Common foot and ankle disorders in pregnancy: the role of diagnostic ultrasound.

Foot and ankle disorders are common during pregnancy, driven by significant physiological changes including weight distribution, hormonal fluctuations, and fluid balance. These changes often result in conditions such as varicose veins, thrombophlebitis, deep vein thrombosis (DVT), edema, overpronation, ankle sprains, metatarsalgia, stress fractures, ligament tears, synovitis, tendon tears, tenosynovitis, paratenonitis, plantar fasciitis, and Morton's neuroma. This paper emphasizes the diagnostic utility of ultrasound for these conditions, given its safety, non-invasiveness, and real-time imaging capabilities without ionizing radiation. Ultrasound is particularly effective for diagnosing venous disorders like varicose veins and thrombophlebitis, leveraging Doppler ultrasound to assess vein structure and function. It is also instrumental in identifying DVT, detecting vein dilation, reflux, and thrombosis. For conditions such as edema, ultrasound helps differentiate physiological from pathological causes, ensuring accurate diagnosis and management. In cases of musculoskeletal issues like overpronation, ankle sprains, ligament tears, and tendon pathologies, ultrasound provides detailed images of soft tissues, allowing for precise diagnosis and effective treatment planning. It is equally useful for detecting metatarsalgia, plantar fasciitis, and Morton's neuroma, offering insights into soft tissue abnormalities and guiding therapeutic interventions. Ultrasound's role extends to diagnosing foreign bodies in the foot and ankle, where it demonstrates high sensitivity and specificity. The accessibility and cost-effectiveness of ultrasound make it an invaluable tool in various healthcare settings, ensuring timely and accurate diagnosis and management of foot and ankle disorders during pregnancy, ultimately enhancing patient outcomes and quality of life.

Distribution of indications and procedures within the framework of centers participating in the WAA apheresis registry.

The WAA apheresis registry was established in 2003 and an increasing number of centers have since then included their experience and data of their procedures. The registry now contains data of more than 74,000 apheresis procedures in more than 10,000 patients. This report shows that the indications for apheresis procedures are changing towards more oncological diagnoses and stem cell collections from patients and donors and less therapeutic apheresis procedures. In centers that continue to register, the total extent of apheresis procedures and patients treated have expanded during the latest years.

Adverse events in apheresis: An update of the WAA registry data.

Apheresis with different procedures and devices are used for a variety of indications that may have different adverse events (AEs). The aim of this study was to clarify the extent and possible reasons of various side effects based on data from a multinational registry. The WAA-apheresis registry data focus on adverse events in a total of 50846 procedures in 7142 patients (42% women). AEs were graded as mild, moderate (need for medication), severe (interruption due to the AE) or death (due to AE). More AEs occurred during the first procedures versus subsequent (8.4 and 5.5%, respectively). AEs were mild in 2.4% (due to access 54%, device 7%, hypotension 15%, tingling 8%), moderate in 3% (tingling 58%, urticaria 15%, hypotension 10%, nausea 3%), and severe in 0.4% of procedures (syncope/hypotension 32%, urticaria 17%, chills/fever 8%, arrhythmia/asystole 4.5%, nausea/vomiting 4%). Hypotension was most common if albumin was used as the replacement fluid, and urticaria when plasma was used. Arrhythmia occurred to similar extents when using plasma or albumin as replacement. In 64% of procedures with bronchospasm, plasma was part of the replacement fluid used. Severe AEs are rare. Although most reactions are mild and moderate, several side effects may be critical for the patient. We present side effects in relation to the procedures and suggest that safety is increased by regular vital sign measurements, cardiac monitoring and by having emergency equipment nearby.

Serological and molecular evidence of a plausible transmission of hepatitis E virus through pooled plasma.

