Macroreplantations of the upper extremity: a series of 11 patients

INTRODUCTION Micro- or macroreplantation is classified depending on the level of amputation, distal or proximal to the wrist. This study was performed to review our experience in macroreplantation of the upper extremity with special attention to technical considerations and outcomes. MATERIALS AND METHODS Between January 1990 and December 2010, 11 patients with a complete amputation of the upper extremity proximal to the wrist were referred for replantations to our department. The patients, one woman and ten men, had a mean age of 43.4 ± 18.2 years (range 19-76 years). There were two elbow, two proximal forearm, four mid-forearm, and three distal forearm amputations. The mechanism of injury was crush in four, crush-avulsion in five and guillotine amputation in two patients. The Chen classification was used to assess the postoperative outcomes. The mean follow-up after macroreplantation was 7.5 ± 6.3 years (range 2-21 years). RESULTS All but one were successfully replanted and regained limb function: Chen I in four cases (36 %), Chen II in three cases (27 %), Chen III in two cases (18 %), and Chen IV in one patient (9 %). We discuss the steps of the macroreplantation technique, the need to minimize ischemic time and the risk of ischemia reperfusion injuries. CONCLUSION Thanks to improvements in technique, the indications for limb preservation after amputation can be expanded. However, because of their rarity, replantations should be performed at specialist replantation centers. LEVEL OF EVIDENCE Level IV.

The role of Lmx1b in the control of dorsoventral compartmentalization in the distal mesenchyme of the developing mouse limb

Lmx1b encodes a LIM-homeodomain transcription factor required for dorso-ventral (D-V) patterning in the mesenchyme of the vertebrate limb. In the absence of Lmx1b function, limbs exhibit a bi-ventral pattern indicating that Lmx1b is required for cells to adopt a dorsal cell fate. However, how Lmx1b specifies dorsal cell fates in the mesenchyme of the distal limb is unknown. Lmx1b is initially expressed throughout the dorsal and ventral limb bud mesenchyme, then becomes dorsally restricted around E10.5. At this stage, there is a sharp boundary between Lmx1b expressing and Lmx1b non-expressing cells. How the dorso-ventral Lmx1b expression boundary is formed and maintained is currently unknown. One mechanism that may contribute to establishing and/or maintaining the Lmx1b expression boundary is if the dorsal mesenchyme is a lineage-based compartment, where different groups of non-mingling cells are separated. Compartment formation has been proposed to rely on compartment-specific selector gene activity which functions to restrict cells to a compartment and specifies the identity of cells within that compartment. Based on the evidence that the dorsal limb identity relies on the expression of Lmx1b in the dorsal half of the limb mesenchyme, we hypothesized that Lmx1b might function as a dorsal limb bud mesenchyme selector gene to set up a dorsal compartment. To test this hypothesis, we developed an inducible CreERT2/ loxP based fate mapping approach that permanently marks Lmx1b wild-type and mutant cells and examined the distribution of their descendents in the developing limb. Our data is the first to show that dorso-ventral lineage compartments exist in the limb bud mesenchyme. Furthermore, Lmx1b is required for maintenance of the dorso-ventral compartment lineage boundary. The behavior of Lmx1b mutant cells that cross into the ventral mesenchyme, as well as previous chimera analysis in which mutant cells spread evenly in the ventral limb and form patches in the dorsal side, suggest that cell affinity differences prevent intermingling of dorsal and ventral cells. ^

A Xenopus distal-less gene in transgenic mice: conserved regulation in distal limb epidermis and other sites of epithelial-mesenchymal interaction.

In this paper, we show the conserved regulation of the homeodomain gene Distal-less-3 (Dlx-3) by analyzing the expression of a promoter from the Xenopus ortholog, Xdll-2, in transgenic mice. A 470-bp frog regulatory sequence confers appropriate expression on a lacZ reporter gene in the ectodermal component of structures derived from epithelial-mesenchymal interactions. Remarkably, this includes structures absent in Xenopus, such as the hair follicle and mammary gland, suggesting that conserved regulatory elements can be used to control the formation of structures peculiar to individual species. In addition, expression of Dlx-3 in developing limbs is highest at the most distal portion. This pattern is duplicated by the Xenopus promoter, indicating that this DNA may include sequences responsive to conserved proximodistal patterning signals in the vertebrate limb.

