Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis

Objective: Despite recent advances, early diagnosis of psoriatic arthritis (PsA) remains a challenge in clinical practice. Ultrasound (US) could be a useful tool for the diagnosis and management of PsA. The objective of this review was to determine the role of US in early diagnosis of PsA.Methods: We have performed a literature review aiming to evaluate studies on US findings in psoriasis and their predictive value of progression to PsA, as well as studies on US features specific for PsA in comparison with other conditions.Results: A total of 40 studies were included. Sixteen studies assessed US findings in psoriasis, of which only 3 prospectively evaluated the role of US in predicting progression to PsA. Patients with PsA had a greater frequency of US abnormalities, in particular enthesitis and Power Doppler(PD) signal compared to patients with psoriasis only. In the longitudinal studies, psoriatic patients with higher enthesopathy scores at baseline were more likely to progress to PsA. Twenty-four studies evaluated US abnormalities in PsA and compared them to other conditions. Most specific US features that distinguish PsA from psoriasis were PD signal and erosions in joints and entheses. Extra-synovial changes, including peri-tendinous dermal soft tissue oedema with associated PD signal and flexor tendon enthesopathy, as well as thickening of the pulleys in the flexor tendons were highly characteristic for PsA, as they were frequently found in PsA patients, but in none of the RA patients. US-detected entheseal abnormalities in particular erosions and PD signal were more frequent in patients with PsA compared to fibromyalgia.Conclusion: Despite the wide use of US in PsA, more research is needed to identify predictive factors of progression to PsA in patients with psoriasis, as well as to determine most specific US features that differentiate PsA from other conditions.

Successful Management of Abdominal Wound Dehiscence with Bogota bag, Vacuum assisted Closure combined with Tension Sutures

The burst abdomen management has advanced significantly. Here we present a management of a burst abdomen of morbid obese patient with combination of modality including Bogota bag, vacuum assisted closure and tension suturing. The patient underwent laparotomy for removal of sigmoid tumor with local infiltration and had wound dehiscence associated with infection, tissue oedema and necrosis. As patient was morbidly obese and had large wound gap, we decided to manage it with Bogota bag principal and Vacuum Assisted Closing. After successful formation of granulation tissue, we were able to apply tension sutures. Hence using combination of above-mentioned options, the patient was successfully sent back to his normal routines without any complication.

Group B streptococcus sepsis in an infant presented with cellulitis of soft tissue of neck

We report a case of cellulitis of the soft tissue of the neck with group B streptococcus (GBS) sepsis in a 4-week-old baby boy presented with a 1-day history of fever, irritability and feed refusal. While in the hospital, a left-sided submandibular swelling extending to preauricular area started emerging, which progressed dramatically. Ultrasound scan of the neck confirmed inflammation of the underlying soft tissue while revealing multiple enlarged lymph nodes without any abscess formation and overlying soft tissue oedema. Blood cultures were flagged positive at 9 hours for GBS. The infant was treated with intravenous antibiotics for 2 weeks. GBS is considered a common cause of early-onset sepsis in neonates. However, it can also lead to late-onset sepsis in infancy with variable presentations. In our case, GBS sepsis manifested with cellulitis of the soft tissue of the neck along with swelling of local lymph nodes.

Anaesthesia for Maxillo Facial Surgery

Maxillofacial surgery presents unique challenges to the anaesthesiologist. The main challenges include working with multiple professionals; managing a shared airway; ensuring good surgical access; identifying difficult airway and choosing an appropriate airway management technique perioperatively; using measures to reduce bleeding and tissue oedema. To achieve this effectively and safely, there is a great need for good communication among anaesthesiologists, surgeons and other team members.