BACKGROUND AND OBJECTIVES: Recently, hepatitis E virus has been recognized as a new transfusion-associated risk; however, its efficiency of transmission through blood products requires further investigation. Asymptomatic viremia of short duration has been observed in blood donors from several European countries to the rate of <1:10,000 and HEV transmission in recipients of blood products has been documented in Japan and Europe. Although HEV RNA was detected in large plasma fractionation pools used for manufacturing of plasma derived products, HEV transmission has not been demonstrated so far. In this study, we investigated the possibility of HEV transmission in patients with thrombotic thrombocytopenic purpura whose treatment included up to 40 l of plasma exchange. MATERIALS AND METHODS: Thirty-six TTP patients received either solvent-detergent-treated plasma prepared by pooling of 2500 single-donor or cryosupernatant plasma. Three samples were collected from TTP patients at time 0, 1 and 6 months post-treatment and tested for anti-HEV antibodies. Patients with HEV seroconversion were also tested for viremia by PCR. RESULTS: Two of seventeen TTP patients treated with SDP showed serological evidence of HEV infection. The 1-month samples from these patients were also positive for HEV RNA. A distinct rise of anti-HEV IgG level was detected in two other TTP patients with weak pre-existing immunity to HEV; this observation is indicative of a possible immune response boost due to a breakthrough infection. CONCLUSION: This work provides, for the first time, indirect evidence of HEV transmission by pooled plasma and warrants further studies.

A 30-Year-Old Man with an Unusually Large Untreated Plantar Fibrolipoma That Disrupted Ambulation and Required Operative Excision.

A 30-year-old man working as a waiter presented with a progressively enlarging and symptomatic soft-tissue mass on the plantar medial aspect of his left foot. The mass was painful and disrupting ambulation, despite footwear modifications. He ultimately underwent excision of what was a determined to be a fibrolipoma, returning to his regular shoes and all activities. Plantar neoplasms, even when benign, can grow to sizes that can result in significant disability. If left untreated, particularly in individuals engaged in occupations requiring frequent standing or walking, excision of the mass will often require a more aggressive operative approach.

A comparison of methods of pathogen inactivation of FFP.

INTRODUCTION: Current methods for pathogen inactivation of plasma involve four major processes using solvent-detergent (SD), methylene blue (MB), amotosalen and riboflavin as additives. Three of these methods involve the use of visible or ultraviolet light. METHODS: A comparison of the four methods was made using publications in Medline, Pubmed, Embase and Biosis to obtain data on the logistics of use, the quality of the plasma proteins and the effectiveness of pathogen inactivation. RESULTS: Three of the methods, MB, amotosalen and riboflavin, are designed for use in a blood bank; the SD method is generally applied at a centralized manufacturing centre and involves large plasma pools. All methods result in a reduction in protein values with the per cent retention of FVIII activity in the range of 67-78% and fibrinogen of 65-84%. Protein S and alpha(2)-antiplasmin are lower following solvent-detergent treatment. Alterations in fibrinogen structure have been reported with methylene blue. DISCUSSION: Three of the methods are designed for small volume use in a blood bank. All four methods have some effect on the coagulant proteins; however, the final concentrations are within regulated limits. While there is variability in the effectiveness against pathogens, direct comparison is difficult because of the methodologies used. Nonetheless, all are effective in inactivating HIV and other lipid-enveloped pathogens. Clinical studies on the effectiveness of these products are surprisingly sparse, and no randomized clinical trials have yet been performed with amotosalen or riboflavin plasmas.

Analyses of data of patients with Thrombotic Microangiopathy in the WAA registry.

