Influence of transducer pressure and examiner experience on muscle active shear modulus measured by shear wave elastography

INTRODUCTION

This study examined the effects of ultrasound transducer pressure and examiner experience on the biceps femoris long head and semitendinosus muscle active shear modulus in healthy individuals (n = 28).

METHODS

Active shear modulus was assessed using shear wave elastography at 20% of knee flexor maximal voluntary isometric contraction. Examiners with different experience levels measured the muscles' shear modulus with three pressure levels: mild, moderate, and hard.

RESULTS

A main effect of transducer pressure was found for both biceps femoris long head (p < 0.001; η2p = 0.314) and semitendinosus muscles (p < 0.001; η2p = 0.280), whereas differences were found between mild-moderate (biceps femoris long head: p = 0.013, d = 0.23; semitendinosus: p = 0.024, d = 0.25), and mild-hard pressures (biceps femoris long head: p = 0.001, d = 0.47; semitendinosus: p = 0.002, d = 0.47). Examiners performed similar shear modulus measurements in the biceps femoris long head (p = 0.299; η2p = 0.041) and semitendinosus (p = 0.177; η2p = 0.066), although the experienced examiner showed a higher measurement repeatability (biceps femoris long head: ICC = 0.86-0.95, semitendinosus: ICC = 0.89-0.96; vs. biceps femoris long head: ICC = 0.78-0.87, semitendinosus: ICC = 0.66-0.87).

CONCLUSION

Transducer pressure influences the active shear modulus measurement between mild and moderate or hard pressures. Additionally, examiner experience seems to have no influence on muscle active shear modulus measurement when assessed at the same site (using casts).

IMPLICATIONS FOR PRACTICE

Future studies assessing active muscle shear modulus should use mild transducer pressure and having experienced examiners in order to improve measurement reliability.

Myositis Multidisciplinary Clinic in a Tertiary Referral Center

Background

Idiopathic inflammatory myopathies (IIM) are a rare heterogeneous group of diseases characterised by chronic skeletal muscle inflammation, but other organs are also frequently involved. IMM represent a diagnostic challenge and a multidisciplinary approach is important to ensure successful diagnosis and adequate follow-up of these patients.

Objective

To describe the general functioning of our multidisciplinary myositis clinic, highlighting the benefits of multidisciplinary team management in patients with confirmed or suspected IIM and to characterise our clinical experience.

Methods

Description of the organization of a dedicated multidisciplinary myositis outpatient clinic, supported by IMM specific electronic assessment tools and protocols based on our Portuguese Register - Reuma.pt. In addition, an overview of our activity between 2017 and 2022 is provided.

Results

An IIM multidisciplinary care clinic, based on a close collaboration between Rheumatologists, Dermatologists and Physiatrist is detailed in this paper. One hundred and eighty-five patients were assessed in our myositis clinic; 138 (75%) of those were female, with a median age of 58 [45-70] years. At the last appointment, 130 patients had a confirmed IIM diagnosis, and the mean disease duration was 4 [2-6] years. The most frequent diagnosis was dermatomyositis (n = 34, 26.2%), followed by antisynthetase syndrome (n = 27, 20.8%) and clinically amyopathic/paucimyopathic dermatomyositis (n = 18, 13.8%). Twenty-four patients (18.5%) were on monotherapy and 94 (72.3%) were on combination therapy.

Conclusion

A multidisciplinary approach is important to ensure the correct diagnosis and follow-up of these patients. A myositis clinic, with a standardised practice at a tertiary hospital level, contributes to a standardization of care and opens research opportunities.

Cutaneous Markers of Cardiovascular Diseases

Cardiovascular diseases are one of the most important global medical challenges because of their high rates of morbidity and mortality. In this narrative review, the authors address the most important dermatologic signs that can be present in patients with cardiovascular disease. The early recognition of these underestimated entities is very important as it may lead to an early diagnosis and timely treatment, thus lessening the effects of long-term disease and possibly improving the prognosis.

Additional activation of the AR gene may be involved in the development of the castration resistance phenotype in prostate cancer

INTRODUCTION

Several studies have already shown that changes in the AR gene may be associated with a more aggressive disease phenotype and even castration-resistant prostate cancer. Thus, we investigated cytogenetic and molecular alterations linked to AR.

MATERIALS AND METHODS

To evaluate AR methylation, we performed a cytogenetic-molecular analysis using fluorescence in situ hybridization that uses specific probes for the AR gene (Xq11.12) and the X chromosome centromere. For AR activity, we performed a qualitative analysis of human androgen receptor activity. To analyze the expression of AR in PC3 and LNCaP cell lines, we used qPCR assays.

RESULTS

In the qPCR assay, we found downregulation of AR in the PC3 cell line compared with the LNCaP. We found the presence of X chromosome polysomy in PC-3 and LNCaP cell lines by FISH assay. In the HUMARA-Q assay, we found two X chromosomes/cell and the activity of both AR in the PC-3 cell line. In LNCaP cells, we found two X chromosomes/cell and methylation of only one AR.

