Tissue Dielectric Constant and Skin Stiffness Relationships in Lower Extremity Lymphedema.

Background: Lower extremity lymphedema or edema (LELE) may progressively transition from a state of excess tissue fluid to increased fat accumulation and collagen deposition, with tissue fibrosis and hardening. Such changes may lead to altered tissue water holding and thereby impact tissue dielectric constant (TDC). This study seeks to evaluate the relationship between TDC and tissue indentation force (TIF) in patients with LELE and assess the utility of the leg/arm TDC ratio (LAR) as an indicator of LELE. Methods and Results: Thirty females (49-91 years) with previously diagnosed LELE were evaluated during a scheduled session. TDC and TIF were measured 8 cm proximal to the medial malleolus on the medial and lateral aspects of both legs and on one forearm 8 cm distal to the antecubital fossa. The TDC-TIC relationship and the LAR were subsequently determined. Main results showed an absence of a significant correlation between TDC and TIF on medial or lateral leg sites but a positive correlation on the normal forearm site. Further, LAR values exceeded the published proposed threshold of 1.35 for 29/30 patients when using medial-side TDC values and 28/30 patients when using lateral-side TDC values. Conclusions: Findings suggest that for patients with LELE, TDC values are significantly elevated on medial and lateral standardized sites. The LAR determined using either medial or lateral sites that are similar to each other and have values consistent with a lymphedema threshold of 1.35. In edematous legs of the type evaluated herein, there is no apparent relationship between TDC values and indentation force.

Monkeypox Proctitis: A Case of Targeted Treatment With Tecovirimat.

Monkeypox (MPX) is an exanthematous disease first identified in the 1950s, associated with animals in Central and Western Africa, and has since been found sporadically worldwide. In May 2022, a returning family from Nigeria tested positive for MPX, which marked the onset of the current outbreak. It has now become a disease of concern in most parts of the world. The current standings are nearing 90,000 cases, with numbers increasing daily. The United States reported 29,711 cases so far. The characteristic exanthem of MPX is known to be present ubiquitously on the human habitus, with recent reports describing anogenital and mucosal lesions. Here, we present a rare case of a 43-year-old male presenting with excruciating perianal pain and purulent discharge, found to have proctitis secondary to MPX, and subsequently treated with Tecovirimat, a targeted antiviral therapy.

Lymphocytic Hypophysitis in a Patient With Suspected Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH).

Lymphocytic hypophysitis (LH) is a rare, autoimmune condition that presents with a range of symptoms that must garner the attention of medical practitioners. Clinically, it is characterized by symptoms of a compressive sellar mass with varying degrees of hypopituitarism due to chronic inflammatory infiltrate of the pituitary gland. It is often seen in women in their third trimester or postpartum and is associated with other autoimmune phenomena. Our case report describes a 73-year-old female with a past medical history of hypothyroidism and hypertension, who presented with continued intermittent dizziness, fatigue, and mild subjective hearing loss for the past several months. She was referred to the emergency department due to a sodium level of 119 and was initially diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient was treated accordingly; however, she failed to show signs of improvement. Due to her clinical presentation, imaging studies, and laboratory results, the patient was suspected to have LH, which was confirmed with the improvement of her symptoms after treatment with steroids. Because of the rare occurrence and possible atypical presentation of LH, this case illustrates the importance of maintaining a high index of clinical suspicion when diagnosing a patient with an unknown cause of hyponatremia, especially in patients with coexisting autoimmune disorders.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis (ANMDARE) in a Patient With Hashimoto's Thyroiditis.

Although encephalitis is more commonly caused by various infections, other etiologies that may rarely cause encephalitis must garner the attention of medical practitioners. In the realm of immune-mediated etiologies, anti-N-methyl-D-aspartate receptor encephalitis (ANMDARE) is the most common. It usually presents in a typical fashion with psychiatric symptoms followed by abnormal movements such as orofacial-lingual dyskinesia, tremor, dystonia, bradykinesia, ballism, or choreoathetosis occurring at or within the first month of onset, often affecting women and having a high correlation with ovarian teratomas. Our case report describes a 59-year-old Hispanic male with Hashimoto thyroiditis who presented with rapid cognitive decline. The diagnosis was confirmed with positive detection of NMDA receptor antibodies in the patient's cerebrospinal fluid following a lumbar puncture. The patient was treated with the first-line therapy of intravenous (IV) immunoglobulins and corticosteroids with temporary relief of symptoms. Due to the rare occurrence and possible atypical presentation of ANMDARE, this case illustrates the importance of maintaining a high index of clinical suspicion when diagnosing a patient with an unknown cause of cognitive dysfunction, especially when considering various differentials based on the patient's history.

