Post-traumatic stress disorder (PTSD) is a potentially serious psychiatric disorder that has traditionally been associated with traumatic stressors such as participation in combat, violent assault, and survival of natural disasters. Recently, investigators have reported that the experience of critical illness can also lead to PTSD, although details of the association between critical illness and PTSD remain unclear.We conducted keyword searches of MEDLINE and Psych Info and investigations of secondary references for all articles pertaining to PTSD in medical intensive care unit (ICU) survivors.From 78 screened papers, 16 studies (representing 15 cohorts) and approximately 920 medical ICU patients met inclusion criteria. A total of 10 investigations used brief PTSD screening tools exclusively as opposed to more comprehensive diagnostic methods. Reported PTSD prevalence rates varied from 5% to 63%, with the three highest prevalence estimates occurring in studies with fewer than 30 patients. Loss to follow-up rates ranged from 10% to 70%, with average loss to follow-up rates exceeding 30%.Exact PTSD prevalence rates cannot be determined due to methodological limitations such as selection bias, loss to follow-up, and the wide use of screening (as opposed to diagnostic) instruments. In general, the high prevalence rates reported in the literature are likely to be overestimates due to the limitations of the investigations conducted to date. Although PTSD may be a serious problem in some survivors of critical illness, data on the whole population are inconclusive. Because the magnitude of the problem posed by PTSD in survivors of critical illness is unknown, there remains a pressing need for larger and more methodologically rigorous investigations of PTSD in ICU survivors. Estimates of post-traumatic stress disorder (PTSD) prevalence in critically ill cohorts are reported to be as high as 63%  and exceA number of recent reviews have looked at the association between medical illness and the development of psychiatric illness -6. HowevA literature search for all articles pertaining to critical illness and PTSD was conducted using both the Psych Info and US National Library of Medicine MEDLINE databases. Key words/phrases used to search these databases included 'post-traumatic stress disorder' AND 'critical illness' (25 abstracts via MEDLINE and 5 via Psych Info) or 'post-traumatic stress disorder' AND 'intensive care' (81 abstracts via MEDLINE and 19 via Psych Info). Reference lists from identified articles were used to identify any additional studies.For inclusion in this review, studies were required (a) to evaluate the association between medical ICU hospitalization and PTSD  and (b) to employ qualitative and/or objective measures of PTSD or PTSS. Investigations published in a language other than English were excluded as were unpublished studies and abstracts. One of the authors (JCJ) reviewed all of the articles in question to ensure that they met the above criteria.The following aspects of each study were identified, abstracted, and analyzed: study population, study design, timing of evaluations, study aims, exclusion criteria, methods of assessing PTSD, and all relevant results compared across study populations, including follow-up rates. All individual articles were assigned a 'quality rating' according to the Oxford Centre for Evidence-Based Medicine guidelines for symptom prevalence studies . Ratingsentirely of physical trauma and/or surgical ICU patients were identified and excluded from review due to the likelihood that the PTSD symptoms experienced by these patient populations could have been generated by either trauma-related injuries or surgical interventions. The authors recognize that trauma and surgical ICU patients may be similar in many respects to their medical ICU counterparts and, indeed, they may have overlapping experiences. Nevertheless, we chose to exclude such patients so as to focus as specifically as possible on the unique contributions of medically related critical illness to the development of PTSD. Similarly, a number of research investigations of medical ICU survivors assessing anxiety or memories of the ICU generically were identified and were also excluded as they did not include a specific focus on PTSD or PTSS. One investigation evaluated PTSD symptoms after critical illness but did not include data regarding prevalence rates and thus was excluded [A total of 78 non-overlapping potential abstracts were identified in the search of the databases and reference lists (the most recent search was performed in October 2006). Of these, 16 papers met inclusion criteria Table . A numbeAll investigations were conducted exclusively on adult critically ill patients. Studies focused on general medical ICU populations -16 as weA total of six studies were prospective in nature; five of these were cohort studies ,13,15,16Studies in which exclusion criteria were stated explicitly included prior psychiatric illness or neurologic trauma or disease ,14,18,22A total of nine investigations relied solely on standardized brief screening tools in their assessment of PTSD or PTSS, including the Post-Traumatic Stress Scale-10 for the ICU (PTSS-10), Impact of Events Scale (IES), IES Revised, Davidson Trauma Scale (DTS), Trauma Symptom Checklist-33, and the Experiences of Treatment in the Intensive Care-7 ,19,20,23Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) (SCID) [A total of five investigations relied on structured clinical interviews such as the Structured Clinical Interview for the DSM-IV  (SCID) ,17,18,22) (SCID) , approxiPrevalence rates ranged from 5% to 63% and showed little variance regardless of whether the outcome in question was PTSD or PTSS; the three highest rates  occurred in investigations that purported to diagnose PTSD ,13,22. IGeneral medical ICU cohorts had both the lowest and highest rates of PTSD or PTSS compared with more specialized populations. In studies of general medical ICU patients, prevalence rates ranged from 5%  to 63% , and ratRisk factors were not studied systematically across studies, although a number of risk factors were identified Table . Two invDemographic and historical variables associated with an increased risk of PTSD or PTSS included younger age ,14,16, aAs others have observed, PTSD, as concurrently conceptualized by the DSM-IV and the psychiatric community, is a complex condition that presents unique diagnostic challenges for clinical researchers . Unlike As previously described, the methodological limitations of the aforementioned studies are significant and may have contributed to overestimates of PTSD or PTSS prevalence. In particular, the practice of using screening tools for diagnostic purposes is problematic. Certainly, screening tools and questionnaires vary widely in quality and comprehensiveness, and some self-report questionnaires possess fairly robust psychometric properties . NeverthAlthough some may argue that critical illness and associated factors such as prolonged hospitalization and mechanical ventilation are always traumatic stressors, this is not necessarily the case; the degree to which these events are experienced as traumatic may be mediated by age, severity of illness, abruptness of onset, religious faith, and individual interpretation . Among iIn addition to relying primarily on screening tools, a majority of investigations failed to assess for previous or intervening trauma, although such information is highly relevant in determining both the genesis of PTSD symptoms and the unique contributions of ICU treatment to the development of PTSD. Data suggest that a majority of community-dwelling individuals have been exposed to at least one traumatic event during their lifetime  and thatYet another limitation of research on PTSD and critical illness pertains to sampling issues. In studies of PTSD in more established populations , sample sizes are often quite large and patients are in many cases relatively homogenous. In contrast, the largest study of PTSD following critical illness contained fewer than 150 patients at follow-up, and the majority of investigations consisted of fewer than 50 patients at follow-up and included patients with substantial differences with regard to key characteristics, including the time to PTSD assessment. These issues, along with consistently and strikingly low follow-up rates, raise questions about the generalizability of study findings and the degree to which study participants are representative of typical critically ill populations. It may be, for example, that high-functioning ICU survivors without psychological sequela might conclude that the study participation is of little value to them and thus decline, or that subjects with PTSD might be particularly inclined to participate as a way of seeking help. Alternatively, it may be that some ICU survivors with PTSD may be less likely than their ICU counterparts to participate because the intense emotional distress they experience precludes them from doing so.Although the experience of critical illness is undoubtedly stressful, aspects of this experience differ in nature from more traditionally defined and widely studied 'traumas' such as severe burns, automobile accidents, sexual assaults, and exposures to combat. For example, ICU patients are frequently unaware of the degree of life-threat their illness poses until after the illness is largely resolved. Additionally, the development of critical illness is frequently a continuation or acceleration of a longstanding disease process  as opposed to an abrupt occurrence. Despite these caveats, key factors associated with critical illness may be traumatogenic. These could potentially include the diagnosis of critical illness, the unique stresses often associated with ICU care such as intubation and weaning from mechanical ventilation, and the occurrence of nightmares and delusions. The cumulative effects of these factors could increase the likelihood of developing PTSD, particularly in patients with pre-existing vulnerabilities such as a prior history of trauma exposure or a history of chronic medical illness -44.explicit memories  [As others have observed, altered mental status (in the forms of both delirium and coma) is common in the ICU, raising important questions about the role of memory  in mediating the development of PTSD . The impousness) ,47 in thousness) -52. Howeousness) ,53-55.The relationship between critical illness and PTSD has been assessed in a limited number of studies over the last decade and a half. These studies have varied widely in their aims and methodological rigor but have raised awareness and generated valuable data and important insights. For example, we now recognize that sedation strategies can influence the development of PTSD symptoms. Additionally, more recent evidence suggests that individuals with predominantly factual, as opposed to delusional, recollections of the ICU may be at reduced risk for PTSD. Furthermore, it appears that the presence of premorbid mental health problems increases the likelihood of developing PTSD in survivors of the ICU.Despite the growing recognition that PTSD may occur following an episode of critical illness, the extent to which it can reliably be considered a threat is unknown, due to the methodological limitations and conflicting results of the current studies. It is highly probable that investigations to date have tended to overestimate PTSD prevalence because of an over-reliance on screening tools (as opposed to diagnostic tools), questionable interpretations of available data, the lack of evaluation of non-ICU-related causes of PTSD, low follow-up rates, and other significant limitations. It is worth noting, in this regard, that the three studies reporting the highest rates of actual PTSD (>50%) had sample sizes of between 11 and 27 patients. Developing conclusions about prevalence on the basis of such limited investigations is both extremely imprudent and inconsistent with sound scientific practice. Nevertheless, PTSD clearly occurs and persists in a subset of ICU survivors.Continued investigation of PTSD in critically ill populations is vitally important for determining the nature and scope of the problem and evaluating possible interventions. However, the relevance and value of a program of investigation will be limited unless it employs the same methodological rigor that characterizes the study of PTSD in other better-established populations such as combat veterans and cancer patients. To that end, specific guidelines should be adhered to and specific goals aggressively pursued. First, studies focused on PTSD as an outcome should use appropriate diagnostic tools and should focus not only on the identification of symptoms but also on the assessment of clinical significance. Researchers should attempt to use populations sufficiently large and representative so as to determine the approximate prevalence of PTSD in critically ill cohorts. In addition to evaluating prevalence rates, investigators should study rates of symptom remission. Second, the incidence of other potentially relevant historical or intervening traumatic stressors and trait variables  should be explored. Third, studies should more fully explore the specific etiologies of ICU-related PTSD, placing particular emphasis on the contributions of factual versus delusional memories to the development of PTSD. Fourth, studies should examine the effects of sedation strategies on the development of PTSD, focusing on the identification of strategies that may be protective against the development of PTSD. Finally, studies should assess specific risk factors for the development of PTSD in ICU survivors, focusing in particular on the identification of modifiable risk factors and potential interventions that might reduce the incidence of PTSD or PTSD symptoms. Understanding the nature of the relationship between critical illness and PTSD is a challenge that demands attention, particularly in an era when mental health professionals are beginning to recognize the significant and sometimes profound costs  associated with this psychiatric syndrome.• PTSD or PTSD symptoms are reported to occur in between 5% and 63% of ICU survivors, and key risk factors include duration of hospital and ICU stays, duration of ventilation, pre-existing psychiatric history, and the presence of delusional memories.• Reported rates of PTSD prevalence following the ICU tend to be extremely high relative to other trauma populations, including medical and surgical patients, and are likely to be overestimates.• Studies of PTSD following critical illness are characterized by significant methodological shortcomings, which raise key questions about the actual prevalence rates of PTSD and the generalizability of study findings.• Future studies on PTSD should be more methodically rigorous and should use larger and more homogeneous samples while also employing comprehensive diagnostic, as opposed to screening, instruments.Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DTS = Davidson Trauma Scale; ICU = intensive care unit; IES = Impact of Events Scale; PTSD = post-traumatic stress disorder; PTSS = post-traumatic stress symptoms; PTSS-10 = Post-Traumatic Stress Scale-10 for the Intensive Care Unit; SCID = Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.ARDS = acute respiratory distress syndrome; DSM-IV = The authors declare that they have no competing interests.JCJ conceived of the manuscript, performed the literature review, and was primarily responsible for writing the manuscript. RPH assisted in the conception of the project and in the writing and drafting of the manuscript, including the creation of tables. SMG assisted in performing the literature review and in the writing and drafting of the manuscript, including the creation of tables. ROH assisted in performing the literature review and the writing, drafting, and editing of the manuscript, including the creation of tables. TDG assisted in the writing, drafting, and editing of the manuscript. EWE contributed to the conception of the project and assisted in the writing and drafting of the manuscript. All authors read and approved the final manuscript.


Ephedra and ephedroids as well as the Gnetum-Welwitschia clade are now well documented in the Early Cretaceous. However, hypotheses on evolutionary relationships among living and fossil species are hampered by restricted knowledge of morphological variation in living groups and recent studies indicate that gnetalean diversity and character evolution may be more complex than previously assumed and involve additional extinct groups .Knowledge on fossil and evolutionary history of the Gnetales has expanded rapidly; Siphonospermum simplex from the Early Cretaceous Yixian Formation, an impression/compression of a reproductive shoot. The slender main axis bears one pair of opposite and linear leaves with primary parallel venation. The reproductive units are ovoid, without supporting bracts and borne on one median and two lateral branches. The most conspicuous feature of the fossil is the long, thread-like micropylar tube formed by the integument. Each ovule is surrounded by two different layers representing one or two seed envelopes; an inner sclerenchymatous layer and an outer probably parenchymatous layer.Here we describe a new fossil related to Gnetales, Siphonospermum simplex exclude a relationship to any other group than the Gnetales. A combination of opposite phyllotaxis, linear leaves and ovules surrounded by seed envelope(s) and with a long exposed micropylar tube are known only for extant and extinct Gnetales. Siphonospermum simplex constitutes a new lineage within the Gnetales. Its morphology cannot be directly linked to any previously known plant, but the organization of the reproductive units indicates that it belongs to the Gnetum-Welwitschia clade. Based on the absence of cone bracts and the inferred histology of the seed envelope(s) it could be related to Gnetum, however, there are also affinities with the ephedran lineage, some of which are likely plesiomorphic features, others perhaps not. Phylogeny and character evolution in the Bennettitales, Erdtmanithecales and Gnetales are currently only partly understood and under debate; the exact systematic position of Siphonospermum simplex, i.e., its position within the Gnetales, cannot be resolved with certainty.The vegetative and reproductive features of  Ephedra L., Gnetum L., Welwitschia Hook. f.)  and ook. f.) ,22].Ephedra has retained many ancestral features, but can be defined by specialized pollen characters , which  details ,18,31. T details ; interprIn this study we add to the knowledge of gnetalean diversity in the Early Cretaceous. We describe and discuss an impression/compression fossil from the Liaoning province of north-eastern China collected in Early Cretaceous sediments of the Yixian Formation.Siphonospermum simplex comprises two impression/compression fossils of a female plant, part and counterpart, with remnants of oxidized organic material . The micropylar tube is straight, appears sturdy, and extends out of the seed envelope(s) at a slight angle. It is nearly equal in width throughout its length Figure ; its diaBuarcospermum, Lignierispermum, Lobospermum, Rugonella . The seSiphonospermum simplex  is more difficult to establish due to the restricted amount of preserved information. Its morphology differs substantially from that of other gnetalean fossils from the Yixian Formation, which have compound cones comprising cone bracts and seeds ); there are no supporting bracts.Higher level relationship of nd seeds ,11,12. TSiphonospermum are well preserved and have not been bent or curled during fossilization. Their walls are prominent  . The. TheSiph Liaoxia . One ephSiphonospermum has several features in common with Gnetum. The "reticulate" venation of Gnetum leaves develops from successive dichotomies in 5-10 parallel veins located in the centre of the leaf , not shSiphonospermum simplex, possesses several key characters that suggest a close relationship with Gnetales and more specifically with the Gnetum-Welwitschia clade. Ovules borne without subtending cone bracts but with a possible second seed envelope indicate a relationship with Gnetum. However, there are also differences between Gnetum and Siphonospermum, most importantly the apparent absence of closure tissue in the micropylar tube.The new Early Cretaceous impression/compression fossil described here, Ephedra lineage, the Gnetum-Welwitschia clade, or the Bennettitales, are seen in recently described charcoalified seeds , corresTo comply with requirements of the ICBN, we have deposited paper copies of this article at the University of Zürich (library of the Institute of Systematic Botany); Stockholm University (library of the Department of Botany); Peking University Library, Beijing; Chinese Academy of Sciences, Beijing (library of the Institute of Botany); and the Swedish Museum of Natural History .CR and EMF conducted data analyses and evolutionary interpretations. CR wrote the manuscript and EMF provided extensive contributions to the text. All authors read and approved the final manuscript.


In recent years, there has been increased interest in the vascular component of airway remodelling in chronic bronchial inflammation, such as asthma and COPD, and in its role in the progression of disease. In particular, the bronchial mucosa in asthmatics is more vascularised, showing a higher number and dimension of vessels and vascular area. Recently, insight has been obtained regarding the pivotal role of vascular endothelial growth factor (VEGF) in promoting vascular remodelling and angiogenesis. Many studies, conducted on biopsies, induced sputum or BAL, have shown the involvement of VEGF and its receptors in the vascular remodelling processes. Presumably, the vascular component of airway remodelling is a complex multi-step phenomenon involving several mediators. Among the common asthma and COPD medications, only inhaled corticosteroids have demonstrated a real ability to reverse all aspects of vascular remodelling. The aim of this review was to analyze the morphological aspects of the vascular component of airway remodelling and the possible mechanisms involved in asthma and COPD. We also focused on the functional and therapeutic implications of the bronchial microvascular changes in asthma and COPD. Bronchial vessels usually originate from the aorta or intercostal arteries, entering the lung at the hilum, branching at the mainstem bronchus to supply the lower trachea, extrapulmonary airways, and supporting structures. They cover the entire length of the bronchial tree as far as the terminal bronchioles, where they anastomose with the pulmonary vessels. The bronchial vessels also anastomose with each other to form a double capillary plexus. The external plexus, situated in the adventitial space between the muscle layer and the surrounding lung parenchyma, includes venules and sinuses, and it constitutes a capacitance system. The internal plexus, located in the subepithelial lamina propria, between the muscularis and the epithelium, is essentially represented by capillaries. These networks of vessels are connected by short venous radicles, which pass through the muscle layer structure. The bronchial submucosal and adventitial venules drain into the bronchial veins which drain into the azygos and hemiazygos veins -3.In normal airways, the bronchial microvasculature serves important functions essential for maintaining homeostasis. In particular, it provides oxygen and nutrients, regulates temperature and humidification of inspired air, as well as being the primary portal of the immune response to inspired organisms and antigens . The higDuring chronic inflammation, the vascular remodelling processes are the consequence of the prevalence of a pro-angiogenetic action, in which many growth factors and inflammatory mediators are involved . AccordiMost of the literature regarding bronchial vascular remodelling in chronic airway inflammation results from studies in asthmatic patients -15, sincEarly observations regarding bronchial vascular changes in asthmatic airways date back to the sixties and concern post-mortem analysis ,20. DunnAn increased blood flow has been shown in the airways of asthmatic patients, in comparison to healthy controls, by measuring dimethyl ether in exhaled air . CalculaActivation of pulmonary c-fibre receptors by irritants and inflammatory mediators may induce vasodilatation mainly via sympathetic motor nerves. Local axon reflexes in response to irritants and inflammatory mediators may release vasodilator neuropeptides such as substance P, neurokinins, and calcitonin gene-related peptides . ConsequIncreased microvascular permeability and oedema are common features during vascular remodelling in bronchial asthma . ElectroPlasma extravasations can compromise epithelial integrity and contribute to formation luminal mucus plugs . Plasma Vascular endothelial growth factor (VEGF) is a potent angiogenic factor, proven to be increased in asthma and correlated to the vascular permeability of airways -30, as wUnlike the pulmonary circulation, the bronchial vessels are known to have a considerable ability to proliferate during several pathological conditions. Leonardo da Vinci is generally regarded as the first person to observe, around a cavitatory lesion in human lung, the presence of vascular phenomena, that could be interpreted as angiogenetic processes . In the To explore and quantify the bronchial microvasculature, different methodological approaches are possible. Biopsy specimens from post-mortem resections provide considerable amounts of tissue with good clinical characterisation ,21. SimiImmunohistochemical analysis represents the gold standard approach to quantify bronchial microvascularity. The quantification of bronchial vessels generally includes the number of vessels per square millimetre of area analyzed, the vascular area occupied by the vessels, expressed as percentage of the total area evaluated, and the mean vessel size, estimated by dividing the total vascular area by the total number of vessels ,42,45,46Two studies used the monoclonal antibody against factor VIII and analyzed the entire submucosa, finding both an increase vascular areas and vessel dimensions in asthmatic patients in comparison to healthy controls ,21. FurtIn asthmatic patients, even with mild to moderate disease, a significant increase in the number of vessels and/or percent vascular area, as well as an increased average capillary dimension, can be observed in comparison to healthy controls ,42,45-47mRNA for VEGF receptors (R1 and R2) on bronchial endothelium in asthmatic patients versus normal subjects. Feltis et al. . Ho. Ho73]. The bulk of the literature regarding the pharmacological effects on the vascular component of airway remodelling has been obtained from studies in asthmatic patients. The efficacy of anti-asthma drugs on vascular remodelling is schematically presented in Table Less experimental evidence is available on the actions of long-acting β2 agonists (LABAs) and leukotriene receptor antagonists (LTRAs) on decreasing the vascular component of airway remodelling. Three months of treatment with salmeterol, in a placebo-controlled study, showed a significant decrease in the vascularity in the lamina propria of asthmatics . This maThere is a dearth of published data regarding the effect of current therapies for COPD on bronchial microvascularity. Recently, in a cross-sectional study on COPD patients, we found that, as compared to untreated patients, treated patients with long-term high doses of beclomethasone showed lower values of vascular area and lower expression of VEGF, bFGF, and TGFβ . FurtherFinally, several inhibitors of angiogenesis have been studied in vitro and consequently progressed to clinical studies. Some of them have shown promising results in lung cancer, but these molecules have not yet been investigated in chronic airway disease . In the In the last two decades there has been an increasing interest in the microvascular changes of bronchial airway mucosa during chronic inflammation, such as asthma and COPD. Up to now, the focus of researchers has been on asthma, while little work has been done in COPD. Moreover, the effects of smoking on bronchial microvascularity need better differentiation from the specific changes due to airflow obstruction.Although evidence suggests that there are vessel changes in the bronchial wall in both asthma and COPD, there are distinct differences in detail between these situations. Angiogenesis seems to be a typical finding in asthma, while, in COPD, little evidence supports the view that vasodilatation is prevalent.Microvascular changes in the bronchial airway mucosa are probably the consequence of the activities of many angiogenic factors, but VEGF seems to be crucially involved both in asthma and COPD, and different types of cells can play a role as the source of VEGF.The clinical and functional relevance of the vascular remodelling remains to be determined both in asthma and COPD; even if some reports suggest that the vascular component of airway remodelling may contribute to worsening of airway function.There are few data regarding the effects of current therapies on bronchial vascular remodelling. Some longitudinal studies were conducted in asthma, with biopsy quantification of vascular changes. These studies showed that inhaled corticosteroids could effectively act on vascular remodelling in asthmatic airways, partially reversing microvascular changes. Evidence from a cross-sectional study suggests also that long-term treatment with inhaled corticosteroids is associated with a reduction in airway microvascularity in COPD.Better knowledge about angiogenic processes and their consequences in the airway wall both in asthma and especially COPD are urgently needed, as well as new therapeutic strategies for these conditions.All authors have no competing interest. There was no funding provided for this manuscript.All authors participated in drafting the manuscript. All authors read and approved the final version of the manuscript.


Calcific tendinitis of the peroneus longus tendon is extremely rare, with only two cases described previously in the literature. Herein we discuss the diagnosis and management of a case with an acute calcific tendonitis of peroneus longus tendon. Periarticular painful calcification is most commonly seen within the rotator cuff of the shoulder, although it may develop around the hip, wrist, elbow, knee, forefoot and neck . The calA 32-year-old man  presented to our emergency department with a 24 hours history of increasing pain on the lateral aspect of his left foot. The patient was unable to bear weight on the affected side, but there was no history of trauma to the ankle. Also no medical history was mentioned.Clinical examination revealed localised tenderness proximal to the base of the fifth metatarsal, under the surface of the cuboid, in the line of the peroneus longus tendon, associated with warmth and redness. Although there was a full range of motion at the ankle, sub-talar and midfoot joint, but foot passive forced supination and active pronation under resistance produced pain exacerbation.A plain lateral radiograph showed homogeneous calcification at the lateral aspect of foot, under the surface of the cuboid in the line of the peroneus longus tendon . LaboratThe patient was treated with a single dose of steroid injection (3 mg Betamethasone Sodium Phosphate + 3 mg Betamethasone Dipropionate mixed with 3 ml xylocaine) delivered at the area of maximum tenderness, following by ankle rest. After injection, the patient obtained dramatic relief from pain and was discharged the next day.At review two weeks, 6 months and two years later the patient was remained without symptoms. A radiograph obtained after 6 months showed that the area of calcification had disappeared.Calcific tendinitis of the peroneus longus tendon is extremely rare, with only two cases described previously in the literature ,3.The differential diagnosis of calcification in the region of peroneus longus includes avulsion fractures, soft tissue infection, myositis ossificans and sesamoid bones in the tendon. The diagnosis of calcific tendonitis is strongly suggested in the absence of foot trauma, systemic septic symptoms, cerebrovascular injury and normal radiographic view of contralateral foot. Also a comet-tail appearance of the calcific deposit on plain x-rays suggests that it lies within a tendon .The exact mechanisms of the origin of the calcium deposits are not clearly understood. Healing of tendon injury by calcification, local stress necrosis directly or through fatty-acid and soap intermediaries and local hypoxia secondary to either mechanical or vascular factors have been proposed as causative factors .Brinsden and Wilson suggested that non-operative management, consisted of NSAID treatment and rest could lead to early clinical improvement . Cox and


The development and application of single neuron electroporation largely advanced the use of traditional genetics in investigations of the central nervous system. This quick and accurate manipulation of the brain at individual neuron level allowed the gain and loss of functional analyses of different genes and/or proteins. This manuscript reviewed the development of the technique and discussed some technical aspects in practical manipulations. Then the manuscript summarized the potential applications with this technique. Last but not least, the technique showed prospective future when combined with other modern methods in neuroscience research. Many strategies have been developed to introduce charged or non-charged compounds into cell cytoplasm, including chemically modified dyes or peptides to cross the cell membrane (e.g. penetrating peptides), viral vectors or lipocomplexes for gene introduction ,2. A maiElectroporation has, since the 1990 s, become a common laboratory technique for non viral transfection and molecule submission, however focused on bacteria or batch of cells in culture until the invention of in vivo electroporation - "modern electroporation". The most outstanding feature of this "modern electroporation" is the adoption of repeated charging with low voltage rectangular pulses, through which this approach could avoid the destroying currents to embryos or painful experiences to animals/human beings when high-voltage pulses were used. Developed on chick embryo ,11, in vin vitro, the process of which is similar to transfection of other cultured cells. People have succeeded in electroporation on isolated neurons or cultured neurons in vitro [Electroporation could be easily performed on isolated neurons in vitro -16. Thesin vitro ,18.In 2001, some neurophysiologists adopted micropipettes that have been used for electrophysiological recording for centuries to apply electrical pulses that electroporate plasmids into single neurons from the brain of intact Xenopus tadpoles or rat hippocampal slices in vivo . Since tet al. (2008) developed the method of shadow-patching/electroporation by loading dyes  in to extracellular spaces of neurons, thus creating contrast between "dark" neurons and "bright" backgrounds, for single neuron targeting and electroporation [During the process of "in ovo electroporation" (which means the electroporation on chicken embryo), Indian ink was injected under the chick embryo to create the shadow-contrast in visualizing the neural tube of the embryo. Similar ideas also emerged recently in single neuron electroporation on adult brain tissues. Because the two-photon microscopy requires pre-labeling of neurons with fluorescence protein, either by transgenic performance or viral-transfection; Kitamura poration . While tporation . This adin vitro electroporation and in vivo electroporation, the settings are completely different. The following paragraphs are going to address some most basic principles in setting up the single neuron electroporation system.The successful establishment of a single neuron electroporation system should consider variances caused by resistance of tissues or solutions in which neurons are suspended, the material nature of the electrodes, the molecular weight and charge of the substances to deliver, and most importantly, the endurance of the tissue to electrical currents. Furthermore, because of the different underlying principles of in vitro neuron electroporation largely depends on cell density, the proper voltage and pulse duration and the presence of calcium ions in buffer used for electroporation [9 forebrain neurons per ml), compared to other types of cells (e.g. 107 HeLa cells per ml) [2 can increase the survival rate as well as the transfection efficiency simultaneously. At the same time, a very high temperature generated by the electrical currents can lead to cell death, and a prior electroporation low-temperature incubation can help [The efficiency of poration -29. The poration . Put in  per ml)  (Though  per ml) , therefocan help . Finallyin vivo electroporation are largely different from what was described in last paragraph. For example, the chicken embryos were manipulated under 20-25 V with five 50 ms pulses [Parameters for s pulses , with a s pulses ,34. For s pulses . The vols pulses ,23,25,35Single neuron electroporation permits the transfection of multiple genes using plasmids at the same time, without the needs of production of several viral vectors . As an eOne obvious advantage of this approach is the possibility to perform electrophysiological or functional analyses shortly before and/or after the electroporation , given tAnother intriguing point for this technique is to label single neuron in vivo by loading fluorescent dyes or fluorescent protein-encoded proteins into the soma. This permits the identification of single neuron in vivo; it is also possible to image microstructure-based plasticity, for instance, by loading the neuron with calcium indicator fluorescent dyes -45. ThisThirdly, It is possible to increase the scale of electroporated area, simply by enlarging the tip diameter or changing the position of the micropipette, and perform repeated electroporation, leading to the sparse and random labeling of a subset of neurons near to the tips with a "Golgi-like staining" pattern . On the Because of the fact that neurons are difficult to transfect, electroporation provides one of the best approaches in non-viral transfection methods. Current advances on the understandings in principles of electroporation and electrophysiological techniques have facilitated the emergence and development of single neuron electroporation technique. Besides all the advantages of electroporation compared to other gene transfer methods discussed above, single neuron electroporation is the best approach so far for substance delivery at single neuron or circuit level.Electroporation was traditionally recognized as a way of substance delivery into the cell. Therefore one important standard in judging the application of single neuron electroporation is the variety of substances that can be delivered. In the past, dyes, heavy metal ions, genetic materials, proteins (including enzymes and antibodies), and many chemicals have been tested for their potential to be used in electroporation . The genIn the area of developmental neurobiology, single neuron electroporation can provide the unique chance for cell lineage analyses in brain development. Currently most available cell labeling methods such as the use of diffusion dyes lack the specificity of single cell labeling, and therefore are only used in a limited way for monitoring of batch cell migration. It is still hard to specify the interaction and communication of single neuron/neuroblast with other cells during its migration and specification following birth Figure . The manIn the area of neuroanatomy, the technique of loading fluorescent dyes into a single neuron without intracellular injection is exciting news for neuroanatomists who are interested in tracing single axon over long distances with high resolution imaging during development and regeneration  CurrentlThe amazing progresses in single neuron electroporation, however, have also left some unsolved problems. First of all, any approach that requires visualization for in vivo single neuron manipulations are currently limited by the depth of microscopy. Hopefully, with the facilities of multi-photon microscopy, or microendoscopy , people Secondly, parameters that maximize the submission of different molecules and cell viability simultaneously are currently limited, which could only be adopted from previous studies on optimal electroporation parameters in other systems. Thirdly, compared to intracellular injection, the loading of dyes through electroporation has the disadvantage of unknown intracellular dye concentration after dye loading , which bNone of the authors have actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations that could inappropriately influence, or be perceived to influence, our work.TFY and OAC designed, conducted the literature review and drafted most of the manuscript. MMG performed the literature review and the drafting of the manuscript. All authors were equally involved in reading and approving the final manuscript.


Pancreatic hypoplasia refers to underdevelopment of pancreatic parenchyma which arises from either the ventral or dorsal anlage. Pancreatic hypoplasia secondary to agenesis of the dorsal pancreas is a rare congenital anomaly, with less than 20 cases reported till date.2 Though A 45-year-old alcoholic, nondiabetic male patient with clinical hepatomegaly and an unremarkable past medical history came for ultrasonography of the abdomen. Laboratory tests, including blood glucose levels, HbAlc levels, liver function tests, and kidney function test were within normal limits.Ultrasonography revealed mild hepatomegaly with grade I fatty infiltration. The pancreas body and tail were not optimally visualized; however, the head of the pancreas appeared normal. The main pancreatic duct was not dilated.Contrast-enhanced computed tomography (CT) of the abdomen revealed complete absence of the neck, body, and tail of the pancreas . The heaBased on the clinical and CT findings, we arrived at the diagnosis of isolated, uncomplicated, agenesis of the dorsal pancreas or hypoplasia of the pancreas secondary to agenesis of the dorsal pancreas.Pancreatic hypoplasia refers to congenital underdevelopment of pancreas and is often referred to as partial agenesis of the pancreas; this agenesis can involve the ventral or dorsal anlage. The common clinical presentation is abdominal pain, which may be nonspecific or secondary to pancreatitis. Recurrent pancreatitis is quite common. Many patImaging in a case of agenesis of the dorsal pancreas reveals a short and truncated head of pancreas, with absence of the neck, body, and tail of the organ. Based on endoscopic retrograde cholangiopancreatography (ERCP), absence of the dorsal anlage is categorized as complete  and partial (when they are remnant). ERCP andImportant differential diagnoses are carcinoma of head of pancreas with secondary atrophy of the distal body and tail of pancreas, pancreatic lipomatosis (fatty replacement of pancreatic parenchyma), and pancreatic divisum. All can be differentiated easily by imaging. Treatment is not required in asymptomatic patients.


