Multiparametric ultrasound images of three different cases of schwannoma of the peripheral nervous system.

This case image illustrates the importance of new sonographic applications such as superb microvascular imaging and shear wave elastography; as showed, they improve the diagnostic recognition of peripheral nerve lesion thanks to a better definition of vascularity and measure of stiffness.

Analogies and differences between cirrhotic cardiomyopathy and hepatopulmonary syndrome.

Cirrhotic cardiomyopathy and hepatopulmonary syndrome are two quite frequent clinical entities that may complicate the course of liver cirrhosis. The common pathophysiological origin and the same clinical presentation make them difficult to compare. Cirrhotic cardiomyopathy and hepatopulmonary syndrome may start with dyspnea and breathlessness but the former is characterized by a chronic cardiac dysfunction and the latter by a defect of oxygenation due to pulmonary shunts formation. The focus is to differentiate them as soon as possible since the treatment is different until the patient undergoes liver transplant that is the real unique cure for them.

Imaging and surgical approach for a schwannoma of the hand.

Schwannomas are benign encapsulated neoplasms of the peripheral nerve sheath. Clinical diagnosis is often difficult, and final diagnosis is usually based on histopathological findings. Imaging techniques, such as magnetic resonance imaging and ultrasonography, can be optimized to improve assessment prior to surgical treatment. The present case demonstrates that high-resolution sonography can be useful in assessing the underlying cause of median nerve pathology.

Performance of classical serum inflammatory markers in healed and unhealed treated patients with joint and prosthetic joint infections.

BACKGROUND: Serum markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and D-dimer, are currently used by clinicians and orthopedic surgeons in diagnosing and managing joint infections (JI), although conflicting results exist on their performance. The aim of this study was to evaluate their performance in assessing healing or unhealing of patients with JI or with prosthetic joint infection (PJI). METHODS: ESR, CRP and D-dimer serum levels were evaluated before, during and after antibiotic treatment in 61 patients (65.1 ± 12.6 years): 49 affected by PJI and 12 by JI, between 2020 and 2022. These patients had undergone orthopedic surgery and were treated with antibiotics. RESULTS: ESR, CRP and D-dimer were significantly lower after treatment than before (p value: 0.001, 0.001 and 0.003, respectively) in healed and unhealed patients. A moderate correlation was found between the three inflammatory markers. CONCLUSIONS: Using a cut off value of 25 mm/h for ESR, 0.5 mg/L for CRP, and 700 ng/ml for D-dimer, it might be possible to discriminate healed from unhealed patients (PPV and NPV: ESR 65.5% and 68.8%, CRP 71.9% and 79.3%, D-dimer 76.9% and 81.8%). The combined use of these three inflammatory markers might be useful in the management of joint infections.

Multiple musculoskeletal abnormalities in a woman with breast cancer treated with aromatase inhibitor.

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Human Monkeypox-A Global Public Health Emergency.

Monkeypox, a viral zoonosis caused by an Orthopoxvirus, is clinically characterized by fever, headache, lymphadenopathy, myalgia, rash and burdened by some complications that can be severe and life threatening. Monkeypox, endemic in some central and west African countries, in tropical areas near equator, rose to the headlines following its recent outbreak in non-endemic countries of Europe and the USA. Thus, the World Health Organization, worried about the growing dimension of the problem, declared monkeypox a global public health emergency. Now, after months of careful observation, the western scientific research is drawing conclusion that African endemic countries represent a reserve pool able to feed, through travelers and sexual networks, the outbreak in non-endemic countries in which high-risk communities such as gay and bisexual men are the most affected. Prevention through vaccination and early diagnosis are the core to breaking the chain of diffusion of this epidemic. Particular attention should be paid to avoid the spread from endemic countries, also implementing the economic investments in their public health system. Information campaigns and assistance to high-risk classes in non-endemic countries are important priorities, however, assuming that specific treatments for this disease are still tentative.

Nosocomial Extracardiac Infections After Cardiac Surgery.

Purpose of Review: Nosocomial extracardiac infections after cardiac surgery are a major public health issue affecting 3-8.2% of patients within 30-60 days following the intervention. Recent Findings: Here, we have considered the most important postoperative infective complications that, in order of frequency, are pneumonia, surgical site infection, urinary tract infection, and bloodstream infection. The overall picture that emerges shows that they cause a greater perioperative morbidity and mortality with a longer hospitalization time and excess costs. Preventive interventions and corrective measures, diminishing the burden of nosocomial extracardiac infections, may reduce the global costs. A multidisciplinary team may assure a more appropriate management of nosocomial extracardiac infections leading to a reduction of hospitalization time and mortality rate. Summary: The main and most current data on epidemiology, prevention, microbiology, diagnosis, and management for each one of the most important postoperative infective complications are reported. The establishment of an antimicrobial stewardship in each hospital seems to be, at the moment, the more valid strategy to counteract the challenging problems.

Which clinical and sonographic parameters may be useful to discriminate NASH from steatosis?

BACKGROUND: The natural history of nonalcoholic steatohepatitis (NASH) includes the passage through steatosis. GOAL: To retrospectively evaluate the usefulness of sonographic parameters compared to histological diagnosis when differentiating steatosis from NASH. STUDY: This retrospective study reviewed records of patients with steatosis from databases of our Departments, selecting only those who had been diagnosed by sonography and liver biopsy [64 males (63.82%); 30 females (36.18%)]. RESULTS: Attenuation of the echo amplitude (P<0.05; odds ratio (OR): 3.43; confidence interval (CI): 1.02-11.57), focal fat sparing (P<0.05; OR: 3; CI: 1.02-11.88) and splenic diameter (P<0.05; OR: 1.66; CI: 1.04-3.26) were independent predictors of NASH. A significantly higher association of attenuation of the echo amplitude, enlarged splenic diameter, and presence of focal fat sparing was observed in NASH patients (P<0.01). CONCLUSIONS: It is very difficult to build a predictive system to distinguish NASH from steatosis based on sonographic scores. However, it is already possible to differentiate NASH from steatosis by combining 3 simple sonographic parameters: attenuation of the echo amplitude, enlarged splenic diameter, and presence of focal fat sparing.

Fatal Clostridium Infection in a Leg-Amputated Patient after Unsuccessful Knee Arthroplasty.

Prosthetic joint infection (PJI) is a possible complication occurring after prosthesis implantