Sensory Ganglion Cells Research Articles

Characterization of rat primary trigeminal satellite glial cells and associated extracellular vesicles under normal and inflammatory conditions

Satellite glial cells (SGCs) in sensory ganglia contribute to the pathogenesis of chronic pain, potentially through mediating extracellular or paracrine signaling. Recently, extracellular vesicles (EVs) in the form of exosomes have been found to play an important role in cell-cell communication. However, their release from SGCs and extent in modulating pain remain unknown. An in vitro cell platform using fresh primary SGCs was used to characterize the shed vesicles by size and proteomic profiling following activation of SGCs by lipopolysaccharide (LPS), simulating neurogenic inflammation in vivo. Results demonstrated that SGCs shed vesicles in the size range of exosomes (>150 nm) but with altered protein expression upon LPS-activation. Proteomic profiling of SGCs-shed EVs showed that a number of proteins were differentially regulated upon LPS stimulation such as junction plakoglobin and myosin 9 that are proposed as novel biomarkers of SGCs activation under inflammatory conditions. Findings from this study highlight the utility of using fresh primary SGC cultures as a model to further investigate EVs under normal and inflammatory conditions. SignificanceThis study demonstrated that1.Primary SGCs express the phenotypic marker GS.2.One ng/mL LPS is sufficient to activate SGCs in vitro without any form of toxicity.3.SGCs shed a population of extracellular vesicles in the exosomal size range and the identified proteins have a potential effect on SGCs morphology upon activation by LPS.4.Myosin-9 was identified as a novel biomarker of LPS-activated fresh primary SGCs that can be applicable for inflammatory pain conditions.

Phoenixin: a novel brain-gut-skin peptide with multiple bioactivity.

In this brief review we summarize the current fndings relative to the discovery of a small peptide ligand, phoenixin (PNX). Using a bioinformatic approach, two novel peptides PNX-14 and PNX-20 containing 14 and 20 amino acids, respectively, were isolated from diverse tissues including the brain, heart, lung and stomach. Mass spectrometry analysis identified a major and minor peak corresponding to PNX-14 and PNX-20, in rat or mouse spinal cord extracts. With the use of a rabbit polyclonal antiserum, phoenixin immunoreactivity (irPNX) was detected in discrete areas of the rodent brain including several hypothalamic subnuclei and dorsal motor nucleus of the vagus. In addition, irPNX was detected in a population of sensory ganglion cells including dorsal root ganglion, nodose ganglion and trigeminal ganglion, and in cell processes densely distributed to the superficial layers of the dorsal horn, nucleus of the solitary tract and spinal trigeminal tract. irPNX cell processes were also detected in the skin and myenteric plexus, suggesting a brain-gut and/or brain-skin connection. Pharmacological studies show that PNX-14 injected subcutaneously to the nape of the neck of mice provoked dose-dependent repetitive scratching bouts directed to the back of the neck with the hindpaws. Our result suggests that the peptide PNX-14 and/or PNX-20, may serve as one of the endogenous signal molecules transducing itch sensation. Additionally, results from other laboratories show that exogenous PNX may affect a number of diverse behaviors such as memory formation, depression, reproduction, food-intake and anxiolytic-like behaviors.

Cell-based platform for studying trigeminal satellite glial cells under normal and inflammatory conditions

Abstract Aims Satellite glial cells (SGCs) in sensory ganglia contribute to the pathogenesis of chronic pain. In vitro, providing enough fresh primary SGCs poses some practical limitations; hence, frozen stocks of primary cells for culture could be an attractive alternative for cell-based studies or drug screening. This study was designed to investigate the morphology and marker expression of frozen and freshly isolated trigeminal SGCs under normal and inflammatory conditions. Methods SGCs from trigeminal ganglia of three male Sprague–Dawley rats and three frozen (sub cultured and passaged) batches of stored primary SGCs were cultured. Their morphology was observed by phase microscopy and the phenotype was characterized by immunocytochemistry of glutamine synthetase (GS) and glial fibrillary acidic protein (GFAP). Lipopolysaccharide (LPS) was used to simulate a state of neurogenic inflammation in vivo. A pilot test was performed to determine the optimal concentration of LPS to activate SGCs based on GFAP expression. A long-term activation of the SGCs with 50 ng/mL LPS was chosen for further characterization. Results The fresh and frozen primary SGCs elicited similar phenotypes based on GS marker expression. However, frozen primary SGCs differed in terms of size and morphology. GFAP was constantly expressed in frozen primary SGCs regardless of LPS stimulation. Activation of primary fresh SGCs with LPS spread the GFAP expression from around the cell body throughout the longer processes and activation was only seen in the LPS treatment. Conclusions The phenotypic marker, GS was independent of culture conditions. There was no difference in upregulation of GFAP in thawed SGCs regardless of LPS stimulation. This indicates that freeze-thawing might activate SGCs and therefore frozen and passaged cells cannot be suitable for use in cell-based models for inflammation. Fresh primary cells are therefore optimal for studying SGCs under normal and inflammatory conditions.

