Atopic dermatitis.

THE COMPARISON: A) Pink scaling plaques and erythematous erosions in the antecubital fossae of a 6-year-old White boy. B) Violaceous, hyperpigmented, nummular plaques on the back and extensor surface of the right arm of a 16-month-old Black girl. C) Atopic dermatitis and follicular prominence/accentuation on the neck of a young Black girl.

Interleukin-6 and triceps skinfold are associated with severity/cancer stage in newly-diagnosed colorectal cancer patients.

INTRODUCTION: Introduction: colorectal cancer (CRC) has an important impact on morbidity and mortality globally, and nitroxidative stress, inflammation, and nutritional status are linked with its progression. Aim: to analyze the association of inflammatory, anthropometric, functional, and oxidative markers with tumor stage in newly-diagnosed CRC patients at a public reference center in Maceió, Alagoas, Brazil. Methods: patient-generated subjective global assessment was applied, and weight, height, arm circumference, triceps skinfold (TSF), arm muscle circumference, and handgrip strength were obtained. A fasting blood sample was collected, centrifuged, and the serum was stored at -80 °C until the analysis. Malonaldehyde levels were quantified by HPLC (high-performance liquid chromatography) and cytokines, namely tumor necrosis factor-alpha, and interleukins IL-6, IL-8, and IL-17 were analyzed by ELISA. Patients were grouped according to cancer stage into group 1 (stage 0-III) and group 2 (stage IV). A binary logistic regression analysis was performed, adjusted for sex and age, to assess the relationships between the variables studied and cancer stage. Significance was considered when p < 0.05. Results: twenty-eight CRC patients were included, twenty (71.4 %) from group 1 and eight (28.6 %) from group 2. The binary logistic regression revealed that lower TSF adequacy (OR = 0.929; CI 95 % = 0.870-0.993; p = 0.029) and higher IL-6 levels (OR = 1.001; CI 95 % = 1.000-1.002; p = 0.012) increased the chance of patients having tumor stage IV. Conclusion: These data support that IL-6 and TSF may help in cancer stage assessment in clinical practice. Modulation of inflammation by IL-6 levels may be a target in CRC treatment.

INTRODUCCIÓN: Introducción: el cáncer colorrectal (CCR) tiene un impacto importante en la morbilidad y mortalidad a nivel mundial, y el estrés nitroxidativo, la inflamación y el estado nutricional están relacionados con su progresión. Objetivos: analizar la asociación de los marcadores inflamatorios, antropométricos, funcionales y oxidativos con el estadio tumoral de pacientes con CCR recién diagnosticados en un centro público de referencia de Maceió, Alagoas, Brasil. Métodos: se aplicó la valoración global subjetiva generada por el paciente y se obtuvieron el peso, la altura, la circunferencia del brazo, el pliegue cutáneo del tríceps (PCT), la circunferencia del músculo del brazo y la fuerza de prensión. Se tomó una muestra de sangre en ayunas, se centrifugó y el suero se almacenó a -80 °C hasta el momento del análisis. Los niveles de malonaldehído se cuantificaron por CLAR (cromatografía líquida de alta resolución) y las citocinas, representadas por el factor de necrosis tumoral alfa y las interleucinas IL-6, IL-8 e IL-17, se analizaron mediante ELISA. Los pacientes se agruparon según el estadio del cáncer en grupo 1 (estadio 0-III) y grupo 2 (estadio IV). Se realizó una regresión logística binaria, ajustada por sexo y edad, para evaluar las relaciones entre las variables estudiadas y el estadio del cáncer. Se consideró la significancia cuando p < 0,05. Resultados: se incluyeron veintiocho pacientes con CCR, de los cuales veinte (71,4 %) eran del grupo 1 y ocho (28,6 %) del grupo 2. La regresión logística binaria reveló que una menor adecuación de PCT (OR = 0,929; IC 95 % = 0,870-0,993; p = 0,029) y los niveles más altos de IL-6 (OR = 1,001; IC 95 % = 1,000-1,002; p = 0,012) aumentaban la probabilidad de que los pacientes tuvieran un tumor en estadio IV. Conclusiones: estos datos señalan que la IL-6 y el PCT pueden ayudar en la evaluación del estadio del cáncer en la práctica clínica. La modulación de la inflamación por los niveles de IL-6 podría ser una diana en el tratamiento del CCR.

Association of Radial Longitudinal Deficiency and Thumb Hypoplasia: An Update Using the CoULD Registry.