UNLABELLED: Thrombotic Microangiopathy (TMA) is a histopathological feature of various diseases including thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. The aim of this study was to investigate the outcome and prognostic variables of TMA-patients. MATERIALS AND METHODS: Data were consecutively retrieved from the WAA-apheresis registry (www.waa-registry.org) during 2003-2009. Included were all 120 patients (1237 procedures) who suffered from various forms of TMA, as registered by the ICD-10 code M31.1. Besides registry data, more extensive information was retrieved from the latest 64 patients. Adverse events of the TMA patients were compared to those of the other patients in the registry. RESULTS: The mean age was 46 years (range 11-85 years, 57% women). In 72% therapeutic apheresis was due to an acute indication while a long-term indication was present in 28%. Plasma exchange was performed by centrifugation and filtration technique (95% and 4%, respectively), and immunoadsorption in 1% of the patients. Only fresh frozen plasma was used as replacement fluid in 69% of procedures. Adverse events were more frequent than in the general apheresis population (10% versus 5%, RR 1.9, CI 1.6-2.3). No death occurred due to apheresis treatment. Three percent of the procedures were interrupted. Bronchospasm and/or anaphylactic shock were present in two patients and one patient suffered from TRALI. At admission 26% were bedridden and needed to be fed. The risk of dying during the treatment period was significantly higher if the patient also suffered from a compromising disease, such as cancer. There was an inverse correlation between the ADAMTS13 level and the antibody titer (r=-0.47, p=0.034). CONCLUSIONS: Patients with TMA have an increased risk for moderate and severe AE compared to the general apheresis population. Many patients were severely ill at admission. The prognosis is worse if the patient also has a severe chronic disease. Even slightly increased ADAMTS13-antibody titers seem to have a negative impact on the ADAMTS13 levels.

Thrombotic microangiopathy.

Thrombotic microangiopathy (TMA) is a histopathological feature of various diseases including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). There are many secondary causes of TMA, many of them could mimic TTP or HUS. This article presents a short overview on TMA. In conclusion TMA is the result of various etiology reasons and pathologic reactions with various clinical entities. It is important to focus on a thorough history including family history when deciding on a diagnosis. Analysis of ADAMTS 13 and ADAMTS 13-antibodies may help to decide continued therapy.

Characterization of plasma protein activity in riboflavin and UV light-treated fresh frozen plasma during 2 years of storage at -30 degrees C.

BACKGROUND: The Mirasol Pathogen Reduction Technology System (PRT) for Plasma (CaridianBCT) is based on a riboflavin and UV light treatment process resulting in pathogen inactivation due to irreversible, photochemically induced damage of nucleic acids. This study evaluated the in vitro protein quality of plasma products treated with riboflavin and UV light following treatment and subsequent storage for up to 104 weeks at -30 degrees C. MATERIALS AND METHODS: Apheresis and whole blood-derived plasma products were combined with riboflavin solution and exposed to ultraviolet light. Treated plasma was then flash frozen, within 8 h of collection, stored at -30 degrees C for up to 104 weeks and analysed at different stages of storage using standard coagulation assays. Results were compared with paired, untreated units stored for the same intervals. RESULTS: The average percent protein retention for all time-points in PRT-treated plasma samples after 36, 69, 87 and 104 weeks of storage at -30 degrees C in comparison with controls held under similar conditions were: Total Protein, 101%, Factor VIII, 79%, Fibrinogen, 78%, Factor II, 87%, Factor XII, 86%, Factor X, 84% and Factor IX, 81%. Anticoagulant and inhibitor proteins showed between 90% and 100% retention after 1 year (52 weeks) and 69 weeks of storage. No clinically relevant complement activation was observed in treated and stored samples. CONCLUSION: Riboflavin and UV light-treated plasma demonstrates reductions in several plasma coagulation factors following treatment. This reduction in activity levels is noted immediately after treatment and remains relatively constant during 2 years of storage at -30 degrees C.

Analysis of the products of cryoprecipitation: RiCoF is deficient in cryosupernatant plasma.

INTRODUCTION: Cryoprecipitate and its byproduct, cryosupernatant plasma (CSP) have been used to treat specific medical diseases such as hemophilia, von Willebrand disease and thrombotic thrombocytopenia purpura. Cryoprecipitate is also widely used to prepare fibrin glue. In many instances, it is given to augment fresh frozen plasma when patients are bleeding. However, the full range of constituents of cryoprecipitate and CSP are not widely appreciated. METHODS: To determine the concentration of the various constituents in plasma and its frozen fractions, we measured levels of Factor VIII, von Willebrand factor antigen, fibrinogen, Factor V, ATIII, functional and antigenic proteins C and S, plasminogen, Total protein, fibronectin, Factor XIII, RiCoF and von Willebrand factor multimers in the starting plasma, the cryoprecipitate and the CSP produced from the plasma in each of the blood groups. RESULTS: While only 4% of the plasma proteins cryoprecipitate, there is considerable enrichment of Factor VIII, von Willebrand factor and RiCoF. However, cryoprecipitate contains only 27% of the plasma fibrinogen and has low levels of Factor V, protein S, protein C, ATIII and plasminogen. Factor VIII and von Willebrand factor are much reduced in the cryosupernatant plasma (0.20 U/ml and 0.16 U/ml) and there is virtually no ristocetin cofactor activity. This is consistent with the absence of the higher molecular weight multimers of VWF found in CSP. The ADAMTS-13 levels are the same as in plasma. All levels vary between blood groups. CONCLUSIONS: While cryoprecipitate is relatively enriched in certain factors, the process does not result in concentration of other coagulation factors so cryoprecipitate cannot be used for the replacement of protein C, protein S or Factor V. SCP is deficient in RiCoF.

Angioleiomyoma (Vascular Leiomyoma) Presenting as a Pseudoaneurysm of the Tibialis Posterior Artery.

Reported here is the case of a 55-year-old woman presenting to a podiatry clinic with a chief complaint of left heel and ankle pain, who ultimately underwent operative excision of an angioleiomyoma adjacent to the tibialis posterior artery at the level of the medial malleolus. Accompanying this case are images from three modalities through which the defining characteristics of an angioleiomyoma can be appreciated. This case advocates for the inclusion of angioleiomyoma in the preoperative differential diagnosis of a mass presenting as a pseudoaneurysm in the lower extremity, particularly among women in the fourth to sixth decades of life.

Autologous blood programs: what is happening?

UNLABELLED: Preoperative autologous blood collection has been advocated for many years and has seen increased application following the AIDS epidemic. Such autologous programs have been both applauded and criticized in recent years with little information available regarding actual application. METHODS: One hundred and fifty-five of the largest hospitals in the province of Ontario received surveys assessing the demographics, logistics and funding of autologous blood programs available to them. Results, a total of 78 hospitals replied, indicating that 77 sites had access to an autologous program with 26 sites having a program within their hospital. The local blood provider, Canadian Blood Services (CBS), provided access to autologous donations either alone or to the hospital in 62 sites. Three hospitals operated the program entirely on their own. Fifteen hospitals had no access to an autologous program at any site. Programs were funded in a variety of ways including patient fees in five hospitals. DISCUSSION: In the largest Canadian province the autologous blood programs are highly variable with service not provided at all in some regions whereas in others there is a very active program often involving Canadian blood services either as a stand-alone or hospital integrated supplier. This variation in activity of the autologous program is in marked contrast to those for whole blood and apheresis collections where great standardization, through the CBS is the norm.

Foot Pain in Relation to Ipsilateral and Contralateral Lower-Extremity Pain in a Population-Based Study.

BACKGROUND: Clinical observations note that foot pain can be linked to contralateral pain at the knee or hip, yet we are unaware of any community-based studies that have investigated the sidedness of pain. Because clinic-based patient samples are often different from the general population, the purpose of this study was to determine whether knee or hip pain is more prevalent with contralateral foot pain than with ipsilateral foot pain in a population-based cohort. METHODS: Framingham Foot Study participants (2002-2008) with information on foot, knee, and hip pain were included in this cross-sectional analysis. Foot pain was queried as pain, aching, or stiffness on most days. Using a manikin diagram, participants indicated whether they had experienced pain, aching, or stiffness at the hip or knee and specified the side of any reported pain. Sex-specific multinomial logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals for the association of foot pain with knee and hip pain, adjusting for age and body mass index. RESULTS: In the 2,181 participants, the mean ± SD age was 64 ± 9 years; 56% were women, and the mean body mass index was 28.6. For men and women, bilateral foot pain was associated with increased odds of knee pain on any side (ORs = 2-3; P < .02). Men with foot pain were more likely to have ipsilateral hip pain (ORs = 2-4; P<.03), whereas women with bilateral foot pain were more likely to have hip pain on any side (OR = 2-3; P < .02). CONCLUSIONS: Bilateral foot pain was associated with increased odds of knee and hip pain in men and women. For ipsilateral foot and hip pain, men had a stronger effect compared with women.

