Subcutaneous fat necrosis of the newborn: clinical and histopathological review and use of cutaneous ultrasound Necrosis grasa subcutánea del recién nacido: revisión clínica e histopatológica y utilidad de la ecografía cutánea.

Subcutaneous fat necrosis of the newborn is a rare lobular panniculitis. It is characteristic of term or post-term neonates with a history of perinatal compromise or maternal gestational pathology. The cutaneous manifestations consist of erythematous and indurated subcutaneous plaques and nodules located over the dorsal region and the shoulders. Diagnosis is clinical and pathological. Histopathological findings include lobular panniculitis with a lymphohistiocytic inflammatory infiltrate with few neutrophils, fatty necrosis, deposition of radial needle-shaped crystals in the adipocytes, and possible calcification and hemorrhage. The cutaneous ultrasound shows hyperechoic and avascular subcutaneous cellular tissue and acoustic shadows may appear corresponding to calcifications. The clinical differential diagnosis includes sclerema neonatorum and post-corticosteroid panniculitis. Histologically crystal-forming panniculitis conditions are in the differential diagnosis. The disease is usually self-limited but complications such as hypercalcemia, hypoglycemia, hypertriglyceridemia, thrombocytopenia, and anemia may occur. Complications should be ruled out and treated at diagnosis and during follow-up. The most important complication is hypercalcemia.La necrosis grasa subcutánea neonatal es una paniculitis lobulillar infrecuente. Es característica de neonatos a término o postérmino con antecedentes de sufrimiento perinatal o patología gestacional materna. Las manifestaciones cutáneas consisten en placas y nódulos subcutáneos eritematosos e indurados localizados preferentemente en la región dorsal y los hombros. El diagnóstico es clínicopatológico. Los hallazgos histopatológicos comprenden una paniculitis lobulillar con un infiltrado inflamatorio linfohistiocitario con escasos neutrófilos, necrosis grasa, depósito de cristales radiados en los adipocitos y posibles focos de calcificación y hemorragia. En la ecografía cutánea se observa hiperecogenicidad y avascularización del tejido celular subcutáneo y pueden aparecer sombras acústicas posteriores que se correspondencon calcificaciones. El diagnóstico diferencial clínico se debe realizar con el escleredema neonatorum y la paniculitis postesteroidea, e histológicamente con las paniculitis con formación de cristales. La enfermedad suele ser autolimitada pero pueden aparecer complicaciones como la hipercalcemia, la hipoglucemia, la hipertrigliceridemia, latrombocitopenia y la anemia. Las complicaciones deben ser descartadas y tratadas en el diagnóstico y durante el seguimiento. La complicación másimportante es la hipercalcemia.

Sonography of Encapsulated Fat Necrosis with Histologic Correlation.

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Relationship between trapezius muscle hardness and transverse cervical artery flow in association with neck and upper-back stiffness.

Neck and upper-back stiffness is a common discomfort encountered occasionally in daily life among otherwise healthy subjects. The pathogenesis of this condition could be attributable to increased tension in muscles such as the trapezius muscle (TM). The transverse cervical artery (TCA) is one of the feeding arteries for the TM, and TCA flow is reportedly related to symptoms of neck and upper-back stiffness. This study quantitatively investigated relationships between TM hardness and TCA hemodynamics as evaluated on Doppler sonography. Questionnaires regarding neck and upper-back stiffness, muscle hardness measurements obtained using a muscle hardness meter and examinations of TCA hemodynamics using Doppler sonography were performed on 55 healthy young adults (25 males, 30 females; mean age, 22 ± 2 years). Subjects displaying neck and upper-back stiffness actually exhibited high muscle hardness (median, 14.0; interquartile range (IQR), 12.9-18.0) compared to those without the symptom (median, 12.0; IQR, 9.9-14.0; p = .002). Peak systolic velocity in the TCA on Doppler sonography was lower in subjects with the symptom (median, 65.1 cm/s; IQR 59.6-72.5 cm/s) than in those without the symptom (median, 72.5 cm/s; IQR 66.5-84.2 cm/s; p = .012). Resistive index in the TCA was high (r2  = .605, p = .014) with increasing TM hardness, particularly among male subjects with the symptom. The present study suggests that high resistance and low blood flow velocity in the TCA could be closely associated with the underlying pathogenesis of neck and upper-back stiffness.