Cigarette smoking, one of the most pervasive habits in society, presents many well established health risks. While lung cancer is probably the most common and well documented disease associated with tobacco exposure, it is becoming clear from recent research that many other diseases are causally related to smoking. Whether from direct smoking or inhaling environmental tobacco smoke (ETS), termed secondhand smoke, the cells of the respiratory tissues and the lining pulmonary surfactant are the first body tissues to be directly exposed to the many thousands of toxic chemicals in tobacco. Considering the vast surface area of the lung and the extreme attenuation of the blood-air barrier, it is not surprising that this organ is the primary route for exposure, not just to smoke but to most environmental contaminants. Recent research has shown that the pulmonary surfactant, a complex mixture of phospholipids and proteins, is the first site of defense against particulates or gas components of smoke. However, it is not clear what effect smoke has on the surfactant. Most studies have demonstrated that smoking reduces bronchoalveolar lavage phospholipid levels. Some components of smoke also appear to have a direct detergent-like effect on the surfactant while others appear to alter cycling or secretion. Ultimately these effects are reflected in changes in the dynamics of the surfactant system and, clinically in changes in lung mechanics. Similarly, exposure of the developing fetal lung through maternal smoking results in postnatal alterations in lung mechanics and higher incidents of wheezing and coughing. Direct exposure of developing lung to nicotine induces changes suggestive of fetal stress. Furthermore, identification of nicotinic receptors in fetal lung airways and corresponding increases in airway connective tissue support a possible involvement of nicotine in postnatal asthma development. Finally, at the level of the alveoli of the lung, colocalization of nicotinic receptors and surfactant-specific protein in alveolar cells is suggestive of a role in surfactant metabolism. Further research is needed to determine the mechanistic effects of smoke and its components on surfactant function and, importantly, the effects of smoke components on the developing pulmonary system. Tobacco in various forms, as well as tobacco-related compounds such as marijuana, represent agents that present serious and insidious health risks to the general population. Both of these drugs have long and interesting histories. As this review is focused primarily on tobacco, marijuana use will be discussed only as it reflects on health effects resulting from both tobacco and marijuana. Tobacco use passed into Europe in the late sixteenth century after initial encounters between Europeans and native North and South Americans . TobaccoThe long history of both tobacco and marijuana as addictive drugs, their common routes of exposure, and their many common components make for an interesting dilemma in the health care field for both common and different reasons. On the one hand, the detrimental effects of cigarette smoking through both primary and secondary routes of exposure have become clear over the past few years . The lis2 by recent estimates [The pulmonary system which encompasses not only the lungs but the conducting airways, the nasal cavities, nasopharynx, oropharynx and larynx, is probably the most complex system in the body. This is due to the fact that the pulmonary system provides the most intimate interface with the external environment of any region of the body. The surface area of the lung tissue, approximately 120 mstimates -13, reprstimates . Some 40stimates . Their fstimates -17. Indestimates . Thus inBefore turning to a discussion of the interaction of tobacco smoke and related agents with the pulmonary surfactant system, it is important to have a conceptual knowledge of exactly what composes the lung surfactant. Therefore, we will begin our discussion in the form of a short review of what our latest concepts are concerning the surfactant, its composition and function. It should be noted, however, that this short review is not intended to be exhaustive as extensive reviews are available by acknowledged experts on pulmonary surfactant .Within the lung, an aqueous lining layer exists to varying degrees within the alveoli and intrapulmonary duct system . The comExcellent recent reviews of the biosynthesis, composition and functional contributions of the lipid components of the pulmonary surfactant are available ,24 and tThe pulmonary surfactant is composed of approximately 90% lipids ,26 with The defining characteristic of lung surfactant is its ability to generate very low surface tension at minimum expansion. Surface tension may be thought of as the force that resists expansion of a liquid . This isThe other surfactant phospholipid of particular note is phosphatidylglycerol (PG). This phospholipid is present at undetectable to very low levels in cells and is predominantly involved in synthesis of cardiolipin (di-phosphatidylglycerol) associated with the inner mitochondrial membrane . During Other minor phospholipids and neutral lipids exist in the pulmonary surfactant and while it is too early to dismiss their contributions as negligible, relatively few investigations into their functions have appeared. The reader is referred to recent reviews for more details ,55.+2-dependent proteins, both of which appear to originate from the surfactant-producing type II alveolar cell (see next section) and possibly the non-ciliated (Clara) cells of the bronchial epithelium [Four major proteins exist in the pulmonary surfactant. While they were recognized some years ago, it is only within the last few years that their functions have begun to be elucidated. Initially the proteins were thought to be derived in part from serum and there was considerable disagreement as to their number and function . Today iithelium . SP-A isithelium . It dispithelium . In lungithelium  while thithelium  dependinithelium ,62. The ithelium . Howeverithelium , restoreithelium  and mediithelium . Furtherithelium ,68, suggithelium ,69.SP-D, a collagenous 43 kDa glycoprotein secreted by type II alveolar cells , has alsThe remaining two surfactant proteins, SP-B and SP-C, are generally considered to be hydrophobic in nature and thus associate readily with the phospholipids of the surfactant. SP-B is expressed by both type II alveolar cells and the nonciliated bronchiolar epithelial Clara cells ,82. Its SP-C exists as a very non-polar α-helical protein of approximately 4.2 kDa composed of a mixture of isoforms (see review by Johansson ). It appSome 40 or more pulmonary cell types have been identified , making DPPC, as the primary phospholipid of the surfactant, is generally considered to display the surface tension characteristics required to withstand the high surface pressures that occur during the exhalation phase of the respiratory cycle . HoweverFrom the foregoing brief description of the pulmonary surfactant system, it is clear that the surfactant and its microenvironment present an extremely complex face, both in terms of composition and function, to any materials reaching the respiratory tissues. At the level of the air exchange tissue, the pulmonary surfactant presents the first interface encountered by inhaled smoke, whether from tobacco, marijuana or any other inhaled aerosolized material, for example fungal spores, mites or other allergens. Tobacco use and the potential for exposure to environmental tobacco smoke (ETS) has become an extremely important issue over the last several decades as it has become apparent that smoking carries with it a major and also preventable risk for the development of lung cancer. Lung cancer accounts for about 30% of all cancer deaths in men and 20% of all cancer deaths in women . In the Tobacco smoke contains between 2,000 and 4,000 agents  that mayStudies of the direct effects of tobacco smoke on pulmonary surfactant have been few. Several older studies ,140 suggSmoking appears to reduce the overall recovery by endobronchial lavage of surface active material and phosphatidylcholine in particular , althougSome changes have also been documented in other phospholipids. Specifically increases in phosphatidylethanolamine and sphingomyelin levels have been noted ,154 poss2 gas exposure, surfactant may improve mucociliary clearance from the bronchial tree [In addition to elevated numbers of alveolar macrophages , smokersial tree . Howeverial tree . This maial tree ,170. Altial tree . In any ial tree , the ultial tree , therebyial tree . What ovAt the molecular level, little is known about how smoke components interact with the surfactant either in the alveolus or at higher levels in the bronchial tree. Subramaniam and colleagues (1996) observed elevated levels of albumin in rat bronchoalveolar lavage following chronic cigarette smoke exposure  which haIn a limited series of experiments, freshly isolated rat alveolar type II cells appeared to undergo cell lysis after exposure to tobacco smoke . The impIn addition to the effects described above, some preliminary studies suggest cigarette smoke or smoke by-products affect the proteins of the pulmonary surfactant. Bronchoalveolar lavage samples from smokers and non-smokers showed reduced levels of SP-A and SP-D, standardized to lavage phospholipid levels  by ELISAMany other constituents of tobacco smoke may potentially alter or harm the pulmonary surfactant or type II cells. Of particular note, nitrogen dioxide, another constituent of tobacco smoke and a major environmental urban pollutant , has beeIt is generally accepted that surfactant deficiency, due to the immature nature of the surfactant-producing type II alveolar cells, is the main causative factor in the development of respiratory distress in prematurely delivered infants . However2, suggesting the pulmonary effects may vary according to the type and composition of the inhaled smoke [2 may have different effects as this compound appears to increase both the incorporation of precursors into surfactant phospholipids through enzyme activation, particularly CTP:cholinephosphate cytidylyltransferase, which regulates phosphatidylcholine synthesis [As noted above there is good evidence that smoking is associated with reduced surfactant phospholipids in the bronchoalveolar lavage . This maed smoke . Furtherynthesis ,201 and ynthesis ,202. In in utero to smoke [in utero and the postnatal period on the pulmonary surfactant is, however, not clear. In rat pups from smoke-exposed mothers and following postnatal sidestream exposure changes in dynamic compliance, reactivity to methacholine [Despite early observations that smoke exposure during pregnancy actually hastens pulmonary maturation ,204 whicto smoke . In factto smoke . These pto smoke , indicatto smoke . The ultacholine , and bioacholine . Howeverin utero [in utero induces altered lung mechanics in the fetus. However as they note, multiple binding sites for nicotine in developing lung, including the neuroendocrine cells, probably signifies a complex, multidimensional effect on the lung including such complex mechanisms as regulation of dichotomous branching, connection tissue interactions and muscle induction [While many agents in smoke may be detrimental to fetal development, some evidence supports a direct effect of nicotine on lung development suggesting that nicotine is capable of altering lung maturation. Nicotine crosses the human placenta with only minimal biotransformation to cotinine . It accuin utero . Changesin utero . Quantifin utero  suggestsin utero . Nicotinin utero ,240. Thenduction . Indeed nduction ,242.in vitro exposure of embryonic lung explants induced morphogenetic branching and enhanced expression of surfactant proteins A and C and the Clara cell-specific marker CC10 [While these studies overwhelming support the detrimental role for tobacco smoke exposure on prenatal and postnatal lung development and the overall well-being of the fetus, paradoxical evidence alluded to at the first of this section suggests that smoke-exposed fetuses display a state of advanced lung maturity ,204. Sucker CC10 . This acker CC10 . NeverthTobacco smoking, primarily through the use of cigarettes, was at one time a pervasive and accepted social habit. While use has declined to some extent in selected areas and the "acceptedness" of smoking, particularly in indoor environments, has similarly declined, exposure to tobacco smoke still remains a major health risk particularly in developing countries . Inhalatin vitro models will be necessary to establish smoke effects on lung function. This will enable characterization of the mechanisms by which agents in smoke potentially alter lung maturation, the developing respiratory tissues, and particularly the pulmonary surfactant.With regard to the developing fetus and fetal lung where the critical nature of the developmental process is underscored by the mortality levels due to respiratory distress, little question remains that smoking during pregnancy is detrimental. Altered fetal intracellular enzyme levels, receptor binding proteins and surfactant proteins are among some of the initial findings. Furthermore these changes are reflected in altered lung mechanics in the newborn which may extend into later periods of development and may compromise normal expansion and compliance during childhood. Clearly more research and application of markedly more sophisticated techniques as well as development of The authors declare that they have no competing interests.