BACKGROUND: Deficiency of the radial aspect of the forearm and hand is the most common congenital longitudinal deficiency of the upper limb. Radial longitudinal deficiency is associated with several named syndromes. The purpose of the present study was to explore patterns of radial longitudinal deficiency and thumb hypoplasia in syndromes and to examine the severity of these differences across various syndromes. METHODS: Data were collected from the Congenital Upper Limb Differences (CoULD) registry. Congenital differences are classified in the registry with use of the Oberg-Manske-Tonkin (OMT) classification system. Diagnosis of a syndrome by a physician as noted in the CoULD registry was recorded. Thumb deficiency and radial deficiency were classified according to the modified versions of the Blauth criteria and the Bayne and Klug criteria, respectively. RESULTS: We identified 259 patients with 383 affected limbs with radial deficiency. Eighty-three of these patients had a diagnosed syndrome. The severity of radial deficiency was correlated with the severity of thumb deficiency. The Kendall tau coefficient indicated significant correlation between radial severity and thumb severity (tau = 0.49 [95% confidence interval = 0.40 to 0.57]; p < 0.05). Subjects with a syndrome were twice as likely to have bilateral deficiency and 2.5 times more likely to have both radial and thumb deficiency compared with subjects without a syndrome. Subjects with VACTERL syndrome (vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies, and limb defects) had patterns of thumb and radial deficiency similar to the general cohort, whereas subjects with Holt-Oram syndrome, TAR (thrombocytopenia absent radius) syndrome, and Fanconi anemia demonstrated varied presentations of thumb and radial deficiency. CONCLUSIONS: The present study investigated the characteristics of patients with radial longitudinal deficiency and thumb hypoplasia. Our results support the findings of previous research correlating the severity of radial deficiency with the severity of thumb deficiency. Furthermore, we identified characteristic features of patients with radial longitudinal deficiency and associated syndromes.

[Concomitant breast surgery with a vertical latero-thoracic incision in continuity with a brachioplasty incision: About twelve (12) cases after massive weight loss]. / Plastie brachio-thoraco-mammaire : à propos de 12 cas après amaigrissement massif.

INTRODUCTION: The need of iterative surgeries, the proximity of two anatomical areas, the combination of an aesthetic surgery with a surgery covered by health insurance are the reasons which motivated the authors to provide a simultaneous procedure on arms and breast in patients achieving massive weight loss. We propose a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision to treat the excess skin and subcutaneous tissue of the lateral chest wall, either by resection, or by increasing the breast with the patients own autologous tissue. METHODS: Between 2010 and 2017, twelve patients aged between 31 and 56 years, with 42 being the average, have undergone a technique that utilises a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision: transverse skin incisions and free nipple transplantation for correction of extreme gynaecomastia (2 cases), mastopexy with resection of the excess tissue of the lateral chest wall (8 cases), autologous breast augmentation by the use of intercostal artery perforator flaps (2 cases). Mean body mass index (BMI) was 24kg/m2 [23; 32] after average weight loss of 56kg [14; 112] following diet (3 cases) or bariatric surgery (9 cases). RESULTS: Mean operative time was 4hours [3: 6], mean length of hospital stay was 4 days [2; 9]. We observed one major complication (hematoma) and one minor complication (wound dehiscence). At a mean follow-up of 21 months (ranged from 15 days to 84 months), the lateral flank scarring was well tolerated, with the additional benefit of reducing flank fullness. CONCLUSION: The extended lateral flank scar allows reducing the excess skin and subcutaneous tissue of the lateral chest wall, while being easily concealable. This technique offers an elegant solution to this excess that used to persist after multistage surgeries.

56-year-old woman • worsening pain in left upper arm • influenza vaccination in the arm a few days prior to pain onset • Dx?

Worsening pain in left upper arm. Pain worsens with movement-especially abduction. Influenza vaccination in the arm a few days prior to pain onset. Dx?

Outcome evaluation of new calcium titanate schanz-screws for external fixators. First clinical results and cadaver studies.