Tuberculosis-The Great Mimicker: A Case of Traumatic Drainage of Cold Abscess.

BACKGROUND: Tuberculosis is characterized by cold abscess, which classically lacks the usual signs and symptoms of inflammation. This case report highlights an atypical presentation of tuberculous cold abscess in the form of appearance of massive swelling in the back overnight after a blunt trauma, mimicking post-traumatic hematoma. CASE DESCRIPTION: A 32-year-old man came to our outpatient department with sudden swelling over the right side of the upper back (25 × 8 × 8 cm) and loin (10 × 4 × 4 cm) after a fall from 1.5 to 2 m height the previous night. The possible differential diagnosis of a traumatic pathology, complicated by a bleeding disorder, resulting in massive hematoma was initially made. However, hematologic investigations were within normal limits. Magnetic resonance imaging suggested an anterior subligamentous abscess at the C7-T1 level tracking through the paraspinal muscles and communicating with the subcutaneous abscess, and at the L3 level, paraspinal abscess tracking to the subcutaneous plane. There was no cord compression or signal changes in the cord. Both the abscesses were pigtailed in antigravity fashion, and material was sent for culture, which proved to be tuberculosis. The patient was treated with antituberculosis treatment for 18 months and improved over the course with complete resolution of symptoms. At 4-year follow-up, the patient is asymptomatic with no evidence of recurrence. CONCLUSIONS: Appearance of massive swelling overnight in patients with cold abscess has not been described in the literature. While evaluating an atypical presentation such as sudden post-traumatic swelling over the thoracolumbar area, the clinician should keep a differential diagnosis of tuberculous abscess and investigate clinicoradiologically to rule out tuberculosis, especially in developing countries.

Predicting spinal profile using 3D non-contact surface scanning: Changes in surface topography as a predictor of internal spinal alignment.

INTRODUCTION: 3D non-contact surface scanners capture highly accurate, calibrated images of surface topography for 3D structures. This study sought to establish the efficacy and accuracy of using 3D surface scanning to characterise spinal curvature and sagittal plane contour. METHODS: 10 healthy female adults with a mean age of 25 years, (standard deviation: 3.6 years) underwent both MRI and 3D surface scanning (3DSS) (Artec Eva, Artec Group Inc., Luxembourg) while lying in the lateral decubitus position on a rigid substrate. Prior to 3DSS, anatomical landmarks on the spinous processes of each participant were demarcated using stickers attached to the skin surface. Following 3DSS, oil capsules (fiducial markers) were overlaid on the stickers and the subject underwent MRI. MRI stacks were processed to measure the thoracolumbar spinous process locations, providing an anatomical reference. 3D coordinates for the markers (surface stickers and MRI oil capsules) and for the spinous processes mapped the spinal column profiles and were compared to assess the quality of fit between the 3DSS and MRI marker positions. RESULTS: The RMSE for the polynomials fit to the spinous process, fiducial and surface marker profiles ranged from 0.17-1.15mm for all subjects. The MRI fiducial marker location was well aligned with the spinous process profile in the thoracic and upper lumbar spine for nine of the subjects. Over the 10 subjects, the mean RMSE between the MRI and 3D scan sagittal profiles for all surface markers was 9.8mm (SD 4.2mm). Curvature was well matched for seven of the subjects, with two showing differing curvatures across the lumbar spine due to inconsistent subject positioning. CONCLUSION: Comparison of the observed trends for vertebral position measured from MRI and 3DSS, suggested the surface markers may provide a useful method for measuring internal changes in sagittal curvature or skeletal changes.

