Shoulder Prosthetic Infection and Humerus Osteomyelitis From Cutibacterium Following Eden-Hybinette Procedure.

We describe the case of a patient who recently underwent a guided arthroscopic Eden-Hybinette procedure for the revision of a previous failed procedure of Latarjet and resurgence of shoulder instability. The subsequent development of painful infectious arthritis of the left shoulder complicated by osteomyelitis of the humerus, caused by Cutibacterium acnes, and accompanied by high fever was resolved only after the removal of synthetic screws and bone grafting and thanks to prolonged intravenous antibiotic treatment. The antibiotic regime was continued, both intramuscularly and orally, after discharge, allowing the full healing of the severe osteoarticular infection of the shoulder.

First case of aorto-bi-iliac endograft thrombotic infection by Listeria monocytogenes: A case report.

Listeria monocytogenes may cause serious vascular and graft infections. In the present case report, a 71-year-old man underwent partial prosthetic endograft replacement due to high-flow endoleak and limb occlusion. Following surgery, a multiple empiric antibiotic regime was initiated due to fever, malaise, abdominal tenderness and signs of an acute abdomen; however, in spite of this, the clinical condition of the patient worsened. An aorto-enteric fistula was discovered, and duodenal resection with duodeno-jejunal anastomosis packaging was performed. Gastrointestinal bleeding originating from this anastomosis both complicated and prolonged the clinical course, necessitating appropriate parenteral support and endoscopic hemostasis. The growth of Candida lusitanae in the drained abdominal and pleural effusion, and the isolation of L. monocytogenes from the thrombus inside the removed abdominal aorto-bi-iliac endograft allowed for establishment of a specific antibiotic treatment. After a suitable period of clinical improvement, the patient was transferred to a clinical rehabilitation center. At the present time, the patient maintains a good condition. To the best of our knowledge, the present study represents the first described case of thrombotic infection of an aorto-bi-iliac endograft by L. monocytogenes. In the event of graft thrombotic occlusion, L. monocytogenes infection should be considered as a potential cause. In case of complications requiring open conversion, even if not suspected from the medical history of the patient, the possibility of an underlying and occult infection should always be excluded with an in-depth preoperative work-up.

Surgical wound dehiscence complicated by methicillin-resistant Staphylococcus aureus infection in a diabetic patient with femorotibial vascular bypass occlusion.

Diabetic patients with critical limb ischaemia may be affected by severe wound and skin ulcer infections. We report a case of a patient with bilateral femorotibial occlusion and methicillin-resistant Staphylococcus aureus infection. The patient was treated with femoroperoneal vascular bypass, debridement of wound dehiscence and targeted antimicrobial therapy for symptom resolution and healing of the wound.

Strain Ultrasound Elastography in the Achilles Tendon of Ankylosing Spondylitis Patients Treated With Anti-TNF-α: A Preliminary Study.

BACKGROUND/AIM: To compare patients affected by ankylosing spondylitis (AS) treated with anti-TNF-α for two years with controls in terms of Achilles tendon stiffness, ultrasound structure and thickness. PATIENTS AND METHODS: B-mode ultrasound evaluation and strain ultrasound elastography were performed in longitudinal and transverse planes on 22 Achilles tendons of 11 AS patients and 26 of 13 controls. RESULTS: There were no significant differences in thickness and stiffness of the Achilles tendon between AS patients and controls, except for an increased thickness in the middle third of the tendon in the AS patients (p=0.04). The Achilles tendon stiffness ratio of AS patients was 1.02±0.36 vs. 1.14±0.38 in the controls (p=0.2). CONCLUSION: AS patients had an Achilles tendon thickness greater than controls at the middle third, but no difference in the stiffness was found among them. Strain ultrasound elastography may be useful to exclude early changes in mechanical properties of tendons.

Five-year-term results in cirrhotics without varices, either affected or not by portal hypertensive gastropathy.