ADAMTS-13 levels in fresh, stored, and solvent detergent treated plasma.

BACKGROUND: ADAMTS-13 is implicated in the pathophysiology of thrombotic thrombocytopenic purpura (TTP). Plasma exchange is thought to be effective through removal of a harmful substance or provision of a required material such as ADAMTS-13. As various methods are used to prepare plasma we determined the effects of storage and solvent detergent treatment on the ADAMTS-13 levels in plasma. METHODS: Samples from fresh plasma and fresh frozen plasma (FFP) were stored at 22 degrees C and ADAMTS-13 levels were measured at 0, 12, 24, 48 and 72 h. Samples were also taken from solvent detergent treated plasma (SDP) and cryosupernatant plasma (CSP). Total protein, albumin, fibrinogen and immunoglobulins were also measured. RESULTS: In fresh plasma, the levels of both the 175 and 140 Kd subunits of von Willebrand factor were consistent at 1.38 and 1.35 OD units from 0 to 48 h indicating normal ADAMTS-13 activity. The Vitex SDP produced slightly more of the 140 Kd subunit than did Octapharma SDP which gave equivalent fragments. Cryosupernatant plasma was the same as normal plasma. None of these values changed over 48 h. There was a 28% decrease in FVIII in fresh plasma over 24 h. Fibrinogen and albumin were unchanged. CONCLUSION: ADAMTS-13 levels are not significantly decreased by storage of plasma at room temperature for up to 48 h. Both CSP and SDP also contained essentially normal levels of ADAMTS-13 and therefore could be used for treatment of patients with TTP.

New methods showing in vitro changes of platelets.

INTRODUCTION: In vitro methods for assessing stored platelets are time consuming and variably correlate with in vivo survival. We used the ADVIA 120 and the Thromboelastogram (TEG) to assess changes during storage to determine a correlation of the results with those of other commonly used measures. METHODS: Platelet concentrates were tested at 1 and 5 days of storage. In vitro test included platelet count, aggregation response, the hypotonic shock response (HSR), The Kunicki morphology score (KMS) and platelet activation using CD62. The ADVIA was used to measure the platelet density and the granule content. The TEG measured the kinetics of clot formation. RESULTS: The platelet count and HRS did not change during storage. Aggregation decreased 50% by day 5. The KMS dropped from 307 at day 2-170. The MPC fell below 200g/l. There was slight platelet activation; the rate of clot formation decreased. CONCLUSIONS: Standard measures of in vitro platelet function indicated alterations during storage. A MPC of less than 200 corresponded to a Kunicki morphology score of less than 200. The TEG results correlated will with the KMS. These measurements may prove useful in predicting platelet survival and recovery.

Ankle Impingement Caused by an Intra-articular Plica: A Report of 2 Cases.

UNLABELLED: Entrapment of soft tissues in the anterolateral gutter of the ankle can cause impingement. When symptomatic, patients complain of chronic ankle pain exacerbated with dorsiflexion. Symptoms of instability and a history of recurring ankle sprains are common findings. Plain radiographs and magnetic resonance imaging may assist clinicians in identifying associated pathology. We present 2 cases of ankle impingement occurring in the setting of equivocal examination and imaging findings. In both cases, arthroscopy revealed a likely congenital, intra-articular plica. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Study.