Ectopic Meis1 expression in the mouse limb bud alters P-D patterning in a Pbx1-independent manner

During limb development, expression of the TALE homeobox transcription factor Meis1 is activated by retinoic acid in the proximal-most limb bud regions, which give rise to the upper forelimb and hindlimb. Early subdivision of the limb bud into proximal Meis-positive and distal Meis-negative domains is necessary for correct proximo-distal (P-D) limb development in the chick, since ectopic Meis1 overexpression abolishes distal limb structures, produces a proximal shift of limb identities along the P-D axis, and proximalizes distal limb cell affinity properties. To determine whether Meis activity is also required for P-D limb specification in mammals, we generated transgenic mice ectopically expressing Meis1 in the distal limb mesenchyme under the control of the Msx2 promoter. Msx2:Meis1 transgenic mice display altered P-D patterning and shifted P-D Hox gene expression domains, similar to those previously described for the chicken. Meis proteins function in cooperation with PBX factors, another TALE homeodomain subfamily. Meis-Pbx interaction is required for nuclear localization of both proteins in cell culture, and is important for their DNA-binding and transactivation efficiency. During limb development, Pbx1 nuclear expression correlates with the Meis expression domain, and Pbx1 has been proposed as the main Meis partner in this context; however, we found that Pbx1 deficiency did not modify the limb phenotype of Msx2:Meis1 mice. Our results indicate a conserved role of Meis activity in P-D specification of the tetrapod limb and suggest that Pbx function in this context is either not required or is provided by partners other than Pbx1.

Multiple Myeloma Presenting with Distal Limb Gangrene: An Odd Case Report

Multiple myeloma (MM) is a plasmocytic malignant proliferation of a single clone resulting in an overabundance of monoclonal immunoglobulins. MM commonly presents with bone disorders, renal failure, anaemia and hypercalcaemia. Hyperviscosity syndrome is rare, as are vaso-occlusive symptoms. The authors report a dramatic case of an 80-year-old woman admitted to the emergency department with full-blown distal gangrene. The culprit turned out to be a MM, unusually presenting with symptomatic hyperviscosity and peripheral occlusive ischaemia. This catastrophic and particularly dramatic presentation is almost unprecedented, with only a few cases reported worldwide.

Distal limb osteoarthritis in the horse

The aim of this thesis was to study two objective methods of osteoarthritis (OA) diagnosis in horses and use them on the assessment of new intra-articular treatments. The studied methods were a new inertial-sensor based system of lameness detection and cartilage biomarkers in serum. It was found that distal limb flexion is significantly correlated to the presence of metacarpo-phalangeal OA in hind limbs and that inertial-sensors are sensitive in detecting asymmetry in these cases. A positive and significant correlation was observed between Coll2-1 concentration in serum and the presence of joint disease in males and young horses. Fib3-2 measurement has good potential to be used since it is not influenced by sex or age. Using an experimental model of OA, adipose stem cells pre-activated with interferon-gamma decreased joint inflammation and radiographic lesions. In clinical cases, a single injection of high-concentrated and high-molecular weight hyaluronic-acid decreased joint inflammation and biomarkers’ concentration; OSTEOARTRITE DO MEMBRO DISTAL NO CAVALO Resumo: A finalidade desta tese foi estudar dois métodos de diagnóstico objetivo de osteoartrite (OA) em equinos e aplicá-los na avaliação de novas terapias intra-articulares. Utilizou-se um sistema de sensores de movimento e foi avaliada a concentração de biomarcadores de cartilagem no soro. Concluiu-se que a flexão distal positiva está correlacionada com OA na articulação metacarpofalângica nos membros posteriores e que os sensores são sensíveis na detecção de assimetria nestes casos. Existe uma correlação positiva e significativa entre as concentrações de Coll2-1 e a presença de doença articular, sobretudo em machos e jovens. A dosagem de Fib3-2 tem utilidade por não ser influenciada pelo sexo nem idade. Num modelo experimental da doença, a terapia à base de células estaminais reduziu a inflamação articular e as lesões radiográficas. Em casos clínicos, o tratamento com ácido-hialurónico de alta concentração e peso molecular provoca uma diminuição da inflamação articular e dos biomarcadores no soro.