OBJECTIVES: Information is lacking on the appearance of varices in cirrhotics, either affected or not by portal hypertensive gastropathy (PHG). We assessed whether the absence or presence and the grade of PHG influenced the development of varices in cirrhotics without varices over time. PATIENTS AND METHODS: Forty cirrhotics without varices affected or not by PHG at baseline underwent follow-up endoscopy after 5 years. One-tailed t-test and the χ-test were used to evaluate variable comparison and the presence of associations. Multivariate logistic regression analysis and the analysis of variance test were carried out to compare the variables and identify predictors of varices. RESULTS: The Child-Pugh score at baseline and after 5 years was significantly different (5.72±0.98 vs. 6.25±1.67, P<0.001). After 5 years, 10 (25%) cirrhotics were affected by varices, whereas 30 (75%) patients remained without varices. PHG was associated significantly with varices (P=0.001), proving to be a significant predictive independent factor for their development over time (F=4.765, significant=0.004; analysis of variance test, P<0.001). CONCLUSION: A link between the duration of PHG and the development of varices is likely. An early therapeutic management of PHG might delay the development of varices in cirrhotics.

Platypnoea-orthodeoxia syndrome in the elderly: A difficult-to-make diagnosis of intracardiac right-to-left shunt.

Introduction Platypnea-orthodeoxia syndrome is a combination of positional dyspnoea and hypoxemia; it is caused by several cardiac, pulmonary and hepatic diseases. Case presentation In this study, we describe a 77-year-old female affected by unexplained dizziness and hypoxia that exacerbated in upright position. After diagnosing platypnea-orthodeoxia syndrome and excluding all possible causes (liver cirrhosis, acute and chronic pulmonary diseases and arteriovenous malformations), the origin of the syndrome was individuated in the presence of a patent foramen ovale with right-to-left shunt. Endovascular patent foramen ovale closure permitted the resolution of symptoms and disappearance of platypnea-orthodeoxia syndrome. Conclusion Although patent foramen ovale may be present since birth without giving clinical signs, it may represent a common enough cause of platypnea-orthodeoxia syndrome and other vascular complications in the elderly.

Leptin, adiponectin and vascular stiffness parameters in women with systemic lupus erythematosus.

The purpose of the present study was to determine levels of adipokines and their relationship with stiffness parameters and disease activity index in SLE patients in comparison with healthy controls. Sixty SLE patients and 29 control subjects were enrolled in the study. Serum leptin and adiponectin levels were determined by commercial sandwich ELISA kits. Colour-coded carotid duplex sonography was performed using a Siemens SONOLINE Antares machine equipped with linear 5-13 MHz. SLEDAI, ECLAM and SLICC were evaluated in all patients. Data were analysed by software for statistical analysis (Prism 5.0). Median leptin is higher among SLE patients compared with controls (p 0.035). Median values of vascular stiffness and PSEM are increased in SLE compared with controls (p = 0.0003 and p = 0.007). Vascular strain and vascular distensibility are lower in SLE patients in comparison with controls (p = 0.0001 and p = 0.0006, respectively). Considering SLE patients, leptin levels correlate with vascular stiffness (r = 0.64, p < 0.0001) and PSEM (r = 0.63, p < 0.0001). Adiponectin levels correlate with vascular strain (r = 0.28, p 0.039) and negatively correlate with vascular stiffness (r = -0.38, p 0.039). Leptin levels correlate with disease activity (SLEDAI and ECLAM) and cumulative damage (SLICC) indexes. This study demonstrates higher values of leptin in SLE patients. Moreover, SLE patients show increased levels of vascular stiffness and PSEM and reduced values of vascular strain and distensibility. These results globally indicate a decline in arterial elasticity. We find a positive correlation of leptin with stiffness parameters. According to its atheroprotective action, adiponectin inversely correlates with stiffness parameters.

Utility of ultrasound in the diagnosis of chronic worsened gout.