Evidence that polycystins are involved in Hydra cnidocyte discharge.

Like other cnidarians, the freshwater organism Hydra is characterized by the possession of cnidocytes (stinging cells). Most cnidocytes are located on hydra tentacles, where they are organized along with sensory cells and ganglion cells into battery complexes. The function of the battery complexes is to integrate multiple types of stimuli for the regulation of cnidocyte discharge. The molecular mechanisms controlling the discharge of cnidocytes are not yet fully understood, but it is known that discharge depends on extracellular Ca2+ and that mechanically induced cnidocyte discharge can be enhanced by the presence of prey extracts and other chemicals. Experiments in this paper show that a PKD2 (polycystin 2) transient receptor potential (TRP) channel is expressed in hydra tentacles and bases. PKD2 (TRPP) channels belong to the TRP channel superfamily and are non-selective Ca2+ channels involved in the transduction of both mechanical and chemical stimuli in other organisms. Non-specific PKD2 channel inhibitors Neo (neomycin) and Gd3+ (gadolinium) inhibit both prey capture and cnidocyte discharge in hydra. The PKD2 activator Trip (triptolide) enhances cnidocyte discharge in both starved and satiated hydra and reduces the inhibition of cnidocyte discharge caused by Neo. PKD1 and 2 proteins are known to act together to transduce mechanical and chemical stimuli; in situ hybridization experiments show that a PKD1 gene is expressed in hydra tentacles and bases, suggesting that polycystins play a direct or indirect role in cnidocyte discharge.

Innocuous warming enhances peripheral serotonergic itch signaling and evokes enhanced responses in serotonin-responsive dorsal horn neurons in the mouse.

Skin warming often exacerbates itch in patients with itchy dermatitis. We demonstrate that warming the skin enhanced serotonin-evoked, but not histamine-evoked, itch behavior and responses of sensory dorsal root ganglion cells. Moreover, serotonin, but not histamine, enhanced responses of superficial dorsal horn neurons to innocuous warming. The results suggest that skin warming selectively enhances the responses of serotonin-sensitive pruriceptors, leading to increased firing of serotonin-sensitive dorsal horn neurons that signal nonhistaminergic itch.

A Morphological and Molecular Characterization of the Spinal Cord after Ventral Root Avulsion or Distal Peripheral Nerve Axotomy Injuries in Adult Rats

Retrograde cell death in sensory dorsal root ganglion cells following peripheral nerve injury is well established. However, available data regarding the underlying mechanism behind injury induced motoneuron death are conflicting. By comparing morphological and molecular changes in spinal motoneurons after L4-L5 ventral root avulsion (VRA) and distal peripheral nerve axotomy (PNA) 7 and 14 days postoperatively, we aimed to gain more insight about the mechanism behind injury-induced motoneuron degeneration. Morphological changes in spinal cord were assessed by using quantitative immunohistochemistry. Neuronal degeneration was revealed by decreased immunostaining for microtubule-associated protein-2 in dendrites and synaptophysin in presynaptic boutons after both VRA and PNA. Significant motoneuron atrophy was already observed at 7 days post-injury, independently of injury type. Immunostaining for ED1 reactive microglia was significantly elevated in all experimental groups, as well as the astroglial marker glial fibrillary acidic protein (GFAP). Quantitative reverse transcription polymerase chain reaction (qRT-PCR) analysis of the ventral horn from L4-L5 spinal cord segments revealed a significant upregulation of genes involved in programmed cell death including caspase-3, caspase-8, and related death receptors TRAIL-R, tumor necrosis factor (TNF)-R, and Fas following VRA. In contrast, following PNA, caspase-3 and the death receptor gene expression levels did not differ from the control, and there was only a modest increased expression of caspase-8. Moreover, the altered gene expression correlated with protein changes. These results show that the spinal motoneurons reacted in a similar fashion with respect to morphological changes after both proximal and distal injury. However, the increased expression of caspase-3, caspase-8, and related death receptors after VRA suggest that injury- induced motoneuron degeneration is mediated through an apoptotic mechanism, which might involve both the intrinsic and the extrinsic pathways.

