Lethal abdominal compartment syndrome after extracorporeal cardiopulmonary resuscitation in a patient with out-of-hospital cardiac arrest: a case report

BACKGROUND

Clinical attempts of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) have increased in recent years; however, it also has life-threatening complications. Massive fluid and transfusion resuscitation, shock status, or low cardiac output status during ECPR may lead to ascites and interstitial edema, resulting in secondary abdominal compartment syndrome (ACS).

CASE PRESENTATION

A 43-year-old male patient was admitted to the emergency department due to cardiac arrest. Due to refractory ventricular fibrillation, ECPR was initiated. Approximately, 3 h after extracorporeal membrane oxygenation support, abdominal distension and rigidity developed. Therefore, ACS was suspected. Decompression laparotomy was required to relieve elevated intra-abdominal pressure.

CONCLUSIONS

We report a case of a patient with OHCA who developed lethal ACS after ECPR. Despite this, the patient was able to recover from several major crises. Regardless of how lethal the patient is, if compartment syndrome develops in any part of the body, we should aggressively consider surgical decompression.

Cardiopulmonary bypass preparation is mandatory in cardiac exploration for blunt cardiac injury patients

Treating cardiac injuries following blunt trauma to the chest requires thorough examination, accurate diagnosis, and therapeutic plan. We present two cases; pulmonary vein rupture and left atrial appendage laceration, both as a result of blunt chest trauma. Through these cases, our team learned the importance of maintaining hemodynamic stability during the examination of injured cardiac structures. And based on the comprehensive cardiac examination, a decision to surgically intervene with median sternotomy via cardiopulmonary bypass was made, saving lives of the patient. This report introduces how such decision was made based on what supporting evidence and the diagnostic process leading to the initiation of surgical intervention. This report may help with decision-making process when confronted by blunt cardiac injury patients who need cardiac exploration.

Cardiac Perforation Caused by Bone Cements as a Complication of Cement Augmented Pedicle Screw Fixation Using the Fenestrated Pedicle Screw: A Case Report

Cement-augmented fenestrated pedicle screw fixation is becoming more popular for osteoporotic patients. Although several reports have been published on leakage-related problems with bone cement, no cases of cardiac perforation after cement-augmented pedicle screw fixation have been reported. We present a case of cardiac perforation after cement-augmented fenestrated pedicle screw fixation. A 67-year-old female was admitted to our hospital with complaints of dyspnea and chest pain after lumbar surgery. She had been treated with L4-5 lumbar interbody fusion and percutaneous pedicle screw fixation with bone cement augmentation seven days earlier for degenerative spondylolisthesis. The right chest pain was observed a day after the surgery; she was treated conservatively but it did not improve for 7 days after surgery. Chest computed tomography (CT) revealed a hemothorax and a large sharp bone cement fragment that perforated the right atrium. Bone cement can be removed with thoracotomy surgery. We have to be aware of cement leakage through the normal venous drain system around the vertebral body. We also have to consider a detailed cardiac workup, which may include chest CT or echocardiography, if a patient complains of chest pain or dyspnea after cement augmentation.

Successful Management of a Rare Gastric Mucormycosis Presenting with Massive Melena in a Polytrauma Patient

Mucormycosis is a rare, life-threatening, and opportunistic fungal infection that usually occurs in immunocompromised patients. Rhinocerebral and pulmonary manifestations are the common form. The rare form of gastrointestinal mucormycosis occur in all parts of the alimentary tract, with emphasis on the stomach being the most common site. Primary gastric mucormycosis following traumatic injury is an extremely rare form that is usually lethal; thus, only a few cases of survival have been reported even after early diagnosis and aggressive surgical resection, combined with antifungal treatment. We herein report a case of delayed-onset gastric mucormycosis in a polytrauma patient without predisposing factors, which was successfully treated by antifungal medical therapy alone with no surgical debridement.

Half-turned truncal switch operation after single ventricle palliation in a patient with borderline left heart hypoplasia

BACKGROUND

The optimal surgical strategy for the correction of double outlet right ventricle (DORV, transposition of the great arteries [TGA] type) or TGA with ventricular septal defect (VSD), pulmonary stenosis (PS), and borderline small left ventricle (LV) is still controversial. The half-turned truncal switch operation (HTTSO) introduced by Yamagishi and colleagues is a good option, but it is still challenging in a patient with borderline small LV. We aimed to describe our experience of a case of HTTSO conversion from single ventricle palliation.

CASE PRESENTATION

A 5-year-old girl with single ventricle physiology was referred to our hospital from Kazakhstan for a Fontan operation. At the time of birth, she was diagnosed with DORV (TGA type), PS, and situs inversus totalis, with moderate valvar and subvalvar stenosis and a relatively small LV cavity. Her LV volume was not adequate to support the systemic circulation; therefore, doctors in Kazakhstan selected the single ventricle palliation course of treatment for the infant. At 4 months of age, she underwent left-sided modified Blalock-Taussig shunt, patent ductus arteriosus ligation, and atrial septectomy. At 2 years of age, shunt takedown, left bidirectional cavopulmonary shunt, and main pulmonary artery division were performed. Annual echocardiography of the patient showed that the LV size was growing too adequately to persist with the single ventricle palliation course of treatment. Via a multidisciplinary approach, we considered her LV to be suitable for biventricular repair and HTTSO was planned. The operation and postoperative course were uneventful. The patient was discharged on postoperative day 6 and went back to Kazakhstan.

CONCLUSIONS

Based on our successful surgical outcome, in patients diagnosed with DORV (TGA type) or TGA with VSD, PS, and borderline LV, HTTSO after achieving adequate LV growth by single ventricle palliation may be considered a good alternative to conventional operations in patients at a high risk for initial biventricular repair.

Enoxaparin related spontaneous fatal retroperitoneal hemorrhage in a patient with atrial fibrillation

Spontaneous retroperitoneal hemorrhage (SRH) is a potentially lethal complication of anticoagulation therapy. The signs and symptoms vary from clinical silence to abdominal pain or hemorrhagic shock. The diagnosis of SRH may be difficult, especially in its early clinical course, due to its varied symptoms. Physicians need to have a high degree of suspicion for its early diagnosis. Delayed diagnosis of SRH can lead to serious complications or death. Bleeding complications in anticoagulated patients are well known; however, reports about SRH with fatal outcomes are sporadic. Here, we describe a case of massive SRH in a patient receiving enoxaparin. In our case, the patient died due to delayed diagnosis and treatment. We, therefore, emphasize that physicians should always consider SRH in any patient receiving anticoagulants who presents with abdominal pain.

Traumatic Right Pulmonary Artery Rupture after Accidentally Being Stepped on the Chest

Traumatic pulmonary artery rupture is a rare, life-threatening injury. Currently, no strict guidelines for its management exist. Herein, we report a successful surgical repair of a right pulmonary artery rupture caused by being stepped on.

Mid-term outcomes of endovascular repair for traumatic thoracic aortic injury: a single-center experience

PURPOSE

Thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury (TTAI) reports short-term benefits. However, long-term durability and the need of reintervention remain unclear. Here, we determined mid-term outcome of TEVAR for TTAI and investigated the influence of the length of proximal landing zone on aorta.

METHODS

Between October 2009 and February 2018, 69 patients diagnosed TTAI and 42 included patients underwent TEVAR. Patients were divided into two groups by the length of proximal landing zone; ≤ 20 mm and > 20 mm. The primary endpoint was success and survival rate, and the secondary endpoint was the increase of aorta size and the need of reintervention.

RESULTS

The mean follow-up period was 47.9 ± 29.6 months and 100% success rate. No endoleaks or additional reinterventions during the follow-up period. The cumulative survival of all-cause death was 90.5 ± 2.3%, 85.7 ± 4.1% and 61.7 ± 8.4% at 1, 5 and 7 years, respectively. There was no statistically significant difference in the increase of aorta size due to the length of the proximal landing zone (p = 0.65).

CONCLUSION

In selective TTAI patients for TEVAR, the length of proximal landing zone did not considerably influence the aorta size or needed further reintervention.

Risk Factors Associated With Reintervention After Thoracic Endovascular Aortic Repair for Descending Aortic Pathologies

BACKGROUND:

Thoracic endovascular aortic repair (TEVAR) is associated with several short-term benefits, including reduced morbidity and mortality; however, the long-term durability of TEVAR and the need for secondary aortic reintervention remain unclear. We aimed to determine the adverse outcomes, including aortic reintervention, after TEVAR for thoracic aortic aneurysms and dissection.

METHODS:

Between October 2009 and July 2016, 130 patients underwent TEVAR at Kyungpook National University Hospital. We excluded 35 patients with traumatic injury and included the remaining 95 patients in our study after TEVAR. The patients included in this study were categorized into 2 groups (reintervention [R] and nonintervention [N] groups) according to the need for reintervention. The mean follow-up period for all 95 patients was 22.4 (20.6) months.

RESULTS:

The overall actuarial survival rates were 83.7% (4.1%) and 63.6% (8.8%) at 1 and 5 years, respectively. The rates of freedom from aortic reintervention after TEVAR were 94.0% (3.5%), 72.8% (8.2%), and 48.9% (10.5%) at 2, 3, and 5 years, respectively. The independent risk factors for aortic reintervention were endoleaks after TEVAR (odds ratio [OR] 6.13, P = .017), increase in aortic size by over 5% per year (OR 20.40, P = .001), and peripheral vascular occlusive disease (PVOD; OR 13.62, P = .007). Patients with preoperative hemoptysis tended to show a greater need for aortic reintervention ( P = .059). Increase in aortic size by over 5% per year and PVOD were the primary risk factors for endoleaks (OR 3.82, P = .013 and OR 4.37, P = .021, respectively).

CONCLUSION:

Survival after TEVAR for thoracic aortic pathologies was satisfactory in most of the patients chosen as candidates for the procedure. However, the occurrence of endoleaks, increase in aortic size by over 5% per year, and PVOD were the primary causes of aortic reintervention.

Photodynamic therapy of red and blue lights on Malassezia pachydermatis: an in vitro study

In veterinary medicine, infection caused by Malassezia pachydermatis is spreading and necessity of alternative treatment is emphasized. Photodynamic therapy (PDT) is therapeutic method using specific spectrum of light with photosensitizer. In this study, applying PDT not only using red light which is used in human medicine commonly, but also using blue light into skin infection causative microorganism with photosensitizer, confirm the effect of PDT and possibility of being an alternative treatment. Four isolates of M. pachyderematis were collected from canine skin and used into this study. Light emitting diode with 495 nm, 625 nm spectrum was applied, and final concentration of δ-aminolevulinic acid (ALA), which is used as a photosensitizer, was adjusted into 20%. To confirm effectiveness of PDT, the number of colony forming unit was checked and variation of optical density values was measured. Antifungal effect of PDT on both spectrums was presented in all condition, and it makes best result when using blue light applied with ALA. Through outcome of this study, PDT using light in 465 nm, 625 nm wavelength combinations with ALA can interrupt proliferation of M. pachydermatis considerably. In consequence, PDT can be alterative treatment of canine Malassezia infection.

Central venous catheterization-induced right brachiocephalic vein pseudoaneurysm: Successfully treated with stent-assisted coiling

INTRODUCTION

Central venous catheterization-induced central vein pseudoaneurysm is rare. Several treatment options have been recommended. We describe a case of central venous catheterization-induced right brachiocephalic vein pseudoaneurysm successfully treated with an uncovered self-expandable stent-assisted coil embolization and discuss the imaging findings, treatment strategy, and review of literature associated with thoracic venous pseudoaneurysm.

CASE REPORT

A 77-year-old woman was referred to our trauma center to undergo treatment for central venous catheterization-induced central vein pseudoaneurysm. The initial contrast-enhanced chest computed tomography revealed a 3.4-cm pseudoaneurysm arising from the right brachiocephalic vein and a surrounding mediastinal hematoma. The pseudoaneurysm was successfully embolized with stent-assisted coiling. Computed tomography angiography was performed 10 days after the procedure and demonstrated a completely embolized pseudoaneurysm and resolved mediastinal hematoma. Blood flow from the right subclavian and left innominate veins was not disturbed by the stent-assisted coils.

CONCLUSION

To our knowledge, this is the first report of treatment of a right brachiocephalic vein pseudoaneurysm with stent-assisted coil embolization. We think that uncovered stent-assisted coil embolization is the safest and most fundamental treatment for wide-neck venous pseudoaneurysm especially in a hemodynamically unstable setting.

Video-Assisted Thoracoscopic Left Cardiac Sympathetic Denervation in Patients with Hereditary Ventricular Arrhythmias

BACKGROUND

Left cardiac sympathetic denervation (LCSD) has been underutilized in patients with hereditary ventricular arrhythmia syndromes such as congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). The purpose of this study was to investigate the safety and efficacy of video-assisted thoracoscopic (VATS) LCSD in such patients.

METHODS

Fifteen patients (four men, 24.6 ± 10.5 years old) who underwent VATS-LCSD between November 2010 and January 2015 for hereditary ventricular arrhythmia syndromes at Kyungpook National University Hospital were enrolled in this study. The safety and efficacy of VATS-LCSD were evaluated by periprocedural epinephrine tests and assessing the development of complications and cardiac events during follow-up.

RESULTS

Fourteen patients with LQTS and one patient with CPVT underwent VATS-LCSD. Six and one patients developed ventricular tachyarrhythmia during preprocedural and postprocedural epinephrine test, respectively (P = 0.063). No serious complications such as Horner syndrome, pneumothorax, or bleeding developed after LCSD. Mean hospital stay after VATS-LCSD was 3.7 ± 1.5 days. During a mean follow-up of 927 ± 350 days, one LQTS patient and one CPVT patient, neither of whom manifested tachyarrhythmia during post-LCSD epinephrine test, developed torsades de pointes and syncope, respectively. The annual event rates of six patients who were symptomatic during the period preceding LCSD decreased from 0.97 to 0.19 events/year (P = 0.045).

CONCLUSIONS

VATS-LCSD was a safe, and effective procedure for patients with hereditary ventricular tachycardia syndrome, with no serious adverse events and with short hospital stay.

Endoscopic Treatment for Persistent Hematospermia: A Novel Technique Using a Holmium Laser

PURPOSE

We present our endoscopic technique for treating ejaculatory duct and seminal vesicle diseases with a holmium laser.

MATERIALS AND METHODS

Fifteen patients with persistent hematospermia were enrolled in this study from June 2007 to April 2014. All patients had failed medical treatments. All patients were evaluated with transrectal ultrasound and pelvic computed tomography or magnetic resonance imaging. We performed endoscopic treatment with a semi-rigid ureteroscope after dilation using a guidewire and ureteral serial dilator. A holmium laser was used to incise the obstructed ejaculatory duct, coagulate hemorrhagic mucosa, and fragment stones in the ejaculatory duct or seminal vesicles. Stones were removed using a basket and forceps.

RESULTS

The mean duration of hematospermia was 30.6 months. Mean patient age was 45.3 years. The mean serum levels of prostate-specific antigen and testosterone were 1.36 and 4.95 ng/mL, respectively. No operative complications were encountered. Mean operative time was 35.4 min. Seven patients had ejaculatory duct or seminal vesicle stones, which were subsequently determined to be carbonate apatite, mucin, struvite, and calcium oxalate dehydrate stones. Mean duration of follow-up was 32.1 months. Although two patients showed recurrent hematospermia 11 and 12 months after the operation, hematospermia resolved in 13 patients (86.7%). The infertile patient showed an improved semen finding and had a successful pregnancy.

CONCLUSION

Endoscopic treatment using a holmium laser is minimally invasive and was effective for treating ejaculatory duct and seminal vesicle diseases, which are the main cause of hematospermia.

Outcomes of nonpledgeted horizontal mattress suture technique for mitral valve replacement

BACKGROUND

Most surgeons favor the pledgeted suture technique for heart valve replacements because they believe it decreases the risk of paravalvular leak (PVL). We hypothesized that the use of nonpledgeted rather than pledgeted sutures during mitral valve replacement (MVR) may decrease the incidence of prosthetic valve endocarditis (PVE) and risk of a major PVL.

METHODS

We analyzed 263 patients, divided into 175 patients who underwent MVR with nonpledgeted sutures from January 2003 to December 2013 and 88 patients who underwent MVR with pledgeted sutures from January 1995 to December 2001. We compared the occurrence of PVL and PVE between these groups.

RESULTS

In patients who underwent MVR with or without tricuspid valve surgery and/or a Maze operation, PVL occurred in 1.1% of the pledgeted group and 2.9% of the nonpledgeted group. The incidence of PVE was 2.9% in the nonpledgeted group and 1.1% in the pledgeted group. No differences were statistically significant.

CONCLUSION

We suggest that a nonpledgeted suture technique can be an alternative to the traditional use of pledgeted sutures in most patients who undergo MVR, with no significant difference in the incidence of PVL.

Gait patterns of patients with inclusion body myositis

Inclusion body myositis (IBM) is a progressive, inflammatory muscle disease that is known to cause quadriceps weakness and knee buckling during gait. This is the first known report of gait characteristics in patients with IBM. Nine subjects with IBM and quadriceps weakness underwent gait analysis and quantitative strength testing. A wide range of strength and gait abilities were present in the subject group. Subjects with stronger knee extensors exhibited nearly normal sagittal knee kinematics and kinetics. As quadriceps strength decreased, kinematic and kinetic patterns were increasingly abnormal. Exceptions to this pattern could be explained by examining strength at adjacent joints. Gait analysis and strength testing is a helpful tool in evaluating the functional status of this population and aiding in determination of the needs for interventions such as assistive devices.

Pinusolide and 15-methoxypinusolidic acid attenuate the neurotoxic effect of staurosporine in primary cultures of rat cortical cells

BACKGROUND AND PURPOSE

Apoptosis is a fundamental process required for neuronal development but also occurs in most of the common neurodegenerative disorders. In an attempt to obtain an anti-apoptotic neuroprotective compound from natural products, we isolated the diterpenoids, pinusolide and 15-MPA, from B. orientalis and investigated their neuroprotective activity against staurosporine (STS) -induced neuronal apoptosis. In addition, we determined the anti-apoptotic mechanism of these compounds in rat cortical cells.

EXPERIMENTAL APPROACH

Primary cultures of rat cortical cells injured by STS were used as an in vitro assay system. Cells were pretreated with pinusolide or 15-MPA before exposure to STS. Anti-apoptotic activities were evaluated by the measurement of cytoplasmic condensation and nuclear fragmentation. The levels of cellular peroxide, malondialdehyde (MDA) and [Ca(2+)]i, as well as the activities of superoxide dismutase (SOD) and caspase-3/7, were measured.

KEY RESULTS

Pinusolide and 15-MPA, at a concentration of 5.0 ìM, reduced the condensed nuclei and rise in [Ca(2+)]i that accompanies apoptosis induced by 100 nM STS. Pinusolide and 15-MPA also protected the cellular activity of SOD, an antioxidative enzyme reduced by STS insult. Furthermore, the overproduction of reactive oxygen species and lipid peroxidation induced by STS was significantly reduced in pinusolide and 15-MPA treated cells. In addition, pinusolide and 15-MPA inhibited STS-induced caspase-3/7 activation.

CONCLUSIONS AND IMPLICATIONS

These results show that pinusolide and 15-MPA protect neuronal cells from STS-induced apoptosis, probably by preventing the increase in [Ca(2+)]i and cellular oxidation caused by STS, and indicate that they could be used to treat neurodegenerative diseases.

Temporospatial sequence of cellular events associated with etoposide-induced neuronal cell death: role of antiapoptotic protein Bcl-X(L)

Etoposide-induced death comprises such nuclear events as the formation of topoisomerase II-DNA cleavable complex and cytosolic events including caspase activation. By first establishing the temporospatial death sequence triggered by etoposide in a neuronal cell line, MN9D overexpressing Bcl-X(L) (MN9D/Bcl-X(L)) or control vector (MN9D/Neo), we examined whether formation of this complex is primarily responsible for cell death and at which strategic points and how Bcl-X(L) blocks etoposide-induced neuronal death. Etoposide induced death that was dependent on caspase, cycloheximide, and calpain in MN9D/Neo cells. Etoposide also induced death in enucleated MN9D/Neo cells, although this was less severe. The level of topoisomerase II-DNA cleavable complex reached at a maximum of 2 hr after etoposide treatment was identical in MN9D/Neo and MN9D/Bcl-X(L) cells. In MN9D/Neo cells, cytochrome c release into the cytosol and caspase activation occurred as early as 2 hr and 3-6 hr after etoposide treatment, respectively. Etoposide-induced DNA laddering potentially via caspase appeared as early as 12 hr after drug treatment, followed by nuclear swelling in MN9D/Neo cells (>18-20 hr). Subsequently, nuclear condensation started by 24-28 hr and became apparent thereafter. All of these events except for nuclear swelling were substantially blocked in MN9D/Bcl-X(L). At the later stage of cell death (<32-36 hr), a specific cleavage of Bax and fodrin appeared that was completely blocked by calpain inhibitor or by Bcl-X(L). Taken together, our data suggest that Bcl-X(L) prevents etoposide-induced neuronal death by exerting its anticaspase and anticalpain effect on cellular events after the formation of topoisomerase II-DNA cleavable complex that may not be a major contributor to cell death.

Overexpression of calbindin-D28K induces neurite outgrowth in dopaminergic neuronal cells via activation of p38 MAPK

An MN9D dopaminergic neuronal cell line overexpressing calbindin-D28K (MN9D/Calbindin) was established in order to investigate directly the potential role of calcium-binding protein in neuronal differentiation. Overexpression of calbindin-D28K in MN9D cells resulted in significant increases in the number of neurites, the length of primary neurites, and the total extent of neurites. This robust neurite outgrowth occurred without cessation of cell division. Analysis of immunoblots revealed that this morphological differentiation was accompanied by increased expression of such markers of maturation as the synaptosomal protein SNAP-25. During calbindin-D28K-evoked neurite outgrowth in MN9D cells, phosphorylation of p38 mitogen-activated protein kinase (MAPK) dramatically increased while the levels and extent of phosphorylation of such other MAPKs as c-Jun N-terminal kinase (JNK) or extracellular response kinase (ERK) were not altered. Consequently, calbindin-D28K-induced neurite outgrowth was largely abolished by treatment with a p38 inhibitor, PD 169316, while the level of SNAP-25 in MN9D/Calbindin cells was not altered by this treatment. These data support an idea that calbindin-D28K and its associated p38 signaling pathway play a role in dopaminergic neuronal differentiation.

MPP(+) downregulates mitochondrially encoded gene transcripts and their activities in dopaminergic neuronal cells: protective role of Bcl-2

The effects of neurotoxins on levels of mitochondrially encoded gene transcripts in a dopaminergic neuronal cell line, MN9D, were examined following treatment with 200 microM N-methyl-4-phenylpyridinium (MPP(+)) or 6-hydroxydopamine (6-OHDA). As confirmed by a Northern blot analysis, levels of cytochrome c oxidase subunit 3 (COX III) and ATPase subunit 6 (ATPase 6) transcript were decreased in a time-dependent manner following treatment with MPP(+) but not with 6-OHDA. Accordingly, enzymatic activity of cytochrome c oxidase (COX) and the intracellular ATP content were also decreased in MPP(+)-treated cells while these remained unaltered in 6-OHDA-treated cells. In the cell death paradigm induced by MPP(+), overexpression of Bcl-2 in MN9D cells (MN9D/Bcl-2) significantly blocked MPP(+)-induced downregulation of COX III and ATPase 6 transcripts. In MN9D/Bcl-2 cells, MPP(+)-induced downregulation of COX activity and the intracellular level of ATP was also blocked. Treatment with a pan-caspase inhibitor, however, neither prevented MPP(+)-induced downregulation of COX activity nor affected intracellular level of ATP in MN9D cells. Taken together, our present data suggest that Bcl-2 may play a regulatory role in energy metabolism by preventing downregulation of mitochondrially encoded gene(s) at a point distinct from its known anticaspase activity in MPP(+)-induced dopaminergic neuronal death.