CONCLUSION

Castration-resistant prostate cancer phenotype represents a significant challenge in the setting of urological management. The X chromosomes and AR-linked alterations may contribute to a better understanding of the disease. However, further studies should be performed in an attempt to elucidate as much as possible the role of AR in the castration-resistant prostate cancer phenotype.

Transient Cutaneous Alterations of the Newborn

Neonatal cutaneous alterations are common, usually appearing at birth or during the first few days of life. Most of these conditions are physiological, benign, and transient, arising from a combination of immaturity of the newborn skin with environmental factors. Nonetheless, some of them may eventually be a clue to underlying disorders. Physicians should therefore be aware of these clinical manifestations so that parents can be reassured and, when necessary, complementary investigations can be undertaken.

Reflectance confocal microscopy for the diagnosis of skin infections and infestations

Reflectance confocal microscopy (RCM) is a noninvasive real-time imaging technique that has been widely used for the diagnosis of skin cancer. More recently, it has been reported as a useful tool for the diagnosis and management of several inflammatory and infectious skin disorders. This article provides an overview of the current available applications of RCM use in cutaneous infections and infestations. PubMed was used to search the following terms in various combinations: reflectance confocal microscopy, skin, hair, nail, infection, parasitosis, mycosis, virus, bacteria. All papers were accordingly reviewed. In most cutaneous infections or infestations, the main alterations are found in the epidermis and upper dermis, where the accuracy of confocal microscopy is nearly similar to that of histopathology. The high resolution of this technique allows the visualization of most skin parasites, fungi, and a few bacteria. Although viruses cannot be identified because of their small size, viral cytopathic effects can be observed on keratinocytes. In addition, RCM can be used to monitor the response to treatment, thereby reducing unnecessary treatments.

Cutaneous Manifestations of Diabetes Mellitus and Prediabetes

Diabetes is a serious, chronic disease with a rising prevalence worldwide. Its complications are a major cause of morbidity and mortality and contribute substantially to health care costs. In this article the authors review the most common and sensitive skin manifestations that can be present on patients with diabetes and prediabetes. The prompt recognition of these frequently underestimated entities is extremely important as it may trigger not only an adequate metabolic evaluation but also a timely referral and appropriate treatment, minimizing the secondary effects of long-term diabetes and improving the prognosis of diabetic patients.

Successful Treatment with Fusidic Acid in a Patient with Folliculitis Decalvans

Dear Editor, Folliculitis decalvans (FD) is a rare form of primary neutrophilic cicatricial alopecia. It is a highly distressing disease that affects young and middle-aged adults, with a slight male predominance (1). The most frequent clinical manifestations are follicular pustules and diffuse and perifollicular erythema that heal with centrifugal scarring. Follicular tufting, erosions, and hemorrhagic crusts can also be present, and this alopecia is most often located at the vertex and occipital area. Patients frequently complain about pain, itching, or burning sensations, and the involvement of other body areas is rare (2). The pathogenesis of this disease remains unclear. Staphylococcus aureus and other hair follicle bacteria can often be isolated from the pustules, suggesting the role of a bacterial infection in its etiology. A defect in the host's immune response can also be postulated by reports of familial cases and the appearance of FD in patients with immunity dysfunctions. Other mechanical factors have been suggested, such as structural abnormalities of the follicle or local inflammation (2). Management of this alopecia is difficult and its course is typically chronic and relapsing. The treatment aim is to stop inflammation and further irreversible destruction of hair follicles. Antibiotics remain the first-line therapy, due both to their anti-inflammatory and antimicrobial properties (1). Although topical fusidic acid is widely used as adjuvant treatment, there are few data regarding its oral use. We report a case of folliculitis decalvans successfully treated with oral fusidic acid. Our patient was a 41-year old Cape Verdean woman with a two month history of alopecia with painful, purulent discharge at the vertex of the scalp. The patient was diagnosed with human immunodeficiency virus type 1 (HIV-1) infection 5 years prior and was stable on her regimen of efavirenz, tenofovir, and emtricitabine, with undetectable viral load. She denied application of topical or capillary products. Dermatological examination revealed a patch of cicatricial alopecia with crusts and follicular pustules (Figure 1). Direct microscopic examination and mycological culture showed no fungal element. A diagnosis of folliculitis decalvans was established and the patient was started on oral fusidic acid at a dose of 500 mg three times a day. Betamethasone dipropionate 0.05% and salicylic acid 3% lotion as well as azelaic acid 5% lotion were also applied to the affected area once daily. After two months of treatment, the patient showed clinical improvement, with less erythema and suppuration of the affected scalp. A partial hair regrowth was noted, mainly at the periphery. Subsequently the patient maintained only topical therapy, and no recurrences were observed after 6-months of follow-up. Fusidic acid is useful in the treatment of skin and soft tissue infections, particularly those due to S. aureus, as shown by randomized controlled studies (3). The clinical efficacy of fusidic acid in the treatment of folliculitis decalvans has been reported previously. Bogg was the first to describe this useful effect (4). Sutter also reported good results with fusidic acid used both topically and orally (500 mg three times a day) (5). However, both failed to report the treatment duration or the outcome on discontinuation. Abeck described three patients that responded to a three week oral course of fusidic acid (500 mg three times a day) and to a maintenance treatment with zinc sulfate (4). During the following year, recurrence was observed in only one patient after ending zinc sulfate therapy. Oral antibiotics are frequently used to treat folliculitis decalvans. Tetracyclines and the combination of clindamycin with rifampicin are the most commonly used (2). However, the disease usually progresses when treatment is stopped. Fusidic acid is an anti-staphylococcal drug with few adverse effects. It is highly bioavailable orally, and has a long plasma half-life. Despite years of clinical use in numerous countries, resistance rates remain at low levels to date (6). Since clinical series or cases including ours have shown good results, this drug should not be forgotten when considering treatment options for folliculitis decalvans.