In Vitro Surfactant and Perfluorocarbon Aerosol Deposition in a Neonatal Physical Model of the Upper Conducting Airways

Objective: Aerosol delivery holds potential to release surfactant or perfluorocarbon (PFC) to the lungs of neonates with respiratory distress syndrome with minimal airway manipulation. Nevertheless, lung deposition in neonates tends to be very low due to extremely low lung volumes, narrow airways and high respiratory rates. In the present study, the feasibility of enhancing lung deposition by intracorporeal delivery of aerosols was investigated using a physical model of neonatal conducting airways. Methods: The main characteristics of the surfactant and PFC aerosols produced by a nebulization system, including the distal air pressure and air flow rate, liquid flow rate and mass median aerodynamic diameter (MMAD), were measured at different driving pressures (4-7 bar). Then, a three-dimensional model of the upper conducting airways of a neonate was manufactured by rapid prototyping and a deposition study was conducted. Results: The nebulization system produced relatively large amounts of aerosol ranging between 0.3 +/- 0.0 ml/min for surfactant at a driving pressure of 4 bar, and 2.0 +/- 0.1 ml/min for distilled water (H(2)Od) at 6 bar, with MMADs between 2.61 +/- 0.1 mu m for PFD at 7 bar and 10.18 +/- 0.4 mu m for FC-75 at 6 bar. The deposition study showed that for surfactant and H(2)Od aerosols, the highest percentage of the aerosolized mass (similar to 65%) was collected beyond the third generation of branching in the airway model. The use of this delivery system in combination with continuous positive airway pressure set at 5 cmH(2)O only increased total airway pressure by 1.59 cmH(2)O at the highest driving pressure (7 bar). Conclusion: This aerosol generating system has the potential to deliver relatively large amounts of surfactant and PFC beyond the third generation of branching in a neonatal airway model with minimal alteration of pre-set respiratory support.

Is perception of upper body orientation based on the inertia tensor? Normogravity versus microgravity conditions

During lateral leg raising, a synergistic inclination of the supporting leg and trunk in the opposite direction to the leg movement is performed in order to preserve equilibrium. As first hypothesized by Pagano and Turvey (J Exp Psychol Hum Percept Perform, 1995, 21:1070-1087), the perception of limb orientation could be based on the orientation of the limb's inertia tensor. The purpose of this study was thus to explore whether the final upper body orientation (trunk inclination relative to vertical) depends on changes in the trunk inertia tensor. We imposed a loading condition, with total mass of 4 kg added to the subject's trunk in either a symmetrical or asymmetrical configuration. This changed the orientation of the trunk inertia tensor while keeping the total trunk mass constant. In order to separate any effects of the inertia tensor from the effects of gravitational torque, the experiment was carried out in normo- and microgravity. The results indicated that in normogravity the same final upper body orientation was maintained irrespective of the loading condition. In microgravity, regardless of loading conditions the same (but different from the normogravity) orientation of the upper body was achieved through different joint organizations: two joints (the hip and ankle joints of the supporting leg) in the asymmetrical loading condition, and one (hip) in the symmetrical loading condition. In order to determine whether the different orientations of the inertia tensor were perceived during the movement, the interjoint coordination was quantified by performing a principal components analysis (PCA) on the supporting and moving hips and on the supporting ankle joints. It was expected that different loading conditions would modify the principal component of the PCA. In normogravity, asymmetrical loading decreased the coupling between joints, while in microgravity a strong coupling was preserved whatever the loading condition. It was concluded that the trunk inertia tensor did not play a role during the lateral leg raising task because in spite of the absence of gravitational torque the final upper body orientation and the interjoint coupling were not influenced.

Patterns of faunal change at an upper Cambrian trilobite extinction event, Nolichucky Formation, Tennessee and Virginia

During the Upper Cambrian there were three mass extinctions, each of which eliminated at least half of the trilobite families living in North American shelf seas. The Nolichucky Formation preserves the record of one of these extinction events at the base of the Steptoean Stage. Sixty-six trilobite collections were made from five sections In Tennessee and Virginia. The lower Steptoean faunas are assigned to one low diversity, Aphelaspis-dominated biofacies, which can be recognized in several other parts of North America. In Tennessee, the underlying upper Marjuman strata contain two higher diversity biofacies, the Coosella-Glaphyraspis Biofacies and the Tricrepicephalus-Norwoodiid Biofacies. At least four different biofacies are present in other parts of North America: the Crepicephalus -Lonchocephalus Biofacies, the Kingstonia Biofacies, the Cedaria Biofacies, and the Uncaspis Biofacies. A new, species-based zonation for the Nolichucky Formation imcludes five zones, three of which are new. These zones are the Crepicephalus Zone, the Coosella perplexa Zone, the Aphelaspis buttsi Zone, the A. walcotti Zone and the A. tarda Zone. The Nolichucky Formation was deposited within a shallow shelf basin and consists largely of subtidal shales with stormgenerated carbonate interbeds. A relative deepening is recorded In the Nolichucky Formation near the extinction, and is indicated In some sections by the appearance of shale-rich, distal storm deposits above a carbonate-rich, more proximal storm deposit sequence. A comparable deepening-upward sequence occurs near the extinction in the Great Basin of southwestern United States and in central Texas, and this suggests a possible eustatic control. In other parts of North America, the extinction IS recorded In a variety of environmental settings that range from near-shore to slope. In shelf environments, there is a marked decrease in diversity, and a sharp reduction in biofacies differentiation. Although extinctions do take place in slope environments, there IS no net reduction in diversity because of the immigration of several new taxa.