Fibrous Epulis: The Reactive Gingival Enlargement to Excise or Not to Excise

The volume thickening of soft tissue covering the alveolar ridges, designed gingival enlargement, is one of the frequent findings in clinical practice. However, they fail under varied presentations and their distinction allows a clinical diagnosis and defines an appropriate treatment to reduce recurrence. Among the diverse types of enlargement, fibrous epulis is the most common one. It is a localized uniform gingival overgrowth caused by tissue oedema and inflammatory hyperplasia in response to local irritations. This report outlines a case of fibrous epulis concerning a 56 years old male patient, in our periodontology department. A careful medical history, examination of the gingival, periodontal health status, and its reevaluation were assessed. Conventional periodontal treatment has been sufficient to minimize the gingival size. After an excisional biopsy, the histopathological examination was the determinants tool to accurate the diagnosis of fibrous epulis. Patient motivation and compliance during and after therapy has been a critical factor in the success of periodontal treatment and a key to prevent the recurrence of such lesions.

A Rare Case of Juvenile Idiopathic Arthritis following a Ruptured Baker’s Cyst in a Toddler

A Baker’s cyst is usually an incidental finding in adults being investigated for a joint arthropathy, and its rupture preceding the diagnosis of juvenile idiopathic arthritis (JIA) is rare in children. Here, we describe a case of a 4-year-old girl who presented to the Emergency Department with right calf pain, swelling, and no preceding history of trauma. MRI confirmed a ruptured Baker’s cyst with inflammatory arthropathy alongside an extensive synovial proliferation throughout the knee joint with large joint effusions and associated soft tissue oedema tracking superiorly and inferiorly along the medial head of gastrocnemius and anteriorly along the tibia. Further investigations revealed bilateral uveitis consistent with a diagnosis of juvenile idiopathic arthritis.

Myocardial perfusion and cardiac dimensions during extracorporeal membrane oxygenation–supported circulation in a porcine model of critical post-cardiotomy failure

Introduction: Venoarterial extracorporeal membrane oxygenation is widely used as mechanical circulatory support for severe heart failure. A major concern with this treatment modality is left ventricular distension due to inability to overcome the afterload created by the extracorporeal membrane oxygenation circuit. The present porcine study evaluates coronary circulation, myocardial perfusion and ventricular distension during venoarterial extracorporeal membrane oxygenation. Methods: Ten anesthetized open-chest pigs were cannulated and put on cardiopulmonary bypass. Heart failure was achieved by 90 minutes of aortic cross-clamping with insufficient cardioplegic protection. After declamping, the animals were supported by venoarterial extracorporeal membrane oxygenation for 3 hours. Continuous haemodynamic measurements were performed at baseline, during cardiopulmonary bypass/aortic cross-clamping and during venoarterial extracorporeal membrane oxygenation. Fluorescent microsphere injections at baseline and after 1, 2 and 3 hours on venoarterial extracorporeal membrane oxygenation evaluated myocardial perfusion. Left ventricular function and distension were assessed by epicardial echocardiography. Results: The myocardial injury caused by 90 minutes of ischaemia resulted in a poorly contracting myocardium, necessitating venoarterial extracorporeal membrane oxygenation in all animals. The circulatory support maintained the mean arterial blood pressure within a satisfactory range. A hyperaemic left anterior descending coronary artery flow while on extracorporeal membrane oxygenation was observed compared to baseline. Myocardial tissue perfusion measured by microspheres was low, especially in the subendocardium. Echocardiography revealed myocardial tissue oedema, a virtually empty left ventricle, and a left ventricular output that remained negligible throughout the extracorporeal membrane oxygenation run. Conclusion: Coronary artery blood flow is maintained during venoarterial extracorporeal membrane oxygenation after cardiopulmonary bypass and cardioplegic arrest despite severely affected performance of the left ventricle. Myocardial perfusion decreases, however, presumably due to rapid development of myocardial tissue oedema.

High-power, Short-duration Radiofrequency Ablation for the Treatment of AF

High-power, short-duration (HPSD) ablation for the treatment of AF is emerging as an alternative to ablation using conventional ablation generator settings characterised by lower power and longer duration. Although the reported potential advantages of HPSD ablation include less tissue oedema and collateral tissue damage, a reduction in procedural time and superior ablation lesion formation, clinical studies of HPSD ablation validating these observations are limited. One of the main challenges for HPSD ablation has been the inability to adequately assess temperature and lesion formation in real time. Novel catheter designs may improve the accuracy of intra-ablation temperature recording and correspondingly may improve the safety profile of HPSD ablation. Clinical studies of HPSD ablation are on-going and interpretation of the data from these and other studies will be required to ascertain the clinical value of HPSD ablation.