An acromioclavicular joint cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the acromioclavicular joint. We present the case of an 81-year-old man affected by an acromioclavicular joint cyst, associated to a massive rotator cuff tear, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint. The mass was 7 × 2.5 cm in size and the overlying skin presented a fistula that drained clear synovial-like fluid. Plain X-ray examination of the left shoulder showed proximal migration of the humeral head migration and osteoarthritis of the gleno-humeral joint, and further MRI evaluation confirmed the clinical diagnosis of a complete rotator cuff tear and observed a large subcutaneous cyst in communication with the degenerative acromioclavicular joint. The patient underwent surgical excision of the cyst and lateral resection of the clavicle to prevent disease recurrence. To the best of our knowledge, this is the first reported case of an acromioclavicular joint cyst complicated by an aseptic fistula resulting from multiple aspirations. An acromioclavicular joint (ACJ) cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the ACJ and gleno-humeral joint .The most frequent presentation of this clinical entity is a painless, enlarging subcutaneous mass over the ACJ, which can often raise the suspicion of a tumor . On arthACJ cysts can be managed either conservatively  or surgically, with or without rotator cuff repair, depending on several factors like age of the patient, symptoms and general health condition -6.We report the case of man affected by an ACJ cyst associated to a massive rotator cuff tear that presented an aseptic cutaneous fistula secondary to multiple ultrasound-guided aspirations of the cyst.In November 2008 an Italian, Caucasian, 81-year-old male, a retired mason, presented to our outpatient clinic with a 1-year history of an enlarging subcutaneous mass over the left ACJ. The patient denied any previous shoulder trauma, but complained a long history of left shoulder discomfort during daily life activities. The patient had been submitted to four ultrasound-guided aspirations of the cyst and steroid injections by an interventional radiologist. After the final aspiration the patient complained recurrence of the cyst and formation of a fistula draining a slightly viscous serous fluid at the puncture site. On physical examination the mass was 7 × 2.5 cm in size, symmetric, firm, adherent to the superior aspect of the ACJ and non-tender on palpation . The ovePlain X-ray examination of the left shoulder showed ACJ degeneration, with acromioclavicular (AC) space narrowing and osteophyte formation, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint . FurtherIn view of the persistence of the cyst and the draining fistula the we decided to submit the patient to surgery, which confirmed clinical and MRI findings. The cyst and the fistula were completely excised and, given the impossibility to repair the massively torn rotator cuff, to avoid recurrence of the cyst, resection of 1 cm of the lateral clavicle was also performed . HistoloWithin three weeks from surgery function and range of motion of the operated shoulder returned to pre-operative levels. To date, the patient is asymptomatic and with no cyst recurrence.et al. proposed that the ACJ cyst is formed by a leakage of synovial fluid through the torn rotator cuff and into a degenerated ACJ [et al. proposed a theory according to which mechanical irritation of the ACJ from direct contact of the humeral head in presence of a torn rotator cuff may lead to cyst formation [ACJ cysts are rare clinical entities that seem to be secondary to traumas, connective tissue degeneration, and synovial extension from an adjacent joint -9. Althoated ACJ . The fluated ACJ . Nardiniormation .et al. and Takagishi et al. demonstrated success of conservative treatment in half of patients with rotator cuff tear [et al. performed aspiration and corticosteroid injection of a cyst without success in terms of avoiding recurrence of the lesion [et al. reported three ACJ cyst cases, one of which was treated with simple excision of the lesion that resulted in disease recurrence one year post-operatively [et al. managed four ACJ synovial cysts associated to gleno-humeral osteoarthritis and irreparable rotator cuff tear performing shoulder hemiarthroplasty, which proved to be an effective treatment [et al. performed excision of the cyst, acromioplasty and closure of the rotator cuff defect with a duramater allograft in a case of ACJ cyst associated to irreparable cuff tear with unsatisfactory functional results [et al. treated three patients with ACJ cysts and massive rotator cuff tears with excision of the cyst, removal of the distal clavicle end and synovectomy of the upper part of the pathological humeral-acromial joint [et al. besides excision of the cyst and lateral resection of the clavicle also repaired the torn cuff [2. Unfortunately, there is no study reporting medium/long-term results of patients affected by ACJ cysts who underwent surgical excision along with rotator cuff repair, acromioplasty, lateral resection of the clavicle or hemiarthroplasty.The literature reports very few cases of ACJ cysts, most of which have been treated surgically, especially if associated to shoulder symptoms ,7,10,12 uff tear ,14 Cvitae lesion . Similarratively . Groh et results . Le Huecal joint . At two-et al. and Postacchini et al. clearly stated that without addressing the underlying pathological process, treatment of ACJ cysts proves to be unpredictable [et al. who reported the successful follow-up at 1 year in a patient with a massive ACJ cyst [Treatment of ACJ cysts can be either conservative or surgical, according to symptoms, patient age, and shoulder function. In the presence of massive tear, few or no symptoms and good shoulder function in elderly patient conservative treatment is recommended. Conversely, patients with chronic shoulder pain and compromised shoulder function should be addressed to surgical treatment, to excise the cyst and possibly repair the torn cuff . Groh etdictable ,7. Nonetdictable ,5. This ACJ cyst .The present case reports an ACJ cyst in an elderly patient affected by rotator cuff arthropathy with negligible symptoms and a good function of the shoulder, that could be eligible for conservative treatment. However, the presence of a non-healing fistula draining synovial-like fluid, which significantly influenced quality of life of the patient, imposed an open surgical treatment. Hemiarthroplasty was not performed in view of the good function of the shoulder in absence of significant pain. To prevent cyst recurrence, we opted for lateral resection of the distal clavicle, in consideration of the irreparable rotator cuff tear.To the best of our knowledge, this is the first reported case of an ACJ cyst complicated by an aseptic fistula resulting from multiple aspirations. Although aspirations of the cyst have been reported in the literature , in viewAlso it is clear that the tendency is to surgically excise symptomatic ACJ cysts, along with the resection of the lateral clavicle. Although this procedure seems to be beneficial in terms of preventing disease recurrence, long-term follow-ups and report of more cases may help confirm the effectiveness of this surgical technique.