OBJECTIVE: External fixators are important for correcting length discrepancies and axis deformities in pediatric or trauma orthopedic surgery. Pin loosening is a common pitfall during therapy that can lead to pain, infection, and necessary revisions. This study aims to present clinical data using calcium titanate (CaTiO3) Schanz screws and to measure the fixation strength. PATIENTS AND METHODS: 22 titanate screws were used for external fixators in 4 pediatric patients. Therapy was initiated to lengthen or correct axial deformities after congenital abnormalities. The maximum tightening torque was measured during implantation, and the loosening torque was measured during explantation. In addition, screws of the same type were used in a cadaver study and compared with stainless steel and hydroxyapatite-coated screws. 12 screws of each type were inserted in four tibias, and the loosening and tightening torque was documented. RESULTS: The fixation index in the in vivo measurement showed a significant increase between screw insertion and extraction in three of the four patients. The pins were in situ for 91 to 150 days, and the torque increased significantly (P = 0.0004) from insertion to extraction. The cadaveric study showed lower extraction torques than insertion torques, as expected in this setting. The calculated fixation index was significantly higher in the CaTiO3 group than in the other groups (P = 0.0208 vs. HA and P < 0.0001 vs. steel) and in the HA group vs. plain steel group (P = 0.0448). CONCLUSION: The calcium titanate screws showed favorable fixation strength compared to HA and stainless steel screws and should be considered in long-term therapy of external fixation.

First use of anatomical networks to study modularity and integration of heads, forelimbs and hindlimbs in abnormal anencephalic and cyclopic vs normal human development.

The ill-named "logic of monsters" hypothesis of Pere Alberch - one of the founders of modern evo-devo - emphasized the importance of "internal rules" due to strong developmental constraints, linked teratologies to developmental processes and patterns, and contradicted hypotheses arguing that birth defects are related to a chaotic and random disarray of developmental mechanisms. We test these hypotheses using, for the first time, anatomical network analysis (AnNA) to study and compare the musculoskeletal modularity and integration of both the heads and the fore- and hindlimbs of abnormal cyclopic trisomy 18 and anencephalic human fetuses, and of normal fetal, newborn, and adult humans. Our previous works have shown that superficial gross anatomical analyses of these specimens strongly support the "logic of monsters" hypothesis, in the sense that there is an 'order' or 'logic' within the gross anatomical patterns observed in both the normal and abnormal individuals. Interestingly, the results of the AnNA done in the present work reveal a somewhat different pattern: at least concerning the musculoskeletal modules obtained in our AnNA, we observe a hybrid between the "logic of monsters" and the "lack of homeostasis" hypotheses. For instance, as predicted by the latter hypothesis, we found a high level of left-right asymmetry in the forelimbs and/or hindlimbs of the abnormal cyclopic trisomy 18 and anencephalic human fetuses. That is, a network analysis of the organization of/connection between the musculoskeletal structures of these fetuses reveals a more "chaotic" pattern than that detected by superficial gross anatomical comparisons. We discuss the broader developmental, evolutionary, and medical implications of these results.

A rare disease with a rare presentation: hemi-atrophy caused by fibromuscular dysplasia in a 27 month old girl.

We discuss the case of a 27-month-old girl afflicted with fibromuscular dysplasia. She presented with hemiatrophy of left upper and lower limbs, nail dystrophy, ulcers on the tips of her toes, cold and painful limbs, foot drop, and hypertension. The initial appearance started at 2 months of age and other diagnoses such as complex regional pain syndrome, reflex sympathetic syndrome, vasculitis and coagulation disorders had been considered. Angiography revealed that all the arterial branches of the left lower and upper limbs, from brachial to ulnar and radial, and from iliac and femoral to tibialis arteries were affected. Sural nerve biopsy confirmed the diagnosis. In the follow-up visits until 2 years after the patient's discharge she did not develop any new problem and her blood pressure was controlled by enalapril and amlodipine.

Coexistence of a pectoralis quartus muscle, a supernumerary head of biceps brachii muscle and an accessory head of flexor digitorum profundus muscle.

Although anatomical variations in the upper limb are frequent, coexistence of multiple combined variations is rare. During a routine educational dissection at Jeju National University Medical School, three muscular variations were found in a 75-year-old Korean male cadaver, in which a supraclavicular cephalic vein was also found in ipsilateral upper extremity during skinning. Here we describe cha- racteristics of the pectoralis quartus muscle, the supernumerary head of biceps brachii muscle and an accessory head of flexor digitorum profundus muscle, and discuss their coexistence from morphological and embryological points of view.

Targeted Muscle Reinnervation: Considerations for Future Implementation in Adolescents and Younger Children.