Percutaneous balloon compression technique using intraoperative contrasted DynaCT for the treatment of refractory trigeminal neuralgia: initial experience.

OBJECTIVE: Percutaneous balloon compression (BC) is a well-established technique that can provide immediate relief to patients suffering from trigeminal neuralgia (TN). The general procedure of BC uses fluoroscopy imaging to guide the needle through the foramen ovale (FO). The aim of this study was to describe our experience with a novel technique using intraoperative contrast-enhanced DynaCT as an adjunct for more accurate and safer guidance of the needle to the FO. METHODS: In this study, DynaCT was used to perform BC in 20 TN cases. The three-dimensional path of the needle was pre-planned using DynaCT obtained during the administration of IV contrast. The FO was accessed in a single pass along the path pre-determined from the DynaCT images, avoiding any major arteries and veins. DynaCT was also used for confirmation of the final position of the needle prior to insertion of the balloon as well as for confirmation of the position of the balloon after inflation. RESULTS: Intravenous contrast-enhanced DynaCT-guided percutaneous BC allowed precise advancement and positioning of the needle within the FO. It facilitated cannulation of the FO along a pre-determined path that avoided any major vascular structures. Clinical outcomes were excellent-all patients had a quick postoperative recovery, and there were no complications. CONCLUSIONS: The advantages of the contrast-enhanced DynaCT-guided technique include a single precise needle pass and avoidance of vessel injury. Precise placement of the balloon into different aspects of the FO can target trigeminal branches more selectively and allow for a better outcome.

Cannabinoid receptor agonists from Conus venoms alleviate pain-related behavior in rats.

Cannabinoid (CB) receptor agonists show robust antinociceptive effects in various pain models. However, most of the clinically potent CB1 receptor-active drugs derived from cannabis are considered concerning due to psychotomimetic side effects. Selective CB receptor ligands that do not induce CNS side effects are of clinical interest. The venoms of marine snail Conus are a natural source of various potent analgesic peptides, some of which are already FDA approved. In this study we evaluated the ability of several Conus venom extracts to interact with CB1 receptor. HEK293 cells expressing CB1 receptors were treated with venom extracts and CB1 receptor internalization was analyzed by immunofluorescence. Results showed C. textile (C. Tex) and C. miles (C. Mil) samples as the most potent. These were serially subfractionated by HPLC for subsequent analysis by internalization assays and for analgesic potency evaluated in the formalin test and after peripheral nerve injury. Intrathecal injection of C. Tex and C. Mil subfractions reduced flinching/licking behavior during the second phase of formalin test and attenuated thermal and mechanical allodynia in nerve injury model. Treatment with proteolytic enzymes reduced CB1 internalization of subfractions, indicating the peptidergic nature of CB1 active component. Further HPLC purification revealed two potent antinociceptive subfractions within C. Tex with CB1 and possible CB2 activity, with mild to no side effects in the CB tetrad assessment. CB conopeptides can be isolated from these active Conus venom-derived samples and further developed as novel analgesic agents for the treatment of chronic pain using cell based or gene therapy approaches.

Microsurgical resection of petroclival meningiomas treated with stereotactic radiosurgery to address persistent post-treatment trigeminal pain.

BACKGROUND: Petroclival meningiomas (PCM) are challenging tumors to manage. Observation, Stereotactic radiosurgery (SRS) and surgical resection have typically been offered as treatment options. A percentage of patients with PCMs present with trigeminal pain. We present four patients with small PCMs presenting with Trigeminal neuralgia (TN) that were treated with radiosurgery and continued to have debilitating trigeminal pain afterwards. All of them underwent microsurgical resection (MR) of their tumor to manage their trigeminal pain. OBJECTIVE: Trigeminal Neuralgia in the setting of PCM is rare. Oftentimes in these subset of patients TN pain persists after radiation and medical therapy. We explore the possibility of addressing intractable TN pain with microsurgical resection. METHODS: Patients with petroclival meningiomas presenting with trigeminal pain and having persistent pain after treatment with radiosurgery were included in our review. Those patients were treated with microsurgical resection of their tumor to help control their persistent pain. The patients' demographics, clinical, and radiological data were reviewed. The primary aim of the review was to assess the patients' Barrow Neurological Institute (BNI) trigeminal neuralgia scores following microsurgical resection. RESULTS: Four female patients were identified. The tumors were locally controlled after SRS, however all four patients continued to have debilitating trigeminal pain despite medical management. All patients had complete resolution of their TN pain in the immediate postoperative period, with a BNI score of I on their last follow up. CONCLUSION: Microsurgical resection is an appropriate option for patient's petroclival meningiomas with persistent facial pain after treatment with SRS.