African Kaposi's Sarcoma

N/A.

Ulcerated Necrobiosis Lipoidica

N/A.

Neonatal Lupus Erythematosus in a newborn with Citrullinemia

A 24-day-old female newborn presented with multiple annular erythematous plaques with a targetoid shape, on the forehead, neck and upper trunk, that had begun ten days earlier. She had been diagnosed with citrullinemia type 1 in the first week of life and arginine supplementation was initiated. Her personal and family history was otherwise unremarkable. Laboratory tests showed high levels of anti-La/SSB and anti-Ro/SSA in both mother and baby. The patient was diagnosed with Neonatal lupus erythematosus on the basis of the clinical, histopathological and laboratorial findings. Neonatal lupus is a rare immune-mediated disease that results from transplacental transfer of maternal IgG antinuclear antibodies. The disease can affect different organs, mainly the skin and heart. Although the skin lesions are usually characteristic, they pose a diagnostic challenge in the absence of maternal history.

[Fresh bipolar osteochondral allograft of the ankle. Review of the literature and case report of a young patient with bilateral post-traumatic osteoarthritis]

OBJECTIVES

The treatment of severe post-traumatic ankle arthritis remains a challenge nowadays. Since patients suffering from this pathology are mainly young and active people, a correct reconstruction, if possible, of the articular cartilage defects of the tibiotalar joint is very important to achieve a good result. Fresh bipolar osteochondral allograft (FBOA) is a promising operative technique, as an alternative to arthrodesis and total ankle replacement, in pain relief, restoration of function and indefinite delay of arthritic disease progression.

METHODS

The authors made a review of the literature and present a case report of a young 30 years-old man, with bilateral post-traumatic osteoarthritis of the ankle, treated with (FBOA). The patient was evaluated clinically and radiographically monthly.

RESULTS

Pain relief and postoperative function was significantly improved reaching 94 points in the left ankle (preoperative of 40 points), and 92 points in the right ankle (preoperative 42 points) AOFAS score.

CONCLUSIONS

Fresh tibiotalar allografting seems to be a good alternative to arthrodesis and prosthetic replacement, in the treatment of ankle arthropathy and big articular cartilage defects mainly in young and active patients. This procedure achieves a good pain relief, maintaining functional joint motion and decreasing the risk of adjacent joint arthritis.

[Influence of Gilbert's syndrome on serum bilirubin levels and gallstone formation in children with chronic hemolytic disease]

To determine whether Gilbert's syndrome increases the risk of gallstone formation in children with chronic hemolytic disease, we studied 44 children with this diagnosis. Gallstones were detected by abdominal ultrasonography. This took place annually in scheduled examinations or in the context of acute abdominal pain. In all patients, the mean values of hemoglobin, reticulocyte and serum bilirubin in the chronic phase were recorded. In addition, TA insertion in the A(TA)nTATAA motif within the promoter region of the enzyme uridine-diphosphate-glucuronyl transferase (UGT1A1) was screened, since this is typically associated with GS.We found 10 (22.7 %) homozygotes for the mutated allele TA*7/TA*7, 12 (27.3 %) TA*6/TA*6 heterozygotes and 22 (50 %) homozygotes for the wild-type allele TA*6/TA*6. No statistically significant differences were found in the values of hemoglobin (Kruskal-Wallis test 2.496; p > 0.05) or in reticulocyte count (Kruskal-Wallis test 1.696; p > 0,05) between the three groups of patients, suggesting a similar degree of hemolysis. Patients with the UGT1A1 TA*7/TA*7 genotype showed higher mean serum bilirubin levels than did patients who were homozygous for the wild-type allele (Mann-Whitney test 35.5; p < 0.05). None of the patients with the TA*6/TA*6 genotype developed gallstones, whereas this complication was found in 2 of 12 (16.6 %) heterozygotes and 6 of 10 (60 %) homozygotes for the allele with TA insertion. In this latter group, 4 patients presented acute pancreatitis as a consequence of gallstone formation.The association between increased bilirubin load due to chronic hemolytic disease and diminished hepatic conjugation leads to raised serum bilirubin levels and consequently to an increased risk of gallstone formation. Therefore, we recommend screening for Gilbert's syndrome in children in the initial phases of chronic hemolytic diseases.