Cleavage of Bax is mediated by caspase-dependent or -independent calpain activation in dopaminergic neuronal cells: protective role of Bcl-2

Two cysteine protease families, caspase and calpain, are known to participate in cell death. We investigated whether a stress-specific protease activation pathway exists, and to what extent Bcl-2 plays a role in preventing drug-induced protease activity and cell death in a dopaminergic neuronal cell line, MN9D. Staurosporine (STS) induced caspase-dependent apoptosis while a dopaminergic neurotoxin, MPP(+) largely induced caspase-independent necrotic cell death as determined by morphological and biochemical criteria including cytochrome c release and fluorogenic caspase cleavage assay. At the late stage of both STS- and MPP(+)-induced cell death, Bax was cleaved into an 18-kDa fragment. This 18-kDa fragment appeared only in the mitochondria-enriched heavy membrane fraction of STS-treated cells, whereas it was detected exclusively in the cytosolic fraction of MPP(+)-treated cells. This proteolytic cleavage of Bax appeared to be mediated by calpain as determined by incubation with [(35)S]methionine-labelled Bax. Thus, cotreatment of cells with calpain inhibitor blocked both MPP(+)- and STS-induced Bax cleavage. Intriguingly, overexpression of baculovirus-derived inhibiting protein of caspase, p35 or cotreatment of cells with caspase inhibitor blocked STS- but not MPP(+)-induced Bax cleavage. This appears to indicate that calpain activation may be either dependent or independent of caspase activation within the same cells. However, cotreatment with calpain inhibitor rescued cells from MPP(+)-induced but not from STS-induced neuronal cell death. In these paradigms of dopaminergic cell death, overexpression of Bcl-2 prevented both STS- and MPP(+)-induced cell death and its associated cleavage of Bax. Thus, our results suggest that Bcl-2 may play a protective role by primarily blocking drug-induced caspase or calpain activity in dopaminergic neuronal cells.

Intracellular calcium mobilization induces immediate early gene pip92 via Src and mitogen-activated protein kinase in immortalized hippocampal cells

Regulation of intracellular calcium levels plays a central role in cell survival, proliferation, and differentiation. A cell-permeable, tumor-promoting thapsigargin elevates the intracellular calcium levels by inhibiting endoplasmic reticulum Ca(2+)-ATPase. The Src-tyrosine kinase family is involved in a broad range of cellular responses ranging from cell growth and cytoskeletal rearrangement to differentiation. The immediate early gene pip92 is induced in neuronal cell death as well as cell growth and differentiation. To resolve the molecular mechanism of cell growth by intracellular calcium mobilization, we have examined the effect of thapsigargin and subsequent intracellular calcium influx on pip92 expression in immortalized rat hippocampal H19-7 cells. An increase of intracellular calcium ion levels induced by thapsigargin stimulated the expression of pip92 in H19-7 cells. Transient transfection of the cells with kinase-inactive mitogen-activated protein kinase kinase (MEK) and Src kinase or pretreatment with the chemical MEK inhibitor PD98059 significantly inhibited pip92 expression induced by thapsigargin. When constitutively active v-Src or MEK was overexpressed, the transcriptional activity of the pip92 gene was markedly increased. Dominant inhibitory Raf-1 blocked the transcriptional activity of pip92 induced by thapsigargin. The transcription factor Elk1 is activated during thapsigargin-induced pip92 expression. Taken together, these results suggest that an increase of intracellular calcium ion levels by thapsigargin stimulates the pip92 expression via Raf-MEK-extracellular signal-regulated protein kinase- as well as Src kinase-dependent signaling pathways.

Role of tumor necrosis factor-alpha in neuronal and glial apoptosis after spinal cord injury

We investigated the role of tumor necrosis factor (TNF)-alpha in the onset of neuronal and glial apoptosis after traumatic spinal cord crush injury in rats. A few TUNEL-positive cells were first observed within and surrounding the lesion area 4 h after injury, with the largest number observed 24-48 h after injury. Double-labeling of cells using cell type-specific markers revealed that TUNEL-positive cells were either neurons or oligodendrocytes. One hour after injury, an intense immunoreactivity to TNF-alpha was observed in neurons and glial cells in the lesion area, but also seen in cells several mm from the lesion site rostrally and caudally. The level of nitric oxide (NO) also significantly increased in the spinal cord 4 h after injury. The injection of a neutralizing antibody against TNF-alpha into the lesion site several min after injury significantly reduced both the level of NO observed 4 h thereafter as well as the number of apoptotic cells observed 24 h after spinal cord trauma. An inhibitor of nitric oxide synthase (NOS), N(G)-monomethyl-l-arginine acetate (l-NMMA), also reduced the number of apoptotic cells. This reduction of apoptotic cells was associated with a decrease in DNA laddering on agarose gel electrophoresis. These results suggest that: (i) TNF-alpha may function as an external signal initiating apoptosis in neurons and oligodendrocytes after spinal cord injury; and (ii) TNF-alpha-initiated apoptosis may be mediated in part by NO as produced by a NOS expressed in response to TNF-alpha.

Rapid increase in immunoreactivity to GFAP in astrocytes in vitro induced by acidic pH is mediated by calcium influx and calpain I

In higher vertebrates, reactive gliosis resulting from injury to the central nervous system (CNS) is characterized by a rapid increase in immunoreactivity (IR) to glial fibrillary acidic protein (GFAP). Little is known about the extracellular signals that initiate the increase in GFAP-IR following CNS injury. We demonstrated recently [T.H. Oh, G.J. Markelonis, J.R. Von Visger, B. Baik, M.T. Shipley, Acidic pH rapidly increases immunoreactivity of glial fibrillary acidic protein in cultured astrocytes, Glia 13 (1995) 319-322] that a rapid increase in GFAP-IR can be evoked in mature astrocyte cultures by exposing the cells to an acidic medium. We investigated the intracellular pathway(s) involved in initiating increased GFAP-IR, a hallmark of reactive astrocytes. The increase in GFAP-IR produced by exposure to acidic medium was blocked by pretreatment with nickel ions, by such blockers of L-type calcium channels as nifedipine, verapamil and diltiazem, by calpain inhibitor I, or by the intracellular calcium chelator, BAPTA-AM. At physiological pH, treatment with the calcium ionophore, A23187, resulted in increased GFAP-IR which could be blocked by pretreatment with calpain inhibitor I. Astrocytes exposed to low pH exhibited a marked increase in a GFAP fragment with a molecular weight of 48 kDa. In astrocytes exposed to acidic medium, alpha-fodrin, a selective endogenous substrate of calpain, was also found to be hydrolyzed producing fragments with molecular weights of 120-150 kDa. As anticipated, pretreatment with calpain inhibitor I prevented the proteolytic degradation of both GFAP and alpha-fodrin in these samples. These results suggest that the initial increase in GFAP-IR after CNS injury appears to be linked to Ca(++) influx, and is mediated further by a proteolytic process that seemingly involves the activation of the calcium-dependent protease, calpain I.