Ultrasound (US) may be used to diagnose chronic worsened gout. US confirmed the clinical evidence of tophaceous deposits in the left elbow of a 75-year-old man; it also identified crystalline materials on the cartilage surface of the second metacarpophalangeal joint of the left hand. US may be helpful to detect signs of deposition of monosodium urate crystals in periarticular and intra-articular joints of patients with clinically suspected chronic worsened gout.

Comparison between conventional and automated software-guided ultrasound assessment of bilateral common carotids intima-media thickness in patients with rheumatic diseases.

Over the last decade, a growing number of studies have been published supporting the high prevalence of atherosclerosis in rheumatic patients with chronic inflammatory diseases. Ultrasound (US) represents the imaging technique of choice for revealing early atherosclerotic changes at carotids level. New US software, mainly developed to rectify its operator dependence, requires a comparison with conventional technique. The main aim of the present study was to compare conventional and software-guided US in the assessment of intima-media thickness (IMT) of common carotids. Thirty-two consecutive patients with chronic inflammatory rheumatic conditions, presenting at the outpatient clinics of the Rheumatology Department--Università Politecnica delle Marche, Italy--were enrolled in the present study. The patients underwent a US assessment of the IMT of the posterior wall of common carotids using a My Lab 70 XVG system (Esaote SpA, Genoa, Italy) equipped with a 4-13 MHz linear probe. The US examinations were performed by two sonographers. One of them used the conventional manual approach and the second sonographer adopted a software-guided technique (named RF-QIMT technology). Inter-observer reliability was determined using intra-class correlation coefficient (ICC) and the Bland-Altman plot. Agreement between the two methods was high with ICC value of 0.74 (0.69 and 0.77 for the right and left common carotid, respectively). The Bland-Altman plot showed minimal proportional error and high limits of agreement. Substantial inter-observer agreement rates for the assessment of the IMT were achieved. Further studies are encouraged to confirm these results in a larger cohort of patients.

Cirrhotic cardiomyopathy.

Cirrhotic cardiomyopathy is a clinical syndrome in patients with liver cirrhosis characterized by an abnormal and blunted response to physiologic, pathologic, or pharmacologic stress but normal to increased cardiac output and contractility at rest. As many as 50% of cirrhotic patients undergoing liver transplantation show signs of cardiac dysfunction, and 7% to 21% of deaths after orthotopic liver transplantation result from overt heart failure. In this review, we critically evaluate the existing literature on the pathophysiology and clinical implications of cirrhotic cardiomyopathy.

Endothelial dysfunction and vascular stiffness in systemic lupus erythematosus: Are they early markers of subclinical atherosclerosis?

In systemic lupus erythematosus (SLE), the risk of development of cardiovascular disease is dramatically increased. Inflammatory and immune-mediated mechanisms, favouring early alterations of the arterial wall are strongly involved in promoting the development of atherosclerosis (ATS) in young SLE patients. In SLE, sonographic measurements of carotid intima-media thickness are able to recognize clinical, but not always subclinical, ATS. On the contrary, assessment of endothelial function and vascular stiffness through sonography-based techniques may be useful to reveal or exclude subclinical ATS. More efforts should be done to find a comprehensive approach to the study of subclinical ATS in SLE patients, since an early diagnosis may have a significant value in preventing the development of major vascular diseases.

N-acetylcysteine infusion reduces the resistance index of renal artery in the early stage of systemic sclerosis.

AIM: To evaluate resistance index (RI) changes in renal artery after N-acetylcysteine infusion in patients with systemic sclerosis. METHODS: In an open-label study 40 patients with systemic sclerosis (SSc) were treated with N-acetylcysteine (NAC) iv infusion over 5 consecutive hours, at a dose of 0.015 g x kg(-1) x h(-1). Renal haemodynamic effects were evaluated by color Doppler examination before and after NAC infusion. RESULTS: NAC infusion significantly reduced RI in a group of sclerodermic patients with early/active capillaroscopic pattern, modified Rodnan Total Skin Score (mRTSS) <14 and mild-moderate score to the vascular domain of Medsger Scleroderma Disease Severity Scale (DSS). RI increased after NAC infusion in patients with late capillaroscopic pattern, mTRSS>14 and severe-end stage score to the vascular domain of DSS. In patients with reduction of RI after NAC infusion, diffusion capacity for carbon monoxide mean value was significantly higher than in those patients with an increase of RI. No significant differences in renal blood flow were found between patients with different subsets of SSc. CONCLUSION: In patients with low disease severity NAC ameliorates vascular renal function.