Dermoscopic aspect of verrucous epidermal nevi: new findings

Background/aim: Verrucous epidermal nevi are cutaneous hamartomas with many clinical variants. Dermoscopic features of verrucous epidermal nevus have rarely been investigated. We aimed to identify dermoscopic findings of the entity which will facilitate the diagnostic process by reducing the use of invasive diagnostic methods. Materials and methods: The study included the patients with histopathologically approved verrucous epidermal nevus. Clinical, dermoscopic, and histopathological features of the patients were retrospectively reviewed and the findings identified were recorded. Dermoscopic examination was performed with a polarized-light handheld dermoscope with 10-fold magnification. Results: The most common dermoscopic features were thick brown circles, thick brown branched lines, and terminal hairs. The most common vessel pattern was dotted vessels. Branched thick brown lines, brown globules, brown dots forming lines, serpiginous brown dots, white and brown exophytic papillary structures, fine scale, thick adherent scale, and cerebriform structures were the other findings. Conclusion: We observed many vascular and nonvascular dermoscopic findings which were not described previously for the entity. Dermoscopic examination of the verrucous epidermal nevi may lead to more reliable clinical interpretation and thus may reduce the need for histopathological investigation.

Comparison of computed tomographic attenuation values for epaxial muscles in old and young dogs.

OBJECTIVE To determine whether the degree of CT attenuation of muscle would differ between healthy old and young dogs. ANIMALS 10 healthy old (> 8 years old) and 9 healthy young (1 to 5 years old) Labrador Retrievers with a body condition score of 5 or 6 on a 9-point scale. PROCEDURES CT was performed with the dogs mildly sedated. A freehand closed polygon tool was used to define the outer margin of the left epaxial muscles on each transverse image obtained from the cranial to caudal endplates of T13. The CT attenuation values from every voxel from within these regions of interest were exported from DICOM software as a single dataset in an extensible markup language file. From these data, mean CT attenuation values were calculated for each dog and these mean values were compared between age groups. RESULTS Mean CT attenuation values for the epaxial muscles were significantly lower in old dogs than in young dogs. A significant negative correlation (r = -0.74) was identified between mean CT attenuation values and dog age. CONCLUSIONS AND CLINICAL RELEVANCE In addition to loss of skeletal muscle mass, low muscle CT attenuation values suggested that the old dogs in this study also had greater muscle fat content than did young dogs. Additional studies are warranted to evaluate qualitative and quantitative muscle changes in old dogs.

Motion Correction in Optical Resolution Photoacoustic Microscopy.

In this paper, we are proposing a novel motion correction algorithm for high-resolution OR-PAM imaging. Our algorithm combines a modified demons-based tracking approach with a newly developed multi-scale vascular feature matching method to track motion between adjacent B-scan images without needing any reference object. We first applied this algorithm to correct motion artifacts within one three-dimensional (3D) data segment of rat iris obtained with OR-PAM imaging. We then extended the application of this algorithm to correct motions to obtain vasculature imaging in the whole mouse back. In here, we stitched five adjacent 3D data segments (large field-of-view) obtained while changing the focus of OR-PAM differently for each subarea. The results showed that the motion artifacts of both large blood vessels and microvessels could be accurately corrected in both cases. Compared to the manually stitching method and the traditional SIFT algorithm, the algorithm proposed in this paper has better performance in stitching adjacent data segments. The high accuracy of the motion correction algorithm makes it valuable in OR-PAM for high-resolution imaging of large animals and for quantitative functional imaging.

Standard reference values of the upper body posture in healthy young female adults in Germany: an observational study.