Preparation of monoclonal antibody against ginsenoside Rf and its enzyme immunoassay

A rapid and sensitive indirect competitive enzyme immunoassay method has been developed for quantitating ginsenoside Rf (Rf) in crude total Panax ginseng saponins and in rat plasma using high titer mouse monoclonal antibody (mAb) raised against a conjugate of Rf and bovine serum albumin (BSA). The isotype of mAb against Rf was IgG3 with a K chain. The presence of Rf inhibited the binding of the mouse anti-Rf mAb to a Rf-BSA solid phase coating antigen. The working range was 0.01-10 ng/assay and detection limits were 20 pg in various ginseng extract fractions or 34 pg in rat plasma per assay. The anti-Rf mAb cross-reacted with ginsenoside Rg2 by 57.5%, but not with other ginsenosides. However, this anti-Rf mAb did not cross-react with BSA or cellubiose, which is a carbohydrate component of Rf. Using this standard curve, we could measure the amount of Rf in ginseng total extract, ginseng total saponins, protopanaxadiol saponins, and propanaxatriol saponins. We could also measure the amount of Rf in rat plasma after the oral administration of Rf and found that Rf reached a maximum level in rat plasma after 16 h. These results indicate that the anti-Rf mAb could be useful for the quantitation of Rf in crude ginseng fractions and in body fluids.

Correlation between structure of Bcl-2 and its inhibitory function of JNK and caspase activity in dopaminergic neuronal apoptosis

To examine the correlation between the structure of Bcl-2 and its inhibitory function of c-Jun N-terminal kinase (JNK) and caspase activity, we established a dopaminergic neuronal cell line, MN9D overexpressing Bcl-2 (MN9D/Bcl-2) or its structural mutants. The mutants comprised a point mutation in the BH1 (G145A; MN9D/BH1) or BH2 (W188A; MN9D/BH2) domain and a deletion mutation in the C-terminal (MN9D/C22), BH3 (MN9D/BH3), or BH4 (MN9D/BH4) domain. As determined by the TUNEL (terminal deoxynucleotidyltransferase nick end-labeling) and MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] reduction assay, apoptotic death of MN9D/Neo cells reached 80-90% within 24 h in response to 1 microM staurosporine. Upon staurosporine treatment, JNK activity increased six- to sevenfold over the basal level within 2-4 h. Treatment of MN9D/Neo with both staurosporine and a caspase inhibitor, Z-VAD, attenuated cell death without suppressing JNK activation. Both staurosporine-induced cell death and JNK activation were attenuated in MN9D/Bcl-2. As determined by cleavage of poly(ADP-ribose) polymerase into 85 kDa, Bcl-2 blocked caspase activity as well. When cells overexpressing one of the Bcl-2 mutants were treated with staurosporine, death was attenuated in MN9D/BH1, MN9D/BH2, and MN9D/C22 but not in MN9D/BH3 and MN9D/BH4. Similarly, both JNK and caspase activation were blocked in MN9D/BH1, MN9D/BH2, and MN9D/C22, whereas they were not suppressed in MN9D/BH3 and MN9D/BH4. Taken together, our data indicate that there exists a close structural and functional correlation of Bcl-2 to JNK and caspase activity in staurosporine-induced dopaminergic neuronal cell death.

Rehabilitation of orthopedic and rheumatologic disorders. 2. Connective tissue diseases

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with connective tissue diseases. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include the management of patients who have polymyalgia rheumatica, juvenile rheumatoid arthritis, ankylosing spondylitis, rheumatoid cervical spine, and rheumatoid hand.

Rehabilitation of orthopedic and rheumatologic disorders. 1. Osteoporosis

This self-directed learning module reviews and summarizes recent literature on osteoporosis. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The areas covered include pathophysiology of primary and secondary osteoporosis, effects of various pharmacologic treatments on bone metabolism, and the utility of available diagnostic tests. Management strategies for perimenopausal women as compared with postmenopausal women with established osteoporosis are discussed. This is followed by an evaluation and management plan for the older man with acute osteoporotic fracture.

Rehabilitation of orthopedic and rheumatologic disorders. 3. Degenerative joint disease

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with osteoarthritis. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include updates on conservative and operative treatment of lumbar spinal stenosis and pediatric hip diseases, prophylactic therapy for thromboembolic disease after lower limb joint replacement, new therapies for osteoarthritis, and the impact of exercise on outcome following hip replacement in active persons.

Rehabilitation of orthopedic and rheumatologic disorders. 4. Musculoskeletal disorders

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with orthopedic and musculoskeletal disorders. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses new advances in such topics as idiopathic scoliosis, nontraumatic shoulder pain, rotator cuff tendinitis, and Dupuytren's disease.

Cynandione A from Cynanchum wilfordii protects cultured cortical neurons from toxicity induced by H2O2, L-glutamate, and kainate

Oxidative stress has been implicated as a primary cause of neuronal death in certain neurodegenerative disorders and in aging brains. Natural products have been used in Asian societies for centuries for treating such neurodegenerative disorders as senile dementia. In an effort to identify active neuroprotective compounds from these products, we have employed cultures of rat cortical neurons as our screening system. A methanolic extract from dried roots of Cynanchum wilfordii Hemsley (Asclepiadaceae) significantly mitigated the neurotoxicity induced by H2O2 in this screening system. Activity-guided fractionation using several chromatographic techniques resulted in the isolation of the neuroprotective compound, cynandione A, a biacetophenone. At a concentration of 50 microM, cynandione A significantly reduced neurotoxicity induced by H2O2. Cynandione A significantly attenuated decreases in levels of glutathione, superoxide dismutase, and other enzymes that participate in the cellular defense against oxidative stress. Furthermore, cynandione A alleviated neurotoxicity induced by the excitotoxic neurotransmitter, L-glutamate, the neurotoxicity induced by kainate, but not that mediated by N-methyl-D-aspartate. Cynandione A was demonstrated to be a natural antioxidant as it facilitated the breakdown of hydrogen peroxide in vitro; however, no mechanism was uncovered to explain its neuroprotectant effects against glutamate and kainate. Therefore, cynandione A may be efficacious in protecting neurons from oxidative stress mediated via activation of alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate/kainate receptors since it exerted significant neuroprotective effects on cultured cortical neurons.