A mocking finding: portal cavernoma mimicking neoplastic mass. First sign of myeloproliferative disorder in a patient with Janus kinase2 V617F mutation.

The most important systemic etiological factors for portal thrombosis are the thrombophilic conditions associated with myeloproliferative disorders (MPDs), either clinically manifest or so-called 'occult'. Latest studies have revealed a strong association between MPDs and a somatic point mutation (V617F) of the tyrosine kinase Janus kinase2. The 'pseudo-cholangiocarcinoma sign' is a well described radiological finding related to portal cavernoma. We describe the case of a 48-year-old man, presenting with cavernomatous transformation of an extrahepatic thrombotic obstruction of the portal vein mimicking a neoplastic mass of the hepatic hilum, who did not present any other cause for thrombosis except for the V617F Janus kinase2 mutation, suggesting an underlying MPD.

Anomalous origin and aneurysm of the suprascapular artery: the first case observed.

A 45-year-old woman was referred to our department having suddenly developed, 9 months earlier, a pulsating mass on the right supraclavicular fossa and torticollis. Colour Doppler sonography and computed tomographic angiography showed the presence of an aneurysm (21 mm in diameter) of the suprascapular artery that had an anomalous origin from the subclavian artery. Thoracic outlet syndrome was excluded. After selective arteriography, the aneurysm of the suprascapular artery was successfully treated with ethylene-vinyl alcohol polymer (Onyx, MicroTherapeutics, Irvine, California, USA), a liquid embolic agent. The patient was discharged on the first postoperative day in good condition. Control colour Doppler sonography at 1 year confirmed the complete thrombosis of the aneurysm sac.

Effort angina in a patient with advanced coronary artery disease. Role played by coronary angiography, Ivus and cardiac CT: case report.

Coronary angiography is considered to be the gold standard technique for assessing the severity of obstructive luminal narrowing; however, in a few circumstances it may be misleading. In these cases, cardiac computed tomography (CT) and intravascular ultrasound (IVUS) may help to give a correct interpretation.In this report, we describe the case of a 62-year-old man whose effort angina was first evaluated with coronary angiography, but whose severe stenosis of the right coronary artery was only observed on cardiac CT and IVUS. This additional diagnosis promptly resulted in a therapeutic approach with percutaneous transluminal coronary angioplasty (PTCA).

Pancreatitis after percutaneous ethanol injection into HCC: a minireview of the literature.

Deaths after percutaneous ethanol injection (PEI) into hepatocellular carcinoma (HCC) may occur within a few hours to a few days following the procedure because of hemoperitoneum and haemorrhage from oesophageal varices or hepatic insufficiency. Pancreatitis has been recently reported as a rare lethal complication of intra-arterial PEI, another modality for treating HCCs. In this minireview, we analyze the literature concerning the development of acute pancreatitis after PEI. Pathogenesis of pancreatitis from opioids and ethanol is also addressed. Treatment with opioids to reduce the patient's abdominal pain after PEI in combination with the PEI itself may lead to direct toxic effects, thus favouring the development of pancreatitis.

New therapeutic approaches to liver fibrosis: a practicable route?