OBJECTIVE: Classifications of posture deviations are only possible compared with standard values. However, standard values have been published for healthy male adults but not for female adults. DESIGN: Observational study. SETTING: Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University Frankfurt/Main. PARTICIPANTS: 106healthy female volunteers (21-30 years old; 25.1±2.7 years) were included. Their body weight ranged from 46 to 106 kg (60.3±7.9 kg), the heights from 1.53 to 1.82 m (1.69±0.06 m) and the body mass index from 16.9 kg/m² to 37.6 kg/m² (21.1±2.6 kg/m²). OUTCOME MEASURES: A three-dimensional back scan was performed to measure the upper back posture in habitual standing. The tolerance ranges and CI were calculated. Group differences were tested by the Wilcoxon Mann-Whitney U test. RESULTS: In normal posture, the spinal column was marginally twisted to the left, and the vertebrae were marginally rotated to the right. The kyphosis angle is larger than the lumbar angle. Consequently, a more kyphotic posture is observed in the sagittal plane. The habitual posture is slightly scoliotic with a rotational component (scapular depression right, right scapula marginally more dorsally, high state of pelvic right, iliac right further rotated anteriorly). CONCLUSIONS: Healthy young women have an almost ideally balanced posture with minimal ventral body inclination and a marginal scoliotic deviation. Compared with young males, women show only marginal differences in the upper body posture. These values allow a comparison to other studies, both for control and patient data, and may serve as guideline in both clinical practice and scientific studies.

Standard values of the upper body posture in male adults.

BACKGROUND: Interactions within the musculoskeletal system have been investigated and confirmed in numerous studies. OBJECTIVES: Since there are no standard values for the posture of healthy persons, this study attempts to define reference values for the upper body posture in healthy men. MATERIAL AND METHODS: A 3-dimensional back scan was performed to quantify the upper back posture while habitually standing. Tolerance regions for habitual posture were calculated, including the upper and lower limit for 95% of all values. Furthermore, the left and right limit of the confidence interval (CI) was carried out. Group differences were tested by using the t-test or the Wilcoxon-Mann-Whitney U test. RESULTS: Height, weight and body mass index (BMI) of the participants were comparable to those of the average young German males. The spinal column was marginally twisted to the right. The spinal curves, defined by the thoracic or lumbar flexion angle, and the kyphosis and lordosis angle, indicated that the angle in the thoracic spine area was larger than that in the lumbar region. Consequently, a more kyphotic posture was observed in the sagittal plane. The habitual posture was slightly scoliotic, with a rotational component (scapular depression left, right scapula marginally located more dorsally, high state of pelvic left, iliac left further rotated posteriorly and simultaneously tilted further ventrally). No significant difference between right and left-handed persons could be proven. CONCLUSIONS: Video raster stereography is a suitable method to measure the 3-dimensional back surface. Using this method for healthy young men, we observed that they had an almost ideally balanced posture with minimal ventral body inclination and a marginal scoliotic deviation. The normal values allow a better comparison of data between different studies of body posture.

Medical Infrared Thermography in back pain osteopathic management.

OBJECTIVES: The objective of this study was to provide proof-of-concept for the use of Medical Infrared Thermography to verify both diagnosis and osteopathic management accuracy in back pain. METHODS: A 50-year-old woman with acute back pain syndrome volunteered to participate in this study. RESULTS: Prior the treatment, thermal image reveals that in a sagittal plane, the inflammation extends from vertebra D8 to L3 with a maximum inflammation between vertebrae D10 to L1. Post-treatment, Medical Infrared Thermography only shows a slight inflammation along the lumbar furrow that does not induce pain in the patient. CONCLUSION: Medical Infrared Thermography has made it possible to scientifically support the osteopathic approach to back pain, both in the initial diagnostic phase and in the validation phase of treatment effectivess.

Cutaneous Manifestation of Sarcoidosis in Lower-Back Tattoo With Increased Uptake of 18F-FDG.

Sarcoidosis, a granulomatous T-cell-mediated multisystem disease with a yearly incidence of 10.9 to 35.5 cases per 100,000 in the United States, affects a variety of organ systems. Although the characteristic radiological finding of a bihilar lymphadenopathy still plays a diagnostic key role, FDG PET/CT is more sensitive in detecting and monitoring various manifestations. We present a rare case of a 37-year-old woman with bihilar, mediastinal, and abdominal lymphadenopathy in conjunction with a histologically proven cutaneous manifestation of sarcoidosis in a tattoo of the lower back exhibiting an increased uptake of FDG.

Lady with wings: a case report of giant neurofibromatosis type I.

