastic anaemia paediatric patients-A single centre study from North India. Int J Lab Hematol 2018; 40:604-610. [PMID: 29938911 DOI: 10.1111/ijlh.12875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/28/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION There is a paucity of literature related to the prevalence of Paroxysmal Nocturnal haemoglobinuria (PNH) clones in paediatric aplastic anaemia (AA) patients. METHODS We performed a retrospective analysis over a period of 42 months to study the prevalence of PNH clones in paediatric (age less than 18 years) AA cases, using Fluorescein-labelled proaerolysin-based flow cytometric screening and analysed their clinico-pathological features. RESULTS PNH clone was identified in 100 (33.2%) of the 301 patients screened. These were comprised of 51 cases of non-severe AA, 33 cases of severe AA and 16 cases of very severe AA. The median age was 13 years with an M:F ratio of 2.5:1. The median clone size (taken as the proportion of PNH-positive neutrophils) was 2.15% (range: 0.05%-93.1%). Although a majority of patients (n = 77) had a clone size of less than 10%, a significant proportion (n = 23) did harbour a clone size of more than 10%. Evidence of haemolysis was observed in 3 patients, all of them having a clone size of more than 10%. Interestingly, 1 patient with dural sinus thrombosis harboured a clone size of 1.25% only. Chromosomal breakage analysis was performed in 61 patients, none of which was positive. Complete and partial response to immunosuppressive therapy was found in 55.1% patients (16/29). CONCLUSION There is a high prevalence of PNH clones in paediatric AA patients, which in a majority of cases are of small clone sizes. The use of immunosuppressive therapy does not show a better outcome as compared to PNH-negative cases.
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Affiliation(s)
- K Rahman
- Department of Hematology, SGPGI, Lucknow, India
| | - N Mittal
- Department of Hematology, SGPGI, Lucknow, India
| | - R Gupta
- Department of Hematology, SGPGI, Lucknow, India
| | - S Kumar
- Department of Hematology, SGPGI, Lucknow, India
| | - T Gupta
- Department of Hematology, SGPGI, Lucknow, India
| | - A Gupta
- Department of Hematology, SGPGI, Lucknow, India
| | - S Nityanand
- Department of Hematology, SGPGI, Lucknow, India
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Gupta S, Malhotra A, Mittal N, Garg SK, Jindal R, Kansay R. The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate. Bone Joint J 2018; 100-B:1094-1099. [PMID: 30062945 DOI: 10.1302/0301-620x.100b8.bjj-2017-1442.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria. Patients and Methods Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. Results The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5). Conclusion Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.
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Affiliation(s)
- S Gupta
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - A Malhotra
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - N Mittal
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - S K Garg
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - R Jindal
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - R Kansay
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
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Gupta R, Mittal N, Rahman K, Sharma A, Singh P, Kumar S, Nityanand S. Rare BCR-ABL1 transcript in a RUNX1-RUNX1T1-positive de novo acute myeloid leukemia: The chicken and egg tale. Int J Lab Hematol 2018; 40:e24-e27. [PMID: 29393574 DOI: 10.1111/ijlh.12779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/19/2017] [Indexed: 11/28/2022]
Affiliation(s)
- R Gupta
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - N Mittal
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - K Rahman
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Sharma
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - P Singh
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - S Kumar
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - S Nityanand
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Mittal N, Thakore N, Bell RL, Maddox WT, Schallert T, Duvauchelle CL. Sex-specific ultrasonic vocalization patterns and alcohol consumption in high alcohol-drinking (HAD-1) rats. Physiol Behav 2017; 203:81-90. [PMID: 29146494 DOI: 10.1016/j.physbeh.2017.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/03/2017] [Accepted: 11/12/2017] [Indexed: 12/29/2022]
Abstract
Ultrasonic vocalizations (USVs) have been established as an animal model of emotional status and are often utilized in drug abuse studies as motivational and emotional indices. Further USV functionality has been demonstrated in our recent work showing accurate identification of selectively-bred high versus low alcohol-consuming male rats ascertained exclusively from 22 to 28kHz and 50-55kHz FM USV acoustic parameters. With the hypothesis that alcohol-sensitive sex differences could be revealed through USV acoustic parameters, the present study examined USVs and alcohol consumption in male and female selectively bred high-alcohol drinking (HAD-1) rats. For the current study, we examined USV data collected during a 12-week experiment in male and female HAD-1 rats. Experimental phases included Baseline (2weeks), 4-h EtOH Access (4weeks), 24-h EtOH Access (4weeks) and Abstinence (2weeks). Findings showed that both male and female HAD-1 rats spontaneously emitted a large number of 22-28kHz and 50-55kHz FM USVs and that females drank significantly more alcohol compared to males over the entire course of the experiment. Analyses of USV acoustic characteristics (i.e. mean frequency, duration, bandwidth and power) revealed distinct sex-specific phenotypes in both 50-55kHz FM and 22-28kHz USV transmission that were modulated by ethanol exposure. Moreover, by using a linear combination of these acoustic characteristics, we were able to develop binomial logistic regression models able to discriminate between male and female HAD-1 rats with high accuracy. Together these results highlight unique emotional phenotypes in male and female HAD-1 rats that are differentially modulated by alcohol experience.
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Affiliation(s)
- N Mittal
- The University of Texas at Austin, College of Pharmacy, Division of Pharmacology and Toxicology, 2409 University Avenue, Stop A1915, Austin, TX 78712, USA; Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, 2500 Speedway, Stop A4800, Austin, TX 78712, USA
| | - N Thakore
- The University of Texas at Austin, College of Pharmacy, Division of Pharmacology and Toxicology, 2409 University Avenue, Stop A1915, Austin, TX 78712, USA; Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, 2500 Speedway, Stop A4800, Austin, TX 78712, USA
| | - R L Bell
- Institute of Psychiatric Research, Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - W T Maddox
- Cognitive Design and Statistical Consulting, LLC, Austin, TX 78746, USA
| | - T Schallert
- Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, 2500 Speedway, Stop A4800, Austin, TX 78712, USA; The University of Texas at Austin, College of Liberal Arts, Behavioral Neuroscience, 108 E. Dean Keeton, Stop A8000, Austin, TX 78712, USA
| | - C L Duvauchelle
- The University of Texas at Austin, College of Pharmacy, Division of Pharmacology and Toxicology, 2409 University Avenue, Stop A1915, Austin, TX 78712, USA; Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, 2500 Speedway, Stop A4800, Austin, TX 78712, USA.
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Mittal N, Vatsa S, Minz AKA. Fatal meningitis by Cryptococcus laurentii in a post-partum woman: A manifestation of immune reconstitution inflammatory syndrome. Indian J Med Microbiol 2015; 33:590-3. [DOI: 10.4103/0255-0857.167337] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Mittal N, Naridze R, James P, Shott S, Valentino LA. Utility of a Paediatric Bleeding Questionnaire as a screening tool for von Willebrand disease in apparently healthy children. Haemophilia 2015; 21:806-11. [PMID: 25982122 DOI: 10.1111/hae.12689] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED von Willebrand disease (VWD), an inherited bleeding disorder caused by deficiency or dysfunction of von Willebrand factor (VWF) is diagnosed when a personal and often a family history of excessive mucocutaneous bleeding is present along with abnormal laboratory studies. An accurate assessment of haemorrhagic symptoms is key in suspecting VWD but presents a challenge especially in children due to overlap between normal and abnormal bleeding. Bleeding questionnaire (BQ) scores have been validated in adults and have recently been validated in children with VWD for assessing bleeding severity. However, there are limited data supporting their use prospectively in healthy children with bleeding complaints. AIM The objectives of this study were to obtain normative data from children and validate a paediatric BQ (PBQ) to determine the discriminative ability of its total score and its individual components for identifying children likely to have VWD. METHODS The PBQ was administered to 1281 multiethnic, healthy children between 30 days and 18 years of age presenting to a general paediatric office and to 35 children with VWD based on VWF antigen, activity and multimer pattern. RESULTS When children with total BQ scores of 3 or more were predicted to have VWD, the sensitivity was 97.2%, the specificity was 97.1%, the positive predictive value was 48.6% and the negative predictive value was 99.9%. CONCLUSIONS The PBQ may help discriminate a significant bleeding history from trivial bleeding, may be integrated into the primary care algorithm for evaluating children suspected with VWD.
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Affiliation(s)
- N Mittal
- Department of Pediatric Hematology Oncology, Rush University Medical Center, Chicago, IL, USA
| | - R Naridze
- Department of Pediatric Hematology Oncology, Rush University Medical Center, Chicago, IL, USA
| | - P James
- Department of Medicine, Queens University, Kingston, ON, Canada
| | - S Shott
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - L A Valentino
- Department of Pediatric Hematology Oncology, Rush University Medical Center, Chicago, IL, USA
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Abstract
The latest developments in zeolite and MOF membranes are reviewed, with an emphasis on synthesis techniques. Industrial applications, hydrothermal stability, polymer-supported and mixed matrix membranes are some of the aspects discussed.
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Affiliation(s)
- N. Rangnekar
- Department of Chemical Engineering and Materials Science
- Minneapolis
- USA
| | - N. Mittal
- Department of Chemical Engineering and Materials Science
- Minneapolis
- USA
| | - B. Elyassi
- Department of Chemical Engineering and Materials Science
- Minneapolis
- USA
| | - J. Caro
- Institut für Physikalische Chemie und Elektrochemie der Leibniz Universität Hannover
- D-30167 Hannover
- Germany
| | - M. Tsapatsis
- Department of Chemical Engineering and Materials Science
- Minneapolis
- USA
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Demuzere M, Orru K, Heidrich O, Olazabal E, Geneletti D, Orru H, Bhave AG, Mittal N, Feliu E, Faehnle M. Mitigating and adapting to climate change: multi-functional and multi-scale assessment of green urban infrastructure. J Environ Manage 2014; 146:107-115. [PMID: 25163601 DOI: 10.1016/j.jenvman.2014.07.025] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 07/17/2014] [Accepted: 07/22/2014] [Indexed: 05/25/2023]
Abstract
In order to develop climate resilient urban areas and reduce emissions, several opportunities exist starting from conscious planning and design of green (and blue) spaces in these landscapes. Green urban infrastructure has been regarded as beneficial, e.g. by balancing water flows, providing thermal comfort. This article explores the existing evidence on the contribution of green spaces to climate change mitigation and adaptation services. We suggest a framework of ecosystem services for systematizing the evidence on the provision of bio-physical benefits (e.g. CO2 sequestration) as well as social and psychological benefits (e.g. improved health) that enable coping with (adaptation) or reducing the adverse effects (mitigation) of climate change. The multi-functional and multi-scale nature of green urban infrastructure complicates the categorization of services and benefits, since in reality the interactions between various benefits are manifold and appear on different scales. We will show the relevance of the benefits from green urban infrastructures on three spatial scales (i.e. city, neighborhood and site specific scales). We will further report on co-benefits and trade-offs between the various services indicating that a benefit could in turn be detrimental in relation to other functions. The manuscript identifies avenues for further research on the role of green urban infrastructure, in different types of cities, climates and social contexts. Our systematic understanding of the bio-physical and social processes defining various services allows targeting stressors that may hamper the provision of green urban infrastructure services in individual behavior as well as in wider planning and environmental management in urban areas.
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Affiliation(s)
- M Demuzere
- KU Leuven, Department of Earth and Environmental Sciences, Leuven, Belgium
| | - K Orru
- Institute for Agriculture and Environment, Estonian University of Life Sciences, Tartu, Estonia; University of Tartu, Institute of Social Sciences, Tartu, Estonia.
| | - O Heidrich
- Newcastle University, School of Civil Engineering and Geosciences, Newcastle, UK
| | - E Olazabal
- Energy and Environment Division, Tecnalia, Derio, Spain; Finnish Environment Institute (SYKE), Helsinki, Finland
| | - D Geneletti
- University of Trento, Department of Civil, Environmental and Mechanical Engineering, Trento, Italy
| | - H Orru
- University of Tartu, Department of Public Health, Tartu, Estonia; Umea University, Department of Public Health and Clinical Medicine, Umeå, Sweden
| | - A G Bhave
- Indian Institute of Technology, Kharagpur, India
| | - N Mittal
- Indian Institute of Technology, Kharagpur, India
| | - E Feliu
- Energy and Environment Division, Tecnalia, Derio, Spain
| | - M Faehnle
- Finnish Environment Institute (SYKE), Helsinki, Finland; University of Helsinki, Helsinki, Finland
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Mittal N, Gaur R, Joshi M. Poster 315 Spectrum of Spinal Injuries Associated with Electrical Accidents in India. PM R 2014. [DOI: 10.1016/j.pmrj.2014.08.694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Nimish Mittal
- All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Gaur
- All India Institute of Medical Sciences, New Delhi, India
| | - Mrinal Joshi
- All India Institute of Medical Sciences, New Delhi, India
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Abstract
Clean intermittent catheterization has been demonstrated to be a safe and effective method of bladder drainage in patients with neurogenic bladder dysfunction. However, breakdowns in technique may allow the introduction of foreign matter into the bladder and thereby result in bladder calculi. The three cases reported herein demonstrate this potential problem in persons with spinal cord injury (SCI) with hair nidus as the source of bladder calculi causing neurogenic bladder. In each situation, the problem was identified, calculi were removed cystoscopically and the patient and/or the ancillary aid were reinstructed. We recommend annual renal function tests, ultrasound and cytoscopic screening in high suspicion cases to allow early detection of bladder calculi in persons with SCI and prevent further urinary tract infections. This report also emphasizes the need for patient education and a careful follow-up preventing bladder calculi and thus, minimizing the morbidity in persons with SCI.
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Affiliation(s)
- Mrinal Joshi
- Department of Physical Medicine and Rehabilitation, Sawai Man Singh Medical College and Associated Hospitals, Jaipur, Rajasthan, India,Correspondence to: Mrinal Joshi, Department of Physical Medicine and Rehabilitation, Sawai Man Singh Medical College and Associated Hospitals, Jaipur, India 302001.
| | - Nimish Mittal
- Department of Physical Medicine & Rehabilitation, All India Institute of Medical Sciences, New Delhi, India
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Amare PSK, Gadage V, Jain H, Nikalje S, Manju S, Mittal N, Gujral S, Nair R. Clinico-pathological impact of cytogenetic subgroups in B-cell chronic lymphocytic leukemia: experience from India. Indian J Cancer 2014; 50:261-7. [PMID: 24061469 DOI: 10.4103/0019-509x.118730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The present study of 238 B-cell Chronic Lymphocytic Leukemia (B-CLL) patients were undertaken to seek the prevalence and to evaluate clinico-pathological significance of recurrent genetic abnormalities such as del(13q14.3), trisomy 12, del(11q22.3) (ATM), TP53 deletion, del(6q21) and IgH translocation/deletion. MATERIALS AND METHODS We applied interphase - fluorescence in situ hybridization (FISH) on total 238 cases of B-CLL. RESULTS Our study disclosed 69% of patients with genetic aberrations such as 13q deletion (63%), trisomy 12 (28%), 11q deletion (18%), 6q21 deletion (11%) with comparatively higher frequency of TP53 deletion (22%). Deletion 13q displayed as a most frequent sole abnormality. In group with coexistence of ≥2 aberrations, 13q deletion was a major clone indicating del(13q) as a primary event followed by 11q deletion, TP53 deletion, trisomy 12, 6q deletion as secondary progressive events. In comparison with del(13q), trisomy 12, group with coexistence of ≥2 aberrations associated with poor risk factors such as hyperleukocytosis, advanced stage, and multiple nodes involvement. In a separate study of 116 patients, analysis of IgH abnormalities revealed either partial deletion (24%) or translocation (5%) and were associated with del(13q), trisomy 12, TP53 and ATM deletion. Two of 7 cases had t(14;18), one case had t(8;14), and four cases had other variant IgH translocation t(?;14). CONCLUSION Detail characterization and clinical impact are necessary to ensure that IgH translocation positive CLL is a distinct pathological entity. Our data suggests that CLL with various cytogenetic subsets, group with coexistence of ≥2 aberrations seems to be a complex cytogenetic subset, needs more attention to understand biological significance and to seek clinical impact for better management of disease.
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Affiliation(s)
- P S Kadam Amare
- Cancer Cytogenetics Laboratory, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Medhi B, Mittal N, Bansal D, Prakash A, Sarangi SC, Nirthi B. Comparison of tolterodine with standard treatment in pediatric patients with non-neurogenic dysfunctional voiding/over active bladder: a systematic review. Indian J Physiol Pharmacol 2013; 57:343-353. [PMID: 24968572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
To examine the efficacy, safety and tolerability of tolterodine in children with overactive bladder in comparison with standard treatment i.e. oxybutynin as demonstrated in randomized clinical trials and other studies. A systematic search was done to screen the studies evaluating the effect of tolterodine in children with non-neurogenic overactive bladder. Results of studies were pooled and compared. Efficacy was determined from micturition diaries and dysfunctional voiding symptoms score. Safety and tolerability were assessed from the reported treatment emergent adverse events. A total of six randomized clinical trials and 11 other studies of tolterodine in children with urinary incontinence were included in the present systematic review. The dose of tolterodine used in different settings ranged from '0.5 to 8 mg/day' instead of '0.5 to 8 mg/kg per day' and the duration of studies ranged from 2 weeks to 12 months. Both extended and immediate release preparations of tolterodine were shown to have comparable efficacy and tolterodine proved to have comparable efficacy with better tolerability than oxybutynin in these studies. It can be concluded that tolterodine is efficacious in treatment of urinary incontinence in children. Moreover, its efficacy is comparable to oxybutynin, the most commonly prescribed anticholinergic in this condition, while having better tolerability. Hence, it can be considered as first line therapy for the treatmentof urinary incontinence in children.
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Pavone M, Malpani S, Dyson M, Monsivais D, Mittal N, Bulun S. Differences in retinoid uptake and metabolism alters paracrine signaling in endometriosis. Fertil Steril 2013. [DOI: 10.1016/j.fertnstert.2013.07.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chowdhury S, Aggarwal A, Mittal N, Shah A. Brown tumor of hyperparathyroidism involving craniomaxillofacial region: a rare case report and literature review. Minerva Stomatol 2013; 62:343-348. [PMID: 24126600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Central giant cell granuloma (CGCG) is a benign, non-odontogenic bone lesion of jaw. The condition is relatively infrequent and affects mainly children and young adults with a certain predominance among females and exhibits variable aggressiveness. Giant cell lesion associated with hyperparathyroidism is known as Brown tumor. Brown tumor is one of the bony complications of hyperparathyroidism. It is a giant cell granuloma which occurs in osteitis fibrosis cystica. It represents the terminal stage of the bone remodelling processes occurring as a result of peritrabecular fibrosis and osteoclastic activity. The mandible is the predominantly affected site in the maxillofacial area. Maxillary involvement is rare. The incidence of Brown tumor associated with hyperparathyroidism is rare (0.1%). Here, an extremely rare case of a 20 year old female patient with Brown tumor in her maxilla and mandible associated with primary hyperparathyroidism was presented. A thorough diagnostic work up showed presence of tumor mass in mandible and maxilla and elevated serum alkaline phosphatase and parathormone level and the patient was treated for both hyperparathyroidism and Brown tumor were discussed. The importance of different radiological evaluation methods and the consultation between the oral and maxillofacial surgeons, dentists, endocrinologists and radiologists were emphasized.
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Affiliation(s)
- S Chowdhury
- Department of Oral and Maxillofacial Surgery Institute of Dental Science, Bareilly Uttar Pradesh, India -
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Mittal N, Majumdar R, Chauhan S, Acharjya M. Sprengel's deformity: association with musculoskeletal dysfunctions and tethered cord syndrome. BMJ Case Rep 2013; 2013:bcr-2013-009182. [PMID: 23605835 DOI: 10.1136/bcr-2013-009182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sprengel's deformity is a rare and complex congenital deformity of the shoulder girdle. The deformity commonly occurs sporadically, though in combination with other congenital anomalies, such as congenital scoliosis, fusion of cervical vertebrae, and conditions like Klippel-Feil syndrome may coexist. We report a case of a 14-year-old girl with bilateral Sprengel's deformity presenting with a progressive bilateral lower limb weakness and gait abnormality. Radiological investigations demonstrated multiple musculoskeletal abnormalities on x-ray and lumbar spina bifida occulta causing tethering of the cord on MRI. The patient consulted neurosurgeons and orthopaedic surgeons, who recommended no operative intervention and conservative management till the end of growth spurt. Therefore, we prescribed a home-based exercise regimen to strengthen the periscapular and intrinsic foot muscles. Although rare, Sprengel's deformity can be associated with other musculoskeletal abnormalities including lumbar spina bifida and comprehensive neurological examination should not be ignored as it is much more than a cosmetic problem.
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Affiliation(s)
- Nimish Mittal
- Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi, India.
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Gadage VS, Kadam Amare PS, Galani KS, Mittal N. Systemic mastocytosis with associated acute myeloid leukemia with t (8; 21) (q22; q22). INDIAN J PATHOL MICR 2013; 55:409-12. [PMID: 23032848 DOI: 10.4103/0377-4929.101761] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Systemic mastocytosis with associated clonal hematological nonmast cell lineage disease (SM-AHNMD) is a subtype of mastocytosis associated commonly with myeloid neoplasms, Non-Hodgkin's lymphoma, or other hematological neoplasms. In these conditions, mastocytosis needs to be differentiated from mast cell hyperplasia or mast cell activation states. Neoplastic nature of mastocytosis is proved either by morphology, aberrant immunophenotype, or detection of point mutation at codon-816 of c-kit gene. This is a rare entity, even more so in pediatric population. Herein, we report a case of 14-year-old girl with SM associated with acute myeloid leukemia with maturation with t(8;21). Multifocal dense infiltrate of spindle-shaped mast cells on bone marrow aspirate and biopsy with coexpression of CD2 and CD25 by flow cytometric analysis proved the SM component at the time of diagnosis and persistence at post induction status also.
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Affiliation(s)
- V S Gadage
- Tata Memorial Hospital, Mumbai, Maharashtra, India
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Abstract
The morphological spectrum of light chain deposition disease (LCDD) may range from normal glomerular morphology to mesangio-proliferative to mesangio-capillary to nodular sclerosing patterns. Due to the inconsistencies regarding treatment and the universally poor graft outcome of post-transplant LCDD, it is imperative to maintain a high index of suspicion and perform relevant investigations for clinching this diagnosis. A 40-year-old lady was diagnosed as a case of membrano-proliferative glomerulonephritis 3 years back, for which she underwent a live unrelated renal allograft transplant. Postoperative period was complicated by an acute rise in serum creatinine on the 21st postoperative day. Biopsy showed patchy acute cortical necrosis, which responded to conservative management. The present admission was for renal failure and subnephrotic proteinuria. A kidney biopsy was performed, and all the 14 glomeruli examined showed a mesangiocapillary pattern of glomerular injury with cellular nodule formation in some. The nodules were PAS and Congo red negative. Immunofluorescence showed glomerular and tubular basement staining for Kappa light chains only. Electron microscopy showed the characteristic granular deposits in subendothelial location in the glomerulus, and in tubular basement membranes, thus confirming the diagnosis of LCDD. Membranoproliferative pattern of glomerular injury in the pre- and posttransplant setting has a wide range of differential diagnoses; LCDD being one of them.
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Affiliation(s)
- N Mittal
- Department of Histopathology, Renal Transplant Surgery, PGIMER, Chandigarh, India
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42
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Chauhan V, Mittal N, Raina S. 5144 POSTER Comparison of Level 3 Nodal Yield in Carcinoma Breast Patients Using the Subpectoral and Interpectoral Approach of Axillary Dissection. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)71586-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Parameswaran S, Mittal N, Joshi K, Rathi M, Kohli HS, Jha V, Gupta KL, Sakhuja V. Tubulointerstitial nephritis with uveitis syndrome: A case report and review of literature. Indian J Nephrol 2011; 20:103-5. [PMID: 20835328 PMCID: PMC2931125 DOI: 10.4103/0971-4065.65307] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Tubulointerstitial nephritis with uveitis (TINU) syndrome is an unusual and under diagnosed cause of acute interstitial nephritis. The interstitial nephritis may precede, follow or develop concurrent to the uveitis. About 200 cases have been reported worldwide with only a single case reported from India. We report a 16-year-old male with TINU syndrome.
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Kaur G, Kaur J, Mittal N, Nath Sanyal S. The effect of prostaglandin synthase inhibitor, aspirin on the rat intestinal membrane structure and function. NUTR HOSP 2010; 25:290-298. [PMID: 20449540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 11/22/2009] [Indexed: 05/29/2023] Open
Abstract
Aspirin at a dose of 50 mg/kg body weight was found to decrease the activity of the rat intestinal brush border membrane (BBM) - associated enzymes such as the sucrase, lactase, maltase and alkaline phosphatase. Aspirin treatment also led to a decrease in the microviscosity in the native as well as the benzyl alcohol treated membrane which might be due to the lipid peroxidative damage in the membrane. Physical correlation of the membrane oxidative damage was evident as the Fourier Transformation Infra Red (FTIR) study of the Aspirin treated membrane, which include an increased proportion of gauche to trans conformer, shift in the methylene C-H asymmetric and symmetric stretching frequencies, C = O double bond stretching, NH bending, antisymmetric (N)-CH3 bending, C-N stretching and antisymmetric CNC stretching while there was no change in the CH2 wagging and twisting as well as in NH-bending amide bond I and II. Aspirin treatment also caused an alteration in the glucose and histidine transport, as evident by a decreased Vmax value while the apparent Km remaining unchanged in the control and Aspirin-treated animals confirming that there was no change in the substrate affinity constant of the membrane transport proteins for the glucose and the basic amino acid, although the rate of transport decreased considerably. There was a decrease noted in the energy of activation of glucose and histidine transport when studied at different temperature but no change in the temperature of phase transition in the BBM with Aspirin treatment, thus implying that perhaps the thermotropic phase transition in the membrane may have relatively little effect on the transport processes. The result suggests an underlying molecular mechanism indicating the implied membrane damage by Aspirin, an important member of the non-steroidal antiinflammatory drug (NSAID) family which could possibly through an oxidative damage may lead to an altered molecular structure, physical state and biological functions of the intestinal membrane.
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Affiliation(s)
- G Kaur
- Department of Biophysics, Panjab University, Chandigarh, India
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Mittal N, Kanwar SS, Sanyal SN. Effect of non-steroidal anti-inflammatory drugs and the pro-carcinogen 1,2 dimethylhydrazine on the rat intestinal membrane structure and function. NUTR HOSP 2008; 23:439-448. [PMID: 19160894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
The present study was designed to evaluate the effects of three non-steroidal anti-inflammatory drugs (NSAIDs) with varying cycloxygenase selectivities on the small intestinal biochemical composition, function and histology during 1, 2-dimethylhydrazine (DMH) administration. Sprague Dawley male rats were divided into five different groups viz: Group 1 (control, vehicle treated), Group 2 (DMH-treated, 30 mg/kg body weight/week in 1 mM EDTA-saline, subcutaneously), Group 3 (DMH + aspirin-60 mg/kg body weight), Group 4 (DMH + celecoxib-6 mg/kg body weight), Group 5 (DMH + etoricoxib-0.64 mg/kg body weight). After six weeks of treatment, brush border membrane was isolated from the jejunum segment of all the groups and changes in the associated enzymes such as sucrase, lactase, maltase, alkaline phosphatase, membrane lipid composition, fluorescence polarizations of diphenylhexatriene, pyrene excimer formation, histological changes and surface characteristics were studied. The results indicated a significant alteration in the enzyme activity as well as changes in the structure and function of the intestine in the presence of the pro-carcinogen, DMH, which suggests the possible chemopreventive efficacy of NSAIDs against the intestinal cancer.
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MESH Headings
- 1,2-Dimethylhydrazine/administration & dosage
- 1,2-Dimethylhydrazine/pharmacology
- Animal Experimentation
- Animals
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/pharmacology
- Aspirin/administration & dosage
- Aspirin/pharmacology
- Body Weight
- Carcinogens/administration & dosage
- Carcinogens/pharmacology
- Celecoxib
- Cyclooxygenase Inhibitors/administration & dosage
- Cyclooxygenase Inhibitors/pharmacology
- Etoricoxib
- Fluorescence Polarization
- Intestinal Mucosa/drug effects
- Intestinal Neoplasms/prevention & control
- Intestine, Small/drug effects
- Intestine, Small/enzymology
- Intestine, Small/metabolism
- Intestine, Small/physiology
- Intestine, Small/ultrastructure
- Male
- Membrane Lipids/metabolism
- Microscopy, Electron, Scanning
- Pyrazoles/administration & dosage
- Pyrazoles/pharmacology
- Pyridines/administration & dosage
- Pyridines/pharmacology
- Rats
- Rats, Sprague-Dawley
- Sulfonamides/administration & dosage
- Sulfonamides/pharmacology
- Sulfones/administration & dosage
- Sulfones/pharmacology
- Time Factors
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Affiliation(s)
- N Mittal
- Department of Biophysics, Panjah University, Chandigarh, India
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Dhawan V, Cherian I, Mittal N. A neurosurgical hand rest. Kathmandu Univ Med J (KUMJ) 2008; 6:426-427. [PMID: 20071833 DOI: 10.3126/kumj.v6i3.1727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
doi: 10.3126/kumj.v6i3.1727 Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 426-427
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Affiliation(s)
- V Dhawan
- Department of Neurosurgery, Manipal College of Medical Sciences, Pokhara, Nepal.
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Wada M, Kato T, Hayashi Y, Selvaggi G, Mittal N, Thompson J, Gonzalez M, Nishida S, Madariaga J, Tzakis A. Intestinal transplantation for short bowel syndrome secondary to gastroschisis. J Pediatr Surg 2006; 41:1841-5. [PMID: 17101355 DOI: 10.1016/j.jpedsurg.2006.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Gastroschisis is the most frequent cause of pediatric intestinal transplantation. This study reviews our experience of intestinal transplantation secondary to gastroschisis to elucidate those factors affecting the outcome of children with short bowel syndrome. METHODS A retrospective review was performed for children who underwent intestinal transplantation for gastroschisis at the University of Miami between June 2003 and August 1994. RESULTS Thirty-two transplants were performed in 28 children with gastroschisis during the study period. Associated intestinal anomalies were present in 22 infants (atresia [n = 14], volvulus [n = 3], and/or ischemia [n = 16]). Spontaneous prenatal closure of gastroschisis, a rare anomaly associated with bowel atresia and ischemia because of a very small abdominal defect, was seen in 9 patients. Most of the patients had a complicated course and required multiple abdominal surgeries before transplant. Fifteen (53.6%) patients are currently alive at a median follow-up of 23.5 months. Short-term survival rate has significantly improved in recent years. CONCLUSIONS Patients with complex gastroschisis and intestinal anomalies have a significant risk for progression to short bowel syndrome. Intestinal transplantation can be a lifesaving option and provides a satisfactory outcome for children with short bowel syndrome secondary to gastroschisis.
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Affiliation(s)
- Motoshi Wada
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai 980-8574, Japan
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Selvaggi G, Sarkar S, Mittal N, Acar BC, Weppler D, Kato T, Tryphonopoulos P, Tzakis A, Ruiz P. Etiology and Management of Alimentary Tract Ulcers in Pediatric Intestinal Transplantation Patients. Transplant Proc 2006; 38:1768-9. [PMID: 16908276 DOI: 10.1016/j.transproceed.2006.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patients who undergo intestinal transplantation encounter several complications in the posttransplant period, one of them being ulcer formation in the alimentary tract. During postoperative endoscopic monitoring of 112 pediatric intestinal transplantation patients at our institution, we identified chronic ulcer formation in 11 patients. There were no common or defining demographic or clinical variables that were found in the patients with ulcers. The ulcers could be located within the allograft or in native tissue. Biopsies were obtained from the ulcer edge and the intervening mucosa as well as an evaluation of possible infectious agents. The most common changes in the ulcers were compatible with Epstein-Barr virus-associated posttransplant lymphoproliferative disorder (PTLD; seven cases), acute rejection (six cases), and less commonly, infectious causes (one case). These changes could occur concomitantly and retrospective analysis after therapy showed that the ulcers could have multiple etiologies. Directed biopsies of ulcer edges often displayed morphological changes compatible with acute rejection of the graft, although some biopsies of the intervening mucosa did not show similar changes. Some patients treated based on the changes within the intervening mucosa responded well and led to resolution of the ulcers. Our findings demonstrate that PTLD and acute rejection are the most common causes of chronic ulcer formation and that biopsy samples should be collected simultaneously from both the ulcer edge and intervening mucosa since pathological changes can vary depending on the underlying cause(s). Infectious agents were rarely present but could be seen superimposed with the underlying cause.
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Affiliation(s)
- G Selvaggi
- University of Miami, Miami, FL 33136, USA
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50
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Kato T, Gaynor JJ, Nishida S, Mittal N, Selvaggi G, Levi D, Moon J, Thompson J, Ruiz P, Madariaga J, Tzakis AG. Zoom endoscopic monitoring of small bowel allograft rejection. Surg Endosc 2006; 20:773-82. [PMID: 16544078 DOI: 10.1007/s00464-005-0331-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 11/08/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND The small bowel has been successfully transplanted in patients with irreversible intestinal failure. This report aims to describe endoscopic monitoring of small bowel rejection. METHODS A magnification endoscope (zoom endoscope) was used in this study. In the first part of the study (October 1998 to March 2000, 271 endoscopy sessions), the specific endoscopic findings that correlated with rejection were determined. An analysis then was performed on data from the second period (March 2001 to November 2002, 499 sessions) to evaluate the zoom endoscope's accuracy in monitoring rejection. RESULTS Specific endoscopic findings of rejection found in the first period included background erythema, villous congestion, blunted villous tip, and shortened villous height. When the rejection was successfully treated, endoscopic appearance returned to normal. On the basis of these findings, five endoscopic criteria (villous shortening, villous blunting, background erythema, villous congestion, and mucosal friability) were used to score endoscopic sessions in the second period. Endoscopic diagnosis of rejection was compared with histology. Adult patients showed a sensitivity of 45%, a specificity of 98%, a positive predictive value of 82%, and a negative predictive value of 88%. In pediatric patients, these values were, respectively, 61%, 84%, 57%, and 86%. On 59 distinct occasions (30 in period 1 and 29 in period 2) in which the results were endoscopy negative yet biopsy positive (mild) for rejection, we elected not to treat these rejections on the basis of clinical evaluation, and 58 (98%) resolved without further therapy. CONCLUSIONS With the use of magnification, endoscopy is a useful tool for monitoring acute rejection in the small bowel allograft.
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Affiliation(s)
- T Kato
- Department of Surgery, University of Miami, School of Medicine, 1801 NW 9th Avenue, 5th Floor, Miami, FL 33136, USA.
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