Desmite dos Ligamentos Colaterais da Articulação Interfalângica Distal em Equinos

Os objectivos deste estudo basearam-se na análise dos aspectos clínicos de cavalos de desporto, aos quais foi diagnosticado através de ecografia, desmite dos Ligamentos Colaterais (LCs) da articulação Interfalângica Distal (IFD). Os cavalos incluídos na amostra foram examinados entre Setembro de 2011 e Junho de 2012 tendo sido selecionados aqueles que apresentaram os critérios de inclusão requeridos, nomeadamente o diagnóstico de desmite em pelo menos um dos LCs da articulação IFD. Foram incluídos 8 animais no estudo, sendo que o diagnóstico foi feito através de um cuidadoso exame ortopédico e de ecografia, tendo-se verificado as lesões nos membros anteriores. O LC Lateral foi o mais afectado (5 cavalos) seguido do Medial (2 cavalos). Apenas em 1 dos casos as lesões eram bilaterais. A maioria dos animais apresentavam distensão da articulação IFD confirmada ecograficamente. A claudicação foi invariavelmente exacerbada em círculo no piso duro, sendo que 7 dos 8 (87.5%) animais aumentaram o grau de claudicação quando o membro afectado estava no interior do círculo. Após o bloqueio digital palmar a claudicação foi atenuada em 7 dos 8 animais (87.5%) sendo totalmente abolida em 3 (37.5%) deles. O bloqueio da articulação IFD foi positivo em todos os animais, e o bloqueio da bursa podotroclear negativa em 7 dos 8 cavalos. Metade dos animais (50%) apresentaram alterações radiográficas como osteoartrite da articulação IFD, remodelação óssea da origem/inserção do LC afectado e um deles apresentava ossificação de uma cartilagem ungular. Todos os animais apresentaram sinais evidentes de lesão na ecografia, sendo que alguns demostraram sinais de desmite crónica e outros aguda. Os tratamentos instituídos variaram de acordo com a história, sinais clínicos, sinais radiográficos e severidade das lesões ecográficas. A desmite dos LC da articulação IFD deve ser considerada como uma causa de claudicação que afecta a performance dos cavalos de desporto. Mais estudos são necessários, de modo a caraterizar melhor estas lesões e avaliar as melhorias após a terapia por forma a determinar os factores que mais influenciam o prognóstico. Palavras-Chave: Equinos, Ligamentos colaterais, Desmite, articulação Interfalângica distal

Four-dimensional variational assimilation of ozone profiles from the Microwave Limb Sounder on the Aura satellite

Ozone profiles from the Microwave Limb Sounder (MLS) onboard the Aura satellite of the NASA's Earth Observing System (EOS) were experimentally added to the European Centre for Medium-range Weather Forecasts (ECMWF) four-dimensional variational (4D-var) data assimilation system of version CY30R1, in which total ozone columns from Scanning Imaging Absorption Spectrometer for Atmospheric CHartographY (SCIAMACHY) onboard the Envisat satellite and partial profiles from the Solar Backscatter Ultraviolet (SBUV/2) instrument onboard the NOAA-16 satellite have been operationally assimilated. As shown by results for the autumn of 2005, additional constraints from MLS data significantly improved the agreement of the analyzed ozone fields with independent observations throughout most of the stratosphere, owing to the daily near-global coverage and good vertical resolution of MLS observations. The largest impacts were seen in the middle and lower stratosphere, where model deficiencies could not be effectively corrected by the operational observations without the additional information on the ozone vertical distribution provided by MLS. Even in the upper stratosphere, where ozone concentrations are mainly determined by rapid chemical processes, dense and vertically resolved MLS data helped reduce the biases related to model deficiencies. These improvements resulted in a more realistic and consistent description of spatial and temporal variations in stratospheric ozone, as demonstrated by cases in the dynamically and chemically active regions. However, combined assimilation of the often discrepant ozone observations might lead to underestimation of tropospheric ozone. In addition, model deficiencies induced large biases in the upper stratosphere in the medium-range (5-day) ozone forecasts.