The progress of research on the molecular pathogenesis of liver fibrosis and the consequent discoveries are likely to open new possibilities for therapeutic approaches to the management of this disease in the future. A key step towards this goal is a deeper comprehension of both the complex molecular and cellular mechanisms and the signaling involved in the development of hepatic fibrosis. It is not yet clear, in fact, what role apoptosis, cytokines, oxidants and other molecules play and what relationships exist between them in favouring or delaying the onset of these adverse mechanisms. At present, a unique mechanism is recognized to be the main reason for the cause and development of liver fibrosis: sustained hepatic stellate cell activation and transformation. Therefore, in this review, after considering the cause, development of fibrosis and interrelation between molecular and cellular profibrotic mechanisms, the part played in counteracting both of these actions by some anti-oxidants and anti-fibrotic molecules such as cytokines, prostacyclin and others will be taken into consideration. The gene therapy and the possible therapeutic use of liver stem cells and tissue engineering will also be dealt with briefly. At the moment, however, the efficacy of these novel strategies still needs to be further validated in animal studies and confirmed in clinical trials. Some data that are already available from in vitro and animal studies demonstrating the effectiveness of novel approaches to inhibiting or treating liver fibrosis can only offer moderate hope.

Percutaneous ultrasound-guided ablation of BW7756-hepatoma using ethanol or acetic acid in a rat model.

BACKGROUND: To compare tumor necrosis in hepatoma induced in rats by a single percutaneous injection of ethanol (PEI) or acetic acid (PAI). METHODS: BW7756 hepatomas of 1 mm3 were implanted in the liver of 40 male healthy rats. After 14 days, the 36 surviving rats were treated, in a single session, by ultrasound-guided injection of 300 microl of 95% ethanol (n = 17) or 100 microl of 50% acetic acid (n = 19). They were sacrificed 14 days after treatment and explanted tumoral livers were examined. The same PAI procedure was repeated on 13 additional rats to exclude a suspected occurrence of technical failures during the experiment, due to a surprisingly high rate of deaths within 30 minutes after PAI. RESULTS: Four rats died within four days after tumor implantation; after PEI, 1/17 (6%) died, whereas after PAI 9/19 (47%) died. The remaining 26 rats, after 14 days post-percutaneous ablation, were sacrificed. Gross and microscopic examinations showed that the hepatoma's nodules treated with PEI had 45.3 +/- 19.4% tumor necrosis compared to 49 +/- 23.3% (P = NS) for those treated with PAI. Complete tumor necrosis was not found in any animal. Peritoneal invasion was present in 4/16 (25%) and 2/10 (20%) rats treated with PEI or PAI, respectively (P = NS). Autopsy was performed in the 5 additional rats that died within 30 minutes after PAI. CONCLUSION: Our results show that there is no significant difference in the percentage of tumor necrosis between two local ablation methods in spite of the different dosages used. However, mortality in the PAI-treated group was greater than in PEI-treated group, presumably due to greater acetic acid systemic diffusion and its metabolic side effects. In human subjects, HCC occurs in the setting of cirrhosis, where the non-tumoral tissue is firmer than the tumor structure, with consequent reduction of drug diffusion. This could be the reason why some human studies have concluded similar or even better safety and efficacy with PAI compared to PEI.

Retroperitoneal fibrosis and ankylosing spondylitis: which links?

OBJECTIVES: To report a case of retroperitoneal fibrosis (RPF) in a patient with ankylosing spondylitis (AS) and to review the medical literature for similar cases to detect possible links between the 2 diseases. METHODS: The presentation, clinical course, diagnostic work-up, and treatment of our patient are described, and the English and French medical literature from 1960 to 2000 is reviewed using a MEDLINE search for cases with coexisting RPF and spondyloarthritis. RESULTS: Our patient with AS had RPF, which mimicked rectal cancer with retroperitoneal and vertebral metastases. Special attention is paid to the unusual clinical presentation, the multistep diagnostic process, and the therapeutic strategy which was both radiologically and histologically successful. Literature review revealed 18 cases of concomitant RPF and spondyloarthritis, mainly AS. Patients were more frequently male (M/F, 3/1) and developed spondyloarthritis several years before RPF. CONCLUSIONS: RPF may result from a local immune response to products of aortic atheromatous plaques, with subsequent periaortic deposition of fibrous tissue. However, the clinical features and the frequent association with other fibrosing disorders suggest that RPF is a systemic inflammatory condition. The role of AS-associated aortitis in the development of RPF warrants consideration.