RATIONALE: Neurofibromatosis type I (NF-I) accounts for approximately 90% of neurofibromatosis. NF-I is an autosomal dominant genetic disease which results from the gene mutation of NF-I situated in chromosome 17q11.2. PATIENT CONCERNS: A 32-year-old lady presented with a giant wing like structure on her back which started growing from her childhood. DIAGNOSIS: A diagnosis of NF-I was confirmed as she presented with multiple cutaneous nodules, multiple café-au-lait macules of different sizes, scoliosis deformity, and positive family history of neurofibroma. INTERVENTIONS: Surgical excision of tumor and multiple Z plasty reconstruction of the back was carried out. OUTCOMES: The excised neurofibroma weighed 6.7 kg containing thickened nerves, nerve roots, and circuitous vessels. The histopathological report confirmed plexiform and diffuse type cutaneous neurofibroma without any malignant transformation. Surgical excision and reconstruction with regular follow-up is an excellent choice of treatment for such a giant neurofibroma as in this case. LESSONS: NF-I is a genetic disease which could present as a giant cutaneous neurofibroma. One of the treatment options for giant neurofibromas causing deformity and physical disability is by surgical excision and histopathological examination with regular follow-up for NF-I recurrence.

Do exercises with the Foam Roller have a short-term impact on the thoracolumbar fascia? - A randomized controlled trial.

Due to new research results in the past few years, interest in the fascia of the human body has increased. Dysfunctions of the fascia are indicated by various symptoms, amongst others, musculoskeletal pain. As a result stronger focus has been put on researching therapeutic approaches in this area. The main aim of this study was to investigate the effect of Foam Roll exercises on the mobility of the thoracolumbar fascia (TLF). Study has been conducted in a randomized and controlled trial which sampled 38 healthy athletic active men and women. The subjects were randomly assigned to a Foam Roll Group (FMG), a Placebo Group (PG) and a Control Group (CG). Depending on the assigned group the volunteers were either instructed to do exercises with the Foam Roll, received a pseudo treatment with the Foam Roll or received no treatment. A total of three measurements were carried out. The most important field of research was the mobility of the TLF, which was determined using a sonographic assessment. In addition the lumbar flexion and the mechanosensivity of relevant muscles were determined. After the intervention, the FMG showed an average increase of 1.7915 mm for the mobility of the TLF (p < 0.001/d = 0.756). In contrast, only an average improvement of 0.1681 mm (p = 0.397) was shown in the PG, while the CG showed a slight improvement of 0.0139 mm (p = 0.861). However, no significant changes were observed with regard to the lumbar flexion and mechanosensivity of the treated muscles. Thus, evidence is that the use of Foam Roll exercises significantly improves the mobility of the thoracolumbar fascia in a healthy young population.

Clinical application of back surface topography by means of structured light in the screening of idiopathic scoliosis.

We present the results of the clinical validity in the screening of idiopathic scoliosis with a nonharming method of back surface topography by means of structured light projection. A total of 155 patients were evaluated (mean age 13.3 years). They were divided into two groups: pathologic patients (scoliosis) and nonpathologic patients (control and asymmetries). An analytical case-control study was carried out. Our topographic method obtained 92% sensitivity and 74% specificity as a screening test in identifying patients with scoliosis (P=0.05). We could quantify the vertebral deformity of scoliosis in the three spatial planes by means of three topographic variables, Horizontal Plane Deformity Index, Posterior Trunk Symmetry Index and Columnar Profile, and to elaborate a combined screening algorithm with good reliability parameters.

Quantification of topographic changes in the surface of back of young patients monitored for idiopathic scoliosis: correlation with radiographic variables.

Idiopathic scoliosis requires a close follow-up while the patient is skeletally immature to detect early progression. Patients who are monitored by radiographs are exposed to high doses of ionizing radiation. The purpose of this study is to evaluate if an optic noninvasive method of back surface topography based on structured light would be clinically useful in the follow-up of young patients with idiopathic scoliosis. This could reduce the number of radiographs made on these children. Thirty-one patients with idiopathic scoliosis were submitted twice to radiograph and our topographic method at intervals of 6 months to 1 year. Three topographical variables were applied horizontal plane deformity index (DHOPI), posterior trunk symmetry index (POTSI), and columnar profile (PC). A statistically significant correlation was found between variations of Cobb angle with DHOPI (r=0.720, p<0.01) and POTSI (r=0.753, p<0.01) during the monitoring period. Hence, this topographic method could be useful in clinical practice as an objective adjuvant tool in routine follow-up of scoliosis.