Ultrasonographic detection, definition and quantification of soft tissue oedema in psoriatic dactylitis

Aim: To define and score finger soft tissue oedema in psoriatic dactylitis by ultrasound.Material and methods: A systematic literature review (SLR) on ultrasound-detected finger soft tissue oedema was performed. Subsequently, based on the SLR, a Delphi survey was developed and circulated among a group of 13 expert sonographers, in order to obtain agreement on detection, definition and scoring of finger oedema by B-mode and power Doppler ultrasound. Agreement was considered achieved when each statement was approved by >75% of participants.Results: At the first Delphi round, 91 % agreement was obtained for the scanning technique to adopt, including the most appropriate area to evaluate. At the second round, 76% agreement was achieved on the definition of soft tissue finger oedema. At the third round, 76% agreement was obtained for B-mode and power Doppler scores. The volar aspect of the finger and comparisons with the contralateral side were agreed to be the most appropriate in terms of scanning technique. Agreed ultrasound definition of finger soft tissue oedema was “abnormal hypoechoic/anechoic areas, diffused or localized within the subcutaneous tissue between the epidermidis and the tendon-related anatomic structures (i.e. flexor tendon sheath, peritenonium, tendon pulleys), with local thickening, with or without local abnormal Doppler signal, visualised in two perpendicular planes and not evident on the contralateral side”. Semiquantitative (0-3) scores for both B-mode and power Doppler were agreed to be the most appropriate to be used.Conclusion: Our work produced, for the first time, technical indications, definition and scoring for the ultrasound assessment of soft tissue oedema in psoriatic dactylitis

Changes of indices of the oxygen-transport state, depending on periodization of the ischemic cerebral stroke

Objective. To elaborate a clinico-pathogenetic periodization of ischemic cerebral stroke, depending on changes of the oxygen-transport state indices in critically ill patents, suffering the ischemic cerebral stroke on background of conduction of complex intensive therapy. Materials and methods. Into the investigation 75 patients, suffering ischemic cerebral stroke, ageing 41 - 77 yrs, were included, in whom the indices of oxygen-transport state and severity of neurological symptoms on background of complex intensive therapy were studied. Depending on severity of neurologic symptoms, three similar groups of patients were formed (25 patients in every one), suffering mild, middle-severe and severe ischemic cerebral stroke, in which the disease severity was determined in accordance to the National Institute of Health Stroke Scale. Results. On background of the complex intensive therapy conduction the duration of the most acute period in mild ischemic stroke have constituted 3 days, in a middle-severe - 4 days, and in a severe one - 7 days. Tendency towards minimization of neurologic deficiency was noted, if parameters of central hemodynamics, the oxygen budget and the cognition level were stabilized during 2 days. Simultaneously the cardiac index values for all groups of patients have been situated in a range of (2.99 ± 0.20) l × min-1 × m-2, the oxygen delivery index have exceeded (509 ± 34) ml × min-1 × m-2. The restored level of neurological symptoms have not a tendency towards improvement or was stable during several days in accordance to data of the National Institute of Health Stroke Scale. The restored level of neurological symptoms had a tendency to improvement or staying during several days stable in accordance to indices of scales of National Institute of Health and Comas Glasgow, than a progressive staged improvement began. Conclusion. Normalization during 2 days of the oxygen-transport state indices without neurological symptoms progression constitutes a criterion of conclusion of the most acute period of the disease in patients, suffering mild, middle-severe and severe ischemic cerebral stroke. The restored due to intensive therapy during 48 h the oxygen-transport state without progressing of neurological symptoms in patients, suffering ischemic cerebral stroke, witnesses lowering of the cerebral tissue oedema and restoration of the autoregulation processes.