Prosthetic options for patients with proximal upper limb absence are limited. Current above-elbow prostheses may restore basic motor functions for crucial activities, but they are cumbersome to operate, lack sensory feedback, and are often abandoned. Targeted muscle reinnervation is a novel surgical procedure that enhances the ability of patients with above-elbow amputations to intuitively control a myoelectric prosthesis. By transferring multiple severed peripheral nerves to a robust target muscle, targeted muscle reinnervation restores physiologic continuity and enables more intuitive prosthetic control. Although reports have been limited to adults, targeted muscle reinnervation has great potential for application in a pediatric population with congenital or acquired proximal upper limb absence. In this review, the authors describe the rehabilitative challenges of proximal upper limb amputees and outline the objectives, techniques, and outcomes of targeted muscle reinnervation. The authors then discuss important considerations for adapting targeted muscle reinnervation to pediatric patients, including cause of upper limb absence, central plasticity, timing of prosthesis fitting, role of the family, surgical feasibility, and bioethical aspects. The authors believe that carefully screened school-age children and adolescents with bilateral proximal upper limb absence, and select adolescents with unilateral proximal upper limb absence, should be seriously considered for targeted muscle reinnervation performed by an experienced surgical and rehabilitation team.

Total reconstruction of giant congenital circumferential nevi of the upper limb using a large pedicle expanded flank flap: A brief report.

Tissue expansion is an invaluable reconstructive strategy after surgical excision of a congenital naevus. However, reducing the number of operations is very important for patients with a giant congenital naevus. We used a large pedicle expanded flank flap to successfully treat a giant circumferential naevus that extended from the left upper arm to the wrist, which also provided excellent contour and colour match. We consider this an effective and convenient method to treat a circumferential naevus covering almost the entire upper limb of the paediatric patient.

Variations in brachial plexus with respect to concomitant accompanying aberrant arm arteries.

INTRODUCTION: Variations in the brachial plexus are the rule rather than the exception. This fact is of special interest for the anesthetist when planning axillary block of brachial plexus. MATERIAL AND METHODS: 167 cadaver arms were evaluated for variations in brachial plexus, with focus on the cords of the plexus, the loop of the median nerve, and the course of the median, musculocutaneous, ulnar, axillary and radial nerves. In addition, concomitant arterial variations were recorded. RESULTS: In 167 arms, variations were detected in 60 cases (36%). With 46 arms (28%) most variations concern the median nerve, followed by 13 cases (8%) which involved the musculocutaneous nerve. Ulnar, axillary and radial nerve variations were rare, amounting to 1.2% for each nerve. In median nerve conditions with a shifted loop of median nerve (12%), a hidden position of the loop or a hidden course of the beginning median nerve (8%) and a doubled loop of median nerve (17%) were observed. In musculocutaneous nerve conditions with a non-perforated coracobrachialis (1.8%), a doubled origin of the nerve (1.2%) and a giving back of branches to the median nerve (1.8%) were noted. Variations in ulnar, axillary and radial nerves concerned lower than normal diameters. CONCLUSIONS: It must be stressed that cases which showed a hidden position or a doubled expression of the loop of the median nerve, a hidden course of its beginning and variable interconnections between musculocutaneous and median nerves are of special interest for anesthetists and surgeons. Hence, it is important to note that variations of arm arteries can be associated with brachial plexus variations. For example, a common trunk of axillary artery followed by a hidden loop and course of the median nerve may result in incomplete axillary block of brachial plexus.

Safety and tolerability of Kinesio Taping in patients with arm lymphedema: medical device clinical study.

PURPOSE: The aim of this study is to assess the safety and tolerability of Kinesio Taping (KT) in patients with arm lymphedema. METHOD: Medical device clinical study in women with arm lymphedema. Kinesio Tex Gold bandage was applied by the KT technique. Assessments and interviews were carried out both at the beginning and 4 days after intervention. Skin disorders, reported tolerance and modification of limb volume and function after intervention were assessed. Changes in limb volume and functionality before and after intervention were compared by the Student's t test and the Wilcoxon Signed-Rank test, considering significant p value <0.05. RESULTS: Twenty-four women were studied. After intervention, no patient had cutaneous lesions, vesicle or limb hyperthermia, and 4.2% presented skin peeling and redness. Most patients reported no change in social life and that they felt safer in the daily activity and were very pleased with the treatment. The patients presented improvement of upper limb functionality after intervention (p < 0.001). No difference of limb volume was found after intervention (p = 0.639). CONCLUSIONS: Kinesio Tex Gold bandage by the KT technique proved to be safe and tolerable in patients with lymphedema, with improved functionality and no change of the affected limb volume.