Two novel MYH7 proline substitutions cause Laing Distal Myopathy-like phenotypes with variable expressivity and neck extensor contracture.

BACKGROUND: Human skeletal muscles express three major myosin heavy chain (MyHC) isoforms: MyHCIIx (MYH1) in fast type 2B muscle fibers, MyHCIIa (MYH2) in fast type 2A fibers and MyHCI/ß-cardiac MyHC (MYH7) in slow type I skeletal fibers and cardiac ventricles. In line with its expression pattern, MYH7 mutations have been reported in association with hypertrophic or dilated cardiomyopathy, skeletal myopathies or a combination of both. We analyzed the clinical and molecular phenotype of two unrelated families of Jewish Moroccan ancestry that presented with apparently autosomal dominant inheritance of progressive Laing-like distal myopathy with non-specific myopathic changes, but uncommon marked contractures and wasting of the neck extensors. METHODS: Clinical phenotyping, whole exome sequencing and restriction analysis, generation of mutants followed by cell culture transfection and imaging. RESULTS: Using whole exome sequencing we identified in both families two novel heterozygous proline substitutions located in exon 31 of MYH7 within its rod domain: c.4309G>C (p.Ala1437Pro) and c.4301G>C (p.Arg1434Pro). Here we show that the phenotype caused by these mutations includes marked cervical muscle contracture, and report that the severity of the phenotype varies significantly, to the extent of non-penetrance in one of the families. Finally, we provide evidence that both proline substitutions impair myosin self-assembly in non-muscle cells transfected with ß-myosin constructs carrying the mutations, but do not prevent incorporation of the mutant molecules into the sarcomere. CONCLUSIONS: This study expands our clinical and molecular knowledge of MYH7 rod mutations causing skeletal myopathies, and underscores the importance of discussing disease penetrance during genetic counseling.

Validity and reliability of photographic measures to evaluate waistline asymmetry in idiopathic scoliosis.

OBJECTIVE: Evaluate the relationship between radiological, clinical and perceived waistline asymmetry (WLA) in a sample of idiopathic scoliosis (IS) patients. METHODS: 77 patients were included (mean age 20.3 years; 85 % women). We obtained a full X-ray of the spine and back clinical photography for all patients. On photographs, waist height angle (WHA), right/left waist angles (WA) and right/left waistline distance ratio were measured. SRS22, Trunk Appearance Perception Scale (TAPS) and Spinal Appearance Questinnaire (SAQ) questionnaires were also completed. The intra and inter-observer reliability of each photographic measure was assessed. A correlation analysis between all variables was done using Pearson Correlations Coefficient. RESULTS: All measures reported have excellent intra- and inter-observer (ICC ≥0.8) reliability. A significant correlation was found between WHA and Cobb angle, mainly with Main Thoracic (MT) (r = -0.56). Right and left waist angles, and especially the difference between them (RLWAD), is related to the thoracolumbar/lumbar (TLL) curve. We have found a significant correlation between RLWAD and TLL curve magnitude (r = -0.54) and with the inclination of the lower end vertebra (LEV) (r = 0.74). Only WHA has a significant, but poor correlation (r â‰… 0.3) with trunk perception scales (TAPS and SAQ). No other significant correlations were found between WLA measures and patient related outcome scores. CONCLUSION: WLA measures proposed in this article are reliable tools to assess WLA. We have found a significant correlation between clinical WLA and skeletal deformity (Cobb angle). WHA is related with MT curve while the RLWAD depends on the TLL curve magnitude and its LEV. We have also found a significant relation between WHA and the patient's perception of the deformity. It seems that WLA is a cosmetic concern to take into account in clinical evaluation of IS patients.