Jet characterization in the upper troposphere/lower stratosphere (UTLS): applications to climatology and transport studies

A method of classifying the upper tropospheric/lower stratospheric (UTLS) jets has been developed that allows satellite and aircraft trace gas data and meteorological fields to be efficiently mapped in a jet coordinate view. A detailed characterization of multiple tropopauses accompanies the jet characterization. Jet climatologies show the well-known high altitude subtropical and lower altitude polar jets in the upper troposphere, as well as a pattern of concentric polar and subtropical jets in the Southern Hemisphere, and shifts of the primary jet to high latitudes associated with blocking ridges in Northern Hemisphere winter. The jet-coordinate view segregates air masses differently than the commonly-used equivalent latitude (EqL) coordinate throughout the lowermost stratosphere and in the upper troposphere. Mapping O3 data from the Aura Microwave Limb Sounder (MLS) satellite and the Winter Storms aircraft datasets in jet coordinates thus emphasizes different aspects of the circulation compared to an EqL-coordinate framework: the jet coordinate reorders the data geometrically, thus highlighting the strong PV, tropopause height and trace gas gradients across the subtropical jet, whereas EqL is a dynamical coordinate that may blur these spatial relationships but provides information on irreversible transport. The jet coordinate view identifies the concentration of stratospheric ozone well below the tropopause in the region poleward of and below the jet core, as well as other transport features associated with the upper tropospheric jets. Using the jet information in EqL coordinates allows us to study trace gas distributions in regions of weak versus strong jets, and demonstrates weaker transport barriers in regions with less jet influence. MLS and Atmospheric Chemistry Experiment-Fourier Transform Spectrometer trace gas fields for spring 2008 in jet coordinates show very strong, closely correlated, PV, tropopause height and trace gas gradients across the jet, and evidence of intrusions of stratospheric air below the tropopause below and poleward of the subtropical jet; these features are consistent between instruments and among multiple trace gases. Our characterization of the jets is facilitating studies that will improve our understanding of upper tropospheric trace gas evolution.

Satellite observations and modeling of transport in the upper troposphere through the lower mesosphere during the 2006 major stratospheric sudden warming

An unusually strong and prolonged stratospheric sudden warming (SSW) in January 2006 was the first major SSW for which globally distributed long-lived trace gas data are available covering the upper troposphere through the lower mesosphere. We use Aura Microwave Limb Sounder (MLS), Atmospheric Chemistry Experiment-Fourier Transform Spectrometer (ACE-FTS) data, the SLIMCAT Chemistry Transport Model (CTM), and assimilated meteorological analyses to provide a comprehensive picture of transport during this event. The upper tropospheric ridge that triggered the SSW was associated with an elevated tropopause and layering in trace gas profiles in conjunction with stratospheric and tropospheric intrusions. Anomalous poleward transport (with corresponding quasi-isentropic troposphere-to-stratosphere exchange at the lowest levels studied) in the region over the ridge extended well into the lower stratosphere. In the middle and upper stratosphere, the breakdown of the polar vortex transport barrier was seen in a signature of rapid, widespread mixing in trace gases, including CO, H2O, CH4 and N2O. The vortex broke down slightly later and more slowly in the lower than in the middle stratosphere. In the middle and lower stratosphere, small remnants with trace gas values characteristic of the pre-SSW vortex lingered through the weak and slow recovery of the vortex. The upper stratospheric vortex quickly reformed, and, as enhanced diabatic descent set in, CO descended into this strong vortex, echoing the fall vortex development. Trace gas evolution in the SLIMCAT CTM agrees well with that in the satellite trace gas data from the upper troposphere through the middle stratosphere. In the upper stratosphere and lower mesosphere, the SLIMCAT simulation does not capture the strong descent of mesospheric CO and H2O values into the reformed vortex; this poor CTM performance in the upper stratosphere and lower mesosphere results primarily from biases in the diabatic descent in assimilated analyses.