P2Y1 Receptor Activation of the TRPV4 Ion Channel Enhances Purinergic Signaling in Satellite Glial Cells

Transient receptor potential (TRP) ion channels of peripheral sensory pathways are important mediators of pain, itch, and neurogenic inflammation. They are expressed by primary sensory neurons and by glial cells in the central nervous system, but their expression and function in satellite glial cells (SGCs) of sensory ganglia have not been explored. SGCs tightly ensheath neurons of sensory ganglia and can regulate neuronal excitability in pain and inflammatory states. Using a modified dissociation protocol, we isolated neurons with attached SGCs from dorsal root ganglia of mice. SGCs, which were identified by expression of immunoreactive Kir4.1 and glutamine synthetase, were closely associated with neurons, identified using the pan-neuronal marker NeuN. A subpopulation of SGCs expressed immunoreactive TRP vanilloid 4 (TRPV4) and responded to the TRPV4-selective agonist GSK1016790A by an influx of Ca(2+) ions. SGCs did not express functional TRPV1, TRPV3, or TRP ankyrin 1 channels. Responses to GSK1016790A were abolished by the TRPV4 antagonist HC067047 and were absent in SGCs from Trpv4(-/-) mice. The P2Y1-selective agonist 2-methylthio-ADP increased [Ca(2+)]i in SGCs, and responses were prevented by the P2Y1-selective antagonist MRS2500. P2Y1 receptor-mediated responses were enhanced in TRPV4-expressing SGCs and HEK293 cells, suggesting that P2Y1 couples to and activates TRPV4. PKC inhibitors prevented P2Y1 receptor activation of TRPV4. Our results provide the first evidence for expression of TRPV4 in SGCs and demonstrate that TRPV4 is a purinergic receptor-operated channel in SGCs of sensory ganglia.

Role of satellite glial cells in gastrointestinal pain.

Gastrointestinal (GI) pain is a common clinical problem, for which effective therapy is quite limited. Sensations from the GI tract, including pain, are mediated largely by neurons in the dorsal root ganglia (DRG), and to a smaller extent by vagal afferents emerging from neurons in the nodose/jugular ganglia. Neurons in rodent DRG become hyperexcitable in models of GI pain (e.g., gastric or colonic inflammation), and can serve as a source for chronic pain. Glial cells are another element in the pain signaling pathways, and there is evidence that spinal glial cells (microglia and astrocytes) undergo activation (gliosis) in various pain models and contribute to pain. Recently it was found that satellite glial cells (SGCs), the main type of glial cells in sensory ganglia, might also contribute to chronic pain in rodent models. Most of that work focused on somatic pain, but in several studies GI pain was also investigated, and these are discussed in the present review. We have shown that colonic inflammation induced by dinitrobenzene sulfonic acid (DNBS) in mice leads to the activation of SGCs in DRG and increases gap junction-mediated coupling among these cells. This coupling appears to contribute to the hyperexcitability of DRG neurons that innervate the colon. Blocking gap junctions (GJ) in vitro reduced neuronal hyperexcitability induced by inflammation, suggesting that glial GJ participate in SGC-neuron interactions. Moreover, blocking GJ by carbenoxolone and other agents reduces pain behavior. Similar changes in SGCs were also found in the mouse nodose ganglia (NG), which provide sensory innervation to most of the GI tract. Following systemic inflammation, SGCs in these ganglia were activated, and displayed augmented coupling and greater sensitivity to the pain mediator ATP. The contribution of these changes to visceral pain remains to be determined. These results indicate that although visceral pain is unique, it shares basic mechanisms with somatic pain, suggesting that therapeutic approaches to both pain types may be similar. Future research in this field should include additional types of GI injury and also other types of visceral pain.

The Order and Place of Neuronal Differentiation Establish the Topography of Sensory Projections and the Entry Points within the Hindbrain.

Establishing topographical maps of the external world is an important but still poorly understood feature of the vertebrate sensory system. To study the selective innervation of hindbrain regions by sensory afferents in the zebrafish embryo, we mapped the fine-grained topographical representation of sensory projections at the central level by specific photoconversion of sensory neurons. Sensory ganglia located anteriorly project more medially than do ganglia located posteriorly, and this relates to the order of sensory ganglion differentiation. By single-plane illumination microscopy (SPIM) in vivo imaging, we show that (1) the sequence of arrival of cranial ganglion inputs predicts the topography of central projections, and (2) delaminated neuroblasts differentiate in close contact with the neural tube, and they never loose contact with the neural ectoderm. Afferent entrance points are established by plasma membrane interactions between primary differentiated peripheral sensory neurons and neural tube border cells with the cooperation of neural crest cells. These first contacts remain during ensuing morphological growth to establish pioneer axons. Neural crest cells and repulsive slit1/robo2 signals then guide axons from later-differentiating neurons toward the neural tube. Thus, this study proposes a new model by which the topographical representation of cranial sensory ganglia is established by entrance order, with the entry points determined by cell contact between the sensory ganglion cell bodies and the hindbrain.

Extended multipotency of neural crest cells and neural crest-derived cells.

Neural crest cells (NCC) are migratory multipotent cells that give rise to diverse derivatives. They generate various cell types during embryonic development, including neurons and glial cells of the peripheral sensory and autonomic ganglia, Schwann cells, melanocytes, endocrine cells, smooth muscle, and skeletal and connective tissue cells of the craniofacial complex. The multipotency of NCC is thought to be transient at the early stage of NCC generation; once NCC emerge from the neural tube, they change into lineage-restricted precursors. Although many studies have described the clear segregation of NCC lineages right after their delamination from the neural tube, recent reports suggest that multipotent neural crest stem cells (NCSC) are present not only in migrating NCC in the embryo, but also in their target tissues in the fetus and adult. Furthermore, fully differentiated NCC-derived cells such as glial cells and melanocytes have been shown to dedifferentiate or transdifferentiate into other NCC derivatives. The multipotency of migratory and postmigratory NCC-derived cells was found to be similar to that of NCSC. Collectively, these findings support the multipotency or plasticity of NCC and NCC-derived cells.

Células gliales satélite de ganglios sensoriales: su papel en el dolor

Background and objectivesSatellite glial cells in sensory ganglia are a recent subject of research in the field of pain and a possible therapeutic target in the future. Therefore, the aim of this study was to summarize some of the important physiological and morphological characteristics of these cells and gather the most relevant scientific evidence about its possible role in the development of chronic pain. ContentIn the sensory ganglia, each neuronal body is surrounded by satellite glial cells forming distinct functional units. This close relationship enables bidirectional communication via a paracrine signaling between those two cell types. There is a growing body of evidence that glial satellite cells undergo structural and biochemical changes after nerve injury, which influence neuronal excitability and consequently the development and/or maintenance of pain in different animal models of chronic pain. ConclusionsSatellite glial cells are important in the establishment of physiological pain, in addition to being a potential target for the development of new pain treatments.

Satellite glial cells in sensory ganglia: its role in pain

Background and objectivesSatellite glial cells in sensory ganglia are a recent subject of research in the field of pain and a possible therapeutic target in the future. Therefore, the aim of this study was to summarize some of the important physiological and morphological characteristics of these cells and gather the most relevant scientific evidence about its possible role in the development of chronic pain. ContentIn the sensory ganglia, each neuronal body is surrounded by satellite glial cells forming distinct functional units. This close relationship enables bidirectional communication via a paracrine signaling between those two cell types. There is a growing body of evidence that glial satellite cells undergo structural and biochemical changes after nerve injury, which influence neuronal excitability and consequently the development and/or maintenance of pain in different animal models of chronic pain. ConclusionsSatellite glial cells are important in the establishment of physiological pain, in addition to being a potential target for the development of new pain treatments.

Sensory pathways in the human embryonic spinal accessory nerve with special reference to the associated lower cranial nerve ganglia.

Muscles supplied by the spinal accessory nerve are particularly prone to the development of trigger points characteristic of myofascial pain. This study aimed to confirm sensory pathways in the spinal accessory nerve and to describe sensory ganglion cell distributions along the lower cranial nerve roots. Using sagittal sections of ten human embryos at 6-7 weeks and horizontal sections of three 15- to 16-week-old embryos, we analyzed ganglion cell distributions along the lower cranial nerve roots, including the spinal accessory (XI) nerve. In all ten 6- to 7-week-old embryos, the XI nerve root contained abundant ganglion cells, which were evenly distributed along the XI nerve root at levels between the jugular foramen and the dorsal root of the second cervical nerve. However, the hypoglossal (XII) nerve roots did not contain ganglion cells and did not communicate with nearby roots in the dural space. Thus, the so-called Froriep's occipital ganglion is unlikely to be associated with the XII nerve but rather with the XI nerve roots. According to observations of three larger fetuses (15-16 weeks), most of Froriep's ganglion cells seemed to have degenerated during early fetal life. Nociceptive sensory pathways in the adult human XI nerve may be much more limited in number than would be expected based on previous animal studies. However, it is possible that sensory ganglion cells in the embryonic XI nerve root send axons toward the developing spinal accessory nerve fibers outside of the jugular foramen.

Glutamate release from satellite glial cells of the murine trigeminal ganglion

It has been proposed that glutamate serves as a mediator between neurons and satellite glial cells (SGCs) in sensory ganglia and that SGCs release glutamate. Using a novel method, we studied glutamate release from SGCs from murine trigeminal ganglia. Sensory neurons with adhering SGCs were enzymatically isolated from wild type and transgenic mice in which vesicular exocytosis was suppressed in glial cells. Extracellular glutamate was detected by microfluorimetry. After loading the cells with a photolabile Ca2+ chelator, the intracellular Ca2+ concentration was raised in SGCs by a UV pulse, which resulted in glutamate release. The amount of released glutamate was decreased in cells with suppressed exocytosis and after pharmacological block of hemichannels. The data demonstrate that SGCs of the trigeminal ganglion release glutamate in a Ca2+-dependent manner.

Systemic inflammation alters satellite glial cell function and structure. A possible contribution to pain

Local peripheral injury activates satellite glial cells (SGCs) in sensory ganglia, which may contribute to chronic pain. We hypothesized that systemic inflammation affects sensory ganglia like local injury. We induced systemic inflammation in mice by injecting lipopolysaccharide (LPS) intraperitoneally, and characterized SGCs and neurons in dorsal root ganglia (DRG), using dye injection, calcium imaging, electron microscopy (EM), immunohistochemistry, and electrical recordings. Several days post-LPS, SGCs were activated, and dye coupling among SGCs increased 3–4.5-fold. EM showed abnormal growth of SGC processes and the formation of new gap junctions. Sensitivity of SGCs to ATP increased twofold, and neuronal excitability was augmented. Blocking gap junctions reduced pain behavior in LPS-treated mice. Thus, changes in DRG due to systemic inflammation are similar to those due to local injury, which may explain the pain in sickness behavior and in other systemic diseases.

Células gliais satélite de gânglios sensitivos: o seu papel na dor

Background and objectivesSatellite glial cells in sensory ganglia are a recent subject of research in the field of pain and a possible therapeutic target in the future. Therefore, the aim of this study was to summarize some of the important physiological and morphological characteristics of these cells and gather the most relevant scientific evidence about its possible role in the development of chronic pain. ContentIn the sensory ganglia, each neuronal body is surrounded by satellite glial cells forming distinct functional units. This close relationship enables bidirectional communication via a paracrine signaling between those two cell types. There is a growing body of evidence that glial satellite cells undergo structural and biochemical changes after nerve injury, which influence neuronal excitability and consequently the development and/or maintenance of pain in different animal models of chronic pain. ConclusionsSatellite glial cells are important in the establishment of physiological pain, in addition to being a potential target for the development of new pain treatments.