Allergen specific immunotherapy (SIT) is the practice of administering gradually increasing doses of the specific causative allergen to reduce the clinical reactivity of allergic subjects, and is the only treatment targeting the causes of hypersensitivity and not only the symptoms, as done by drugs. The traditional, subcutaneous immunotherapy (SCIT) was burdened by the problem of systemic reactions which may be sometimes severe and - though very rarely - even fatal. This was the background to develop non injections routes for SIT and particularly sublingual immunotherapy (SLIT), that emerged as a real treatment option for respiratory allergy.A number of studies was conducted to evaluate efficacy and safety of SLIT, the first meta-analysis - including 22 placebo-controlled trials - concluded for positive results in both issues, but the number of studies on children was too low to draw definite conclusions. Since then, many other studies became available and make possible to analyze SLIT in children in its well defined aspects as well as in sides still requiring more solid data. Allergen specific immunotherapy (SIT) is the practice of administering gradually increasing doses of the specific causative allergen to reduce the clinical reactivity of allergic subjects, and is the only treatment targeting the causes of hypersensitivity and not only the symptoms, as done by drugs . The traA number of studies was conducted to evaluate efficacy and safety of SLIT, the first meta-analysis - including 22 placebo-controlled trials - concluded for positive results in both issues, but the number of studies on children was too low to draw definite conclusions . Since tThe clinically efficacy of SLIT, as of SIT in general, is evaluated by the decrease in symptom scores of rhinitis and asthma and in consumption of symptomatic drugs. Many placebo-controlled studies are conducted on small patient populations and cannot achieve a reliable statistical significance, but their combined evaluation by the tool of meta-analysis is considered an adequate method to obtain more robust data . The resThe progressive increase in number of SLIT studies addressing the pediatric population made possible to perform specific meta-analyses and systematic reviews. The first systematic review included the studies up to June 2003, which were evaluated qualitatively, and concluded for low to moderate efficacy of SLIT only in children with house dust mite induced mild to moderate asthma . A meta-A further meta-analysis on SLIT in children was published in 2006 : in thisThe same group performed a meta-analysis on the efficacy of SLIT in allergic asthma, analyzing 9 studies on pediatric patients which included a total number of 441 patients, 232 actively treated and 209 placebo-treated . A signiA systematic review in the same year by Roder et al evaluating any form of immunotherapy in children concluded for no evidence of effectiveness in the subgroup of 11 studies on SLIT, but the review was based on analysis of each single study and not on pooling all data together [Actually, heterogeneity, which is mainly due to different scoring systems in the various studies. is a limit of meta-analysis. However, a data source alternative to meta-analysis are studies conducted on large numbers of patients that provide adequate statistical power. The recent preparations for SLIT in orosoluble tablet of grass pollen extract were evaluated on large populations, including 253 children treated by a one grass (Phleum pratense) extract , and 278All systematic revisions and meta-analysis found that the most common adverse events to SLIT, regardless the age, are local reactions in the oropharynx - with itching, tingling and swelling in the mouth - followed by local gastrointestinal reactions - with nausea, vomiting or diarrhea - and that systemic reactions such as asthma, rhinitis, or urticaria, are quite rare ,18-20. ASome studies addressed specific safety issues in children. SLIT was well tolerated using ultra-rush schedules - that reach the maintenance dose in a few hours  - and alConcerning SLIT with house dust mites extracts, a recent study (including both adults and children) reported a comparable safety and tolerability in patients treated continuously or intermittently, i.e. 2-month treatment alternate to-2 month suspension .As stated above, SLIT has clear evidence of efficacy and safety. Still, there are aspects influencing its clinical results, such as the compliance, or its prescription, such as the cost-effectiveness.According to established definitions, compliance is "The extent to which a patient's behavior matches the prescriber's advice" and adherence is "The extent to which the patient's behavior matches agreed recommendations from the prescriber" , and botIn a study on children treated with SLIT by an allergen extract in monodoses, parents were interviewed by unscheduled phone calls at the third and sixth month of SLIT and asked to count at once the remaining doses; a compliance rate higher than 75% was found in 85% of children at the third month and in 84% of children at the sixth month; the major cause of withdrawal (5.6% of cases) was the cost of treatment, while side effects accounted for 1.4% of stopping . In a stMany studies are available, recently reviewed, showing that SLIT provides economic advantage compared with drug treatment by bringing a better clinical outcome at a reduced cost or an extra benefit at a very acceptable extra cost . ConcernSLIT was successfully introduced in Europe mainly on safety grounds and in some countries, including Italy, is currently more frequently employed than SCIT. The analysis of the abundant literature supports the use of SLIT in children with rhinitis and asthma caused by sensitization to seasonal allergens, while further studies are needed to demonstrate a full effectiveness in sensitization to perennial allergens. Favourable data obtained from studies on compliance and cost-effectiveness make SLIT a feasible treatment for treatment with respiratory allergy.The authors declare that they have no competing interests.All author participated equally in reviewing the literaure, discussing data and drafting the manuscript. All authors read and approved the final manuscript.


The digestion of purified proteins in simulated gastric fluid typically progresses in an exponential fashion allowing persistence to be quantified using pseudo-first-order rate constants or half lives. However, the persistence of purified proteins in simulated gastric fluid is a poor predictor of the allergenic status of food proteins, potentially due to food matrix effects that can be significant in vivo. The evaluation of the persistence of novel proteins in whole, prepared food exposed to simulated gastric fluid may provide a more correlative result, but such assays should be thoroughly validated to demonstrate a predictive capacity before they are accepted to predict the allergenic potential of novel food proteins.Food allergies affect an estimated 3 to 4% of adults and up to 8% of children in developed western countries. Results from  The adult human gastrointestinal tract (GI) is a tube approximately 9 meters long, running through the body from the mouth to the anus. The lumen of the GI tract is continuous with the external environment, keeping its contents outside of the rest of the body. The epithelial layer, which lines the interior of the GI tract, presents a partial barrier to invasion by ingested pathogens, parasites, toxins and antinutrients. If pathogens, toxins and food proteins breach the epithelium barrier, the immune system acts as our primary defense system. Antibodies are formed that specifically react with epitopes on certain antigenic proteins, and subsequent binding of subtypes of these antibodies to proteins can result in the mobilization of host defenses, including deleterious responses like allergy.The GI tract helps prevent food antigen penetration through its gut epithelial barrier. Epithelial cells are joined together with their neighbors via tight junctions and mucus produced by goblet cells . In the Despite these host defense mechanisms, antigens can be absorbed and distributed in the body. Intact food proteins can be detected in plasma -6 and guFailure of oral tolerance leading to food allergies is most often due to an IgE-mediated hypersensitivity to a small subset of proteins found in milk, eggs, peanuts, fish, shellfish, soy, wheat and tree nuts . TypicalThe exact site of food absorption and allergy induction is still unknown. It is believed that most food allergens are absorbed in the intestines, prior to initiating an immune response, requiring proteins to move through the stomach in an immunologically intact form. Food protein can also enter the circulation through the oral mucosa ,17. CertThe majority of ingested food proteins break down as they travel through the GI tract. This occurs through the processes of digestion, where the food is exposed to the denaturing environment of hydrochloric acid in the stomach, bile from the liver and digestive enzymes released by the salivary glands, chief cells in the stomach, and the pancreas. The proteases and peptidases produced and secreted by chief cells and the pancreas digest proteins into small peptides typically less than 8 amino acids in size . This exin vitro digestion experiments have been considered to assess the allergenic potential of new food proteins. In this paper, we review the influence of gastric digestion on the development of food allergy, and evaluate the currently applied digestion assays for testing the allergenic potential of novel food proteins. We start by defining a food allergen, and then discuss the standard simulated gastric fluid digestion (SGF) assay currently used to assess allergenic potential of food proteins. We found that results from SGF assays with pure proteins are not a good predictor of the allergenic potential of food proteins, but rather that they simply measure the resistance of purified food proteins to in vitro digestion. Moreover resistance to SGF is not a sufficient or useful criterion for evaluating food allergen sensitization or induction.Based on the relationship between GI digestion and food allergy, results of Before we discuss the use of digestion experiments for predicting the allergenic potential of food proteins, we must define a "food allergen". This term is general and ambiguous. Food allergens have at least three potential attributes:(1) Induction of allergic sensitization.(2) Reaction with IgE antibodies(3) Induction of allergic reactions.The food proteins which do all three of the above are known as complete food allergens , while tDigestion assays in simulated gastric fluid (SGF) are commonly employed to predict the allergenic potential of food proteins -31, and As a result of the Astwood et al.  report, Pepsin is an aspartic protease generated from the auto-cleavage of pepsinogen under the acidic conditions in the stomach. Pepsin has broad substrate specificity, preferentially cleaving proteins at leucine, phenylalanine and tyrosine . PepsinoThe analytical tool generally used to track the digestion of substrate protein in SGF is sodium dodecyl polyacrylimide gel electrophoresis (SDS-PAGE). SDS-PAGE separates denatured proteins on polyacrylamide gels based primarily on molecular mass, and thus does not distinguish enzyme-bound from non-bound substrate. Proteins are visualized by staining with various dyes such as colloidal Coomassie brilliant blue. While the density of stained bands is generally directly proportional to the protein concentration for any given protein ,44,45, dIn some cases, discrete smaller-molecular-weight protein fragments appear, and sometimes disappear, as digestion progresses ,47. ThesThe SGF assays can produce complex patterns of digestions in SDS-PAGE gels. These patterns revolve around the multiple cleavage sites on the protein substrate rather than from the presence of multiple enzymes or compartments. However, the digestion of the substrate protein generally follows an exponential decline.in vitro protein-protease systems [The SGF assay is similar to other dissipation experiments, which are conducted to track the disappearance of substrates in complex systems. One example is the tracking of pest-control substances in soil. Microbial digestion of compounds, via many enzymes, in soil often predominates in such systems, and in spite of the complexity of the processes, dissipation of substrate often closely follows a negative exponential pattern ,50. Simi systems , particu systems  and peps systems ,54. The  systems . The pro systems ,47,56,57There are four possible explanations for the biphasic and pseudo-first order decay pattern observed in proteolysis experiments: (i) Protein digestion is dominated by a first-order rate-limiting step. A possible rate-limiting step can be the acid-induced unfolding of the protein under the low pH (1.2) of SGF ,58. UnfoWhile the predictive power of the SGF assay has been promulgated in a number of papers -31, and in vitro and in vivo. Similarly, Chikwamba et al. [Escherichia coli heat-labile enterotoxin facilitated the association of this protein with starch granules that protected it against digestion in SGF. Thus the evaluation of purified proteins in the SGF assay may be misleading.Likely reasons for the poor predictive capability of this assay include a lack of consideration of the prevalence of the allergen in food, effects of food processing, and food-matrix interactions -73. The a et al.  found thin vitro, unless the digestion process is inhibited by antacid medication [Also there are a number of complete or potent allergens which are not stable in SGF assays ,66,74, bdication . In the dication . A similFood allergies are complex, and can be the result of complex interactions. There are also food allergens which can only cause symptoms under cross-reactivity conditions. For example, pollen-allergic patients frequently present food allergies after the ingestion of several plant foods . On the in vivo digestion of an allergenic food protein increases its potential for causing an allergic reaction in susceptible individuals. We also know that some peptide fragments of digested proteins can be recognizable by allergen-specific T cells. However, the amount of food protein and the condition under which can trigger the allergic reaction are largely unknown [Although the value of comparing the stability of proteins in SGF for the purpose of evaluating the allergenic potential of novel food proteins is dubious, such comparisons are routinely used for this purpose. The nature of allergy to food proteins is still unknown. At the moment, we know that the resistance to  unknown .The limitations of the SGF assays for predicting the allergenic potential are becoming apparent to the food allergy community ,65,66,74in vitro digestion [in vitro measure of the persistence of food proteins.A kinetic approach to measuring SGF digestion is currently the most reasonable method to quantitatively compare the persistence of purified food proteins during igestion ,47,54,56in vivo persistence of food proteins. The proteolysis of food proteins can be affected as a result of processing and interaction with food ingredients. For example, β-lactoglobulin proteolysis by trypsin and chymotrypsin is reduced in the presence of polysaccharides such as gum arabic, low methylated pectin or xylan [in vitro [Apart from the quantitative estimates of protein persistence, other aspects of the SGF assay protocol can also be improved. The evaluation of the persistence of novel proteins in whole, prepared food exposed to SGF  may provor xylan . Peanut or xylan . Finallyor xylan ,84,86. Tin vitro . Some ofin vitro .in vitro provides little value in the absence of evidence that a particular protein can induce IgE antibodies or elicit an allergic response. The allergenic potential of a food can only be diagnosed through sensitive analytical methods which recognize the presence of allergenic antigens in food. For novel food proteins, where populations of allergic individuals are absent or limited, results from SGF assays with pure proteins are of little value in predicting allergenicity. Continued work on new animal models of sensitization for food proteins will be of critical importance for accurately predicting the allergenicity of novel food proteins [in vitro and isolating peptide fragments with potential allergenic epitopes. Therefore the assessment of food allergen requires the use of both digestion and immunology assays as a means to ensure consumer safety to food proteins.We emphasize that the persistence to SGF proteins . SGF assSS declares that he has no competing interests. RAH is employed by Dow AgroSciences LLC which develops and markets agricultural products, including transgenic crops.SS and RH collaborated on the conceptualization and preparation of the manuscript equally.


L) and dynamic compliance (Cdyn); measurement of low-frequency forced oscillations (LFOT)) and noninvasive technologies in conscious animals . Outlined are the technical principles, validation and applications as well as the strengths and weaknesses of each methodology. Reviewed is the current set of invasive and noninvasive methods of measuring murine pulmonary function, with particular emphasis on practical considerations that should be considered when applying them for phenotyping in the laboratory mouse.The widespread use of genetically altered mouse models of experimental asthma has stimulated the development of lung function techniques in vivo to characterize the functional results of genetic manipulations. Here, we describe various classical and recent methods of measuring airway responsiveness in vivo including both invasive methodologies in anesthetized, intubated mice (repetitive/non-repetitive assessment of pulmonary resistance (R The widespread use of genetically altered mouse models of experimental asthma has stimulated the development of lung function techniques in vivo to characterize the functional results of genetic manipulations. The ability to determine in vivo the respiratory function in laboratory mice is of great interest because of the prominent role played by these animals in biomedical, pharmacological and toxicological research. Mice are, at present, the preferred species used as an experimental model of allergic airway disease. This is largely due to a number of advantages including a well characterized genome and immune system, short breeding periods, the availability of inbred and transgenic strains, suitable genetic markers, the ability to readily induce genetic modifications and pragmatically, relatively low maintenance costs. The development of viable mouse models has largely contributed to a better understanding of the pathomechanisms underlying allergic airway inflammation and airway hyperresponsiveness (AHR) -3.To fully explore the value of mouse models of experimental asthma, however, it is necessary to develop sensitive physiological methodologies that allow the quantitative assessment of airway responsiveness in intact organisms. Measurement of pulmonary function in mice clearly presents significant challenges due to the small size of their airways. In recent years, considerable progress has been made in developing valid and suitable measures of mouse lung function. Accordingly, several different invasive and noninvasive lung function techniques have been developed to characterize the phenotype of experimental models of lung disease -7. TableIt is important to recognize that each approach represents a compromise between accuracy, noninvasiveness, and convenience. As a result, a correlation exists between the invasiveness of a measurement technique and its precision . The lesL) or dynamic compliance (Cdyn) is the classical method for accurate and specific determination of pulmonary mechanics. RL is the sum of airway (Raw) and tissue (Rti) resistance, which are fairly comparable at normal breathing rate. Drawbacks of conventional invasive methodologies particularly include the surgical instrumentation of the trachea thus often excluding the practicality of repeated measurements. Modifications of the invasive approach involving orotracheal intubation, however, now have enabled repetitive monitoring of pulmonary mechanics in anesthetized, spontaneously breathing mice  that is directly related to airway resistance, thus enabling quantitative interpretation of airway changes between animals [Validation studies in mice have demonstrated that the decline in EFe (Cdyn) . The EF5c agents ,39,48-54 animals . In prin animals .50 may underestimate the magnitude of bronchoconstriction [50 measurements should be confirmed by more direct assessments of pulmonary resistance. Table 50 measurements.Concerns include the uncertainty about the potential contribution of upper airway resistance. To minimize effects of restraint stress on responses, monitoring of respiratory function should not be started until animals and individual measurements have settled down to a stable level. Because it has been shown that EFtriction ,10 it isIn this manuscript we have tried to provide a review of the advantages and disadvantages of different methods of assessing pulmonary function in mice. Although mice may be far from perfect models of human lung disease, the advantages of using mouse models has made them the choice for many experimental studies, e.g. experimental asthma. In these models measuring lung function and particularly airway responsiveness is a major outcome parameter. To this end it is critically important to have suitable methods of phenotyping lung function. Although many of the methodologies for measuring pulmonary function have been developed, there are important limitations and considerations such as expertise, technical difficulty of the procedure, and costs, which should be recognized when applying them in the mouse. Unfortunately, at the present time, there is no gold standard for measuring lung function in mice, since none of the available methods is optimal in all regards. Some investigations require more detailed measurement of the individual mechanical properties, and these studies normally require invasive determination of pulmonary mechanics. The ability to make longitudinal measurements in intact conscious mice, however, allows investigators to make use of more powerful statistics with smaller numbers of animals. We have discussed the merits of several of these approaches that may be useful for investigators requiring this approach. In particular in situations where the measurements are applied to develop a potential therapeutic or clinical trial design, these should always be confirmed by the more conservative invasive methodologies.The author(s) declare that they have no competing interests.TG and CT conceived of the review and drafted the manuscript, AB helped to draft the manuscript, WM helped to draft, discuss and revise the manuscript. All authors read and approved the final manuscript.