Immunogenicity of alpha-toxin, capsular polysaccharide (CPS) and recombinant fibronectin-binding protein (r-FnBP) of Staphylococcus aureus in rabbit

This study was conducted to evaluate the antibody levels of alpha-toxin, capsular polysaccharides (CPS) and fibronectin-binding protein (FnBP) in rabbits immunized with an experimental vaccine against Staphylococcus aureus and to develop the bovine mastitis subunit vaccine in the future. Enzyme immunoassay was used for detection of IgG antibodies against staphylococcal CPS, alpha-toxin and FnBP. The levels of specific antibodies against CPS, alpha-toxin and FnBP in immunized rabbits were significantly increased after first immunization compared with control animals (p<0.05). Of three antigen used in vaccine, immunogenicity of CPS was relatively lower, compared with those of alpha toxin and fibronectin binding protein. Numbers of S. aureus in blood of immunized groups were lower than those of control group after bacterial challenge. But the bacterial numbers among immunized groups were not significantly different. S. aureus counts in excised organs were significantly lower in all immunized rabbits than in PBS-control group (p<0.05). The present study showed that alpha-toxin, capsular polysaccharide and fibronectin binding protein included in a subunit vaccine were protective.

Characterization of MPP(+)-induced cell death in a dopaminergic neuronal cell line: role of macromolecule synthesis, cytosolic calcium, caspase, and Bcl-2-related proteins

To further characterize MPP(+)-induced cell death and to explore the role of Bcl-2-related proteins in this death paradigm, we utilized a mesencephalon-derived dopaminergic neuronal cell line (MN9D) stably transfected with human bcl-2 (MN9D/Bcl-2), its C-terminal deletion mutant (MN9D/Bcl-2Delta22), murine bax (MN9D/Bax), or a control vector (MN9D/Neo). As determined by electron microscopy and TUNEL assay, MN9D/Neo cells exposed to MPP(+) underwent a cell death that was characterized by mitochondrial swelling and irregularly scattered heterochromatin without accompanying DNA fragmentation. However, cell swelling typically seen in necrosis did not appear. To examine the biochemical events associated with MPP(+)-induced cell death, various analyses were conducted. Addition of a broad-spectrum caspase inhibitor, N-benzyloxycarbonyl-Val-Ala-Asp-fluoromethylketone (50-400 microM) or Boc-aspartyl(OMe)-fluoromethylketone (50-200 microM) did not attenuate MPP(+)-induced cell death while the same treatment protected MN9D/Neo cells against staurosporine-induced apoptotic cell death. Concurrent treatment with an inhibitor of macromolecule synthesis such as cycloheximide, emetine, or actinomycin D blocked MPP(+)-induced cell death, suggesting that new protein synthesis is required as demonstrated in many apoptotic cell death. The level of cytosolic calcium in MN9D/Neo cells was unchanged over 24 h following MPP(+) treatment, as monitored by means of the fluorescent probe Fura-2. Western blot analysis indicated that expression level of proapoptotic protein, Bax was not significantly altered after MPP(+) treatment. In this death paradigm, overexpression of Bcl-2 but not its C-terminal deletion mutant attenuated MPP(+)-induced cell death whereas overexpression of Bax had no effect. Taken together, these data indicate that (i) MPP(+) induces a distinct form of cell death which resembles both apoptosis and necrosis; and (ii) full-length Bcl-2 counters MPP(+)-induced morphological changes and cell death via a mechanism that is dependent on de novo protein synthesis but independent of cytosolic calcium changes, Bax expression, and/or activation of caspase(s) in MN9D cells.

Two distinct mechanisms are involved in 6-hydroxydopamine- and MPP+-induced dopaminergic neuronal cell death: role of caspases, ROS, and JNK

In this study, we examined the possibility that MPTP and 6-hydroxydopamine (6-OHDA) act on distinct cell death pathways in a murine dopaminergic neuronal cell line, MN9D. First, we found that cells treated with 6-OHDA accompanied ultrastructural changes typical of apoptosis, whereas MPP+ treatment induced necrotic manifestations. Proteolytic cleavage of poly-(ADP-ribose)polymerase by caspase was induced by 6-OHDA, whereas it remained uncleaved up to 32 h after MPP+ treatment and subsequently disappeared. Accordingly, 6-OHDA- but not MPP(+)-induced cell death was significantly attenuated in the presence of a broad-spectrum caspase inhibitor, N-benzyloxy-carbonyl-Val-Ala-Asp-fluomethylketone (Z-VAD-fmk). As measured by fluorometric probes, the level of reactive oxygen species (ROS) significantly increased after 6-OHDA treatment. In contrast, the level of dihydroethidium-sensitive ROS following MPP+ treatment remained unchanged while a slight increase in dichlorofluorescin-sentive ROS was temporarily observed. As demonstrated by immunoblot analysis, the level of superoxide dismutase was down-regulated following 6-OHDA treatment, whereas it remained unchanged after MPP+ treatment. Cotreatment of cells with antioxidants such as N-acetylcysteine or Mn(III)tetrakis(4-benzoic acid)porphyrin chloride (MnTBAP, cell-permeable superoxide dismutase mimetic) rescued 6-OHDA- but not MPP(+)-induced cell death, whereas inclusion of catalase or N(G)-nitro-L-arginine had no effect in both cases. In addition, 6-OHDA induced ROS-mediated c-Jun N-terminal kinase (JNK) activation that was attenuated in the presence of N-acetylcysteine or MnTBAP but not catalase or Z-VAD-fmk. In contrast, MPP+ has little effect on JNK activity, indicating that ROS and/or ROS-induced cell death signaling pathway seems to play an essential role in 6-OHDA-mediated apoptosis but not in MPP(+)-induced necrosis in a mesencephalon-derived, dopaminergic neuronal cell line.