Possible role of gap junction intercellular channels and connexin 43 in satellite glial cells (SGCs) for preservation of human spiral ganglion neurons

Human spiral ganglion (SG) neurons show remarkable survival properties and maintain electric excitability for a long time after complete deafness and even separation from the organ of Corti, features essential for cochlear implantation. Here, we analyze and compare the localization and distribution of gap junction (GJ) intercellular channels and connexin 43 (Cx43) in cells surrounding SG cell bodies in man and guinea pig by using transmission electron microscopy and confocal immunohistochemistry. GJs and Cx43 expression has been recognized in satellite glial cells (SGCs) in non-myelinating sensory ganglia including the human SG. In man, SG neurons can survive as mono-polar or “amputated” cells with unbroken central projections following dendrite degeneration and consolidation of the dendrite pole. Cx43-mediated GJ signaling between SGCs is believed to play a key role in this “healing” process and could explain the unique preservation of human SG neurons and the persistence of cochlear implant function.Electronic supplementary materialThe online version of this article (doi:10.1007/s00441-013-1735-2) contains supplementary material, which is available to authorized users.

Communication between neuronal somata and satellite glial cells in sensory ganglia

Studies of the structural organization and functions of the cell body of a neuron (soma) and its surrounding satellite glial cells (SGCs) in sensory ganglia have led to the realization that SGCs actively participate in the information processing of sensory signals from afferent terminals to the spinal cord. SGCs use a variety ways to communicate with each other and with their enwrapped soma. Changes in this communication under injurious conditions often lead to abnormal pain conditions. "What are the mechanisms underlying the neuronal soma and SGC communication in sensory ganglia?" and "how do tissue or nerve injuries affect the communication?" are the main questions addressed in this review.

P2Y purinergic receptors: New targets for analgesic and antimigraine drugs

Millions of individuals worldwide suffer from acute and, more severely, chronic pain conditions (e.g., neuropathic pain, and migraine). The latter bear tremendous personal, familial, and social costs, since sufferers and their relatives undergo a complete turnaround of their lives with the search of relief from pain becoming their pivotal thought. Sadly, to date no effective pharmacological approaches are available which can alleviate chronic pain significantly or in the long run in all patients. The current central strategy for the development of new and effective painkillers lies in the hypothesis that cellular and/or molecular players in nociception must exists that are not targeted by “classical” analgesics, and therefore researchers have put tremendous efforts into the in-depth analysis of the pathways leading to pain development and maintenance over time. In this complex scenario, two outsiders are now taking the center stage: glial cells in sensory ganglia and in the central nervous system, thanks to their ability to communicate with neurons and to modulate their firing, and the purinergic system. Extracellular purine and pyrimidine nucleotides are involved in the physiology of virtually every body district, and their extracellular concentrations massively increase under pathological situations, suggesting that they might represent potential targets for the modulation of disease-associated symptoms, like pain. Here, we provide an overview of the present knowledge of the role of nucleotides in nociception, with a particular emphasis on G protein-coupled P2Y receptors and their involvement in the communication between first- and second-order neurons in sensory nerve pathways and surrounding glial cells.

Study on Morphological and Clinical Characteristics of Herpes Zoster In A Tertiary Medical College Hospital

Herpes zoster is caused by reactivation of VZV (varicella zoster virus) following primary infection or vaccination. VZV remains latent in sensory dorsal root ganglion cells. The virus begins to replicate in some later time, traveling down the sensory nerve into the skin. Forty one cases (3 children and 38 adults) of Herpes Zoster were assessed over a period of three and half years. Structured questionnaire, check-list and face-to-face interview were used as tools of data collection. The prevalence of herpes zoster amongst Skin & Eye OPD cases were found 0.60 percent. Maximum cases (23; 63.41%) were above 45 years of age. The male female ratio was 1.4:1.0. By socioeconomic status maximum patient from middle class (13; 31.70%), followed by poor (12; 26.26%) and very poor (11; 26.82%). Prodromal syndrome in maximum cases was paresthesia (13; 31.70%) and pain (11; 26.82%). Cases were mostly presented with pain (35; 85.36%). Twenty-three cases had classic herpes zoster followed by necrotic or ulcerated herpes zoster (16 cases) and hemorrhagic herpes zoster (2 case). Trigeminal dermatome was the most common involvement in 18 cases (43.9%) followed by thoracic dermatome 16 cases (39.02%). Unidermatomal involvement was seen in 97.56% cases (40) followed by multidermatomal 1 case (2.43%). Nine cases were screened for HIV-1 by ELISA, but none was detected as seropositive. . The analysis and findings put this recommendation that large scale study needed to examine the correlation ship between VZV infection and socioeconomic status of patients. Medicine Today 2010 Volume 22 Number 02 Page 80-82 DOI: http://dx.doi.org/10.3329/medtoday.v22i2.12439