Calcium influx and activation of calpain I mediate acute reactive gliosis in injured spinal cord

Buffering extracellular pH at the site of a spinal cord crush-injury may stimulate axonal regeneration in rats (1; Guth et al., Exp. Neurol. 88: 44-55, 1985). We demonstrated in cultured astrocytes that acidic pH initiates a rapid increase in immunoreactivity for GFAP (GFAP-IR), a hallmark of reactive gliosis (2; Oh et al., Glia 13: 319-322, 1995). We extended these studies by investigating the effects of certain treatments on reactive gliosis developing in situ in a rat spinal cord injury model. A significant reactive gliosis was observed within 2 days of cord lesion in untreated crush or vehicle-treated, crush control animals as evidenced by increased GFAP-IR and hypertrophy of astrocytes. By contrast, infusion of Pipes buffer (pH 7.4) into the lesion site significantly reduced this increase. The increased GFAP-IR appeared to be linked to Ca2+ influx since infusion of a blocker of L-type calcium channels, nifedipine, reduced the ensuing reactive gliosis significantly. While Ca2+ modulates many signaling pathways within cells, its effect on reactive gliosis appeared to result from an activation of calpain I. Calpain inhibitor I, a selective inhibitor of mu-calpain, also significantly reduced reactive gliosis. However, calpain inhibitor II, a close structural analog which blocks m-calpain, had no salutary effect. We suggest, therefore, that the initial reactive gliosis seen in vivo may result from the activation of a neutral, Ca2+-dependent protease, calpain I, through calcium influx.

Protopine from Corydalis ternata has anticholinesterase and antiamnesic activities

While screening extracts of natural products in search of anticholinesterase activity, we found that a total methanolic extract of the tuber of Corydalis ternata (Papaveraceae) showed significant inhibitory effects on acetylcholinesterase. Further fractionation of this extract using acetylcholinesterase inhibition as the parameter screened resulted in the isolation and purification of an alkaloid, protopine. Protopine inhibited acetylcholinesterase activity in a dose-dependent manner. The concentration required for 50% inhibition was 50 microM. The anti-acetylcholinesterase activity of protopine was specific reversible and competitive in manner. Furthermore, when mice were pretreated with protopine, the alkaloid significantly alleviated scopolamine-induced memory impairment. In fact, protopine had an efficacy almost identical to that of velnacrine, a tacrine derivative developed by a major drug manufacturer to treat Alzheimer's disease, at an identical therapeutic concentration. We suggest, therefore, that protopine has both anti-acetylcholinesterase and antiamnesic properties that may ultimately hold significant therapeutic value in alleviating certain memory impairments observed in dementia.

Ginsenosides Rb1 and Rg3 protect cultured rat cortical cells from glutamate-induced neurodegeneration

Certain natural products and Asian herbal remedies have been used in Asia to attenuate neurodegenerative diseases, including senile dementia. We have examined derivatives of several natural products for potential neuroprotective activity in an in vitro test system. In the present study, we assayed a number of compounds that were isolated from Panax ginseng C.A. Meyer (Araliaceae) for an ability to protect rat cortical cell cultures from the deleterious effects of the neurotoxicant, glutamate. We found that ginsenosides Rb1 and Rg3 significantly attenuated glutamate-induced neurotoxicity. Brief exposure of cultures to excess glutamate caused extensive neuronal death. Glutamate-induced neuronal cell damage was reduced significantly by pretreatment with Rb1 and Rg3. Ginsenosides Rb1 and Rg3 inhibited the overproduction of nitric oxide, which routinely follows glutamate neurotoxicity, and preserved the level of superoxide dismutase in glutamate-treated cells. Furthermore, in cultures treated with glutamate, these ginsenosides inhibited the formation of malondialdehyde, a compound that is produced during lipid peroxidation, and diminished the influx of calcium. These results show that ginsenosides Rb1 and Rg3 exerted significant neuroprotective effects on cultured cortical cells. Therefore, these compounds may be efficacious in protecting neurons from oxidative damage that is produced by exposure to excess glutamate.

Infant apnea detection after herniorrhaphy

STUDY OBJECTIVE

To elucidate risk factors for apnea in preterm infants discharged from the hospital and in full-term healthy infants. To determine the efficacy of real-time cardiopulmonary monitoring versus computerized storage and retrieval for infants at risk.

STUDY DESIGN

Prospective study.

SETTING

Operating rooms and pediatric patient care units of university medical center.

PATIENTS

27 preterm infants and 20 full-term infants no more than 60 weeks' post-conceptional age, who were admitted for elective herniorrhaphy.

INTERVENTIONS

Infants were monitored before and after herniorrhaphy with general anesthesia using an infant apnea impedance monitor, pulse oximetry, and nursing observation.

MEASUREMENTS AND MAIN RESULTS

Demographic information and medical history were correlated with postoperative apnea. The sensitivity and specificity of nursing observation and oximetry were compared with computerized apnea monitors. Five patients (11%, four preterm, one full-term) were apneic postoperatively as recorded by computerized pneumocardiography. Previous apnea history, gestational age at birth, and postconceptional age at operation positively correlated with postoperative apnea. Nursing observation failed to detect 4 of 5 patients with documented apnea (sensitivity 20%, positive predictive value 50%). Pulse oximetry failed to detect 3 of 5 patients with apnea (sensitivity 40%, positive predictive value 66%).

CONCLUSIONS

Although it is easier to predict postoperative respiratory dysfunction in previously sick or very young infants, absolute predictability for all neonates remains elusive. Clinical monitors with both storage and retrieval capabilities and real-time monitoring increase our ability to detect significant events in children at risk for apnea after herniorrhaphy.

Rehabilitation in joint and connective tissue diseases. 1. Systemic diseases

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses treatment and outcome in rheumatoid arthritis, musculoskeletal involvement in human immunodeficiency virus infection, scleroderma, systemic lupus erythematosus, and intraarticular injection of corticosteroids.

Rehabilitation in joint and connective tissue diseases. 3. Limb disorders

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the following: differential features, diagnostic strategy, and rehabilitation management of hip, knee, foot, and shoulder pain; indications, contraindications, and postsurgical management for joint arthroplasty; management of gout and chondrocalcinosis; and rehabilitation issues related to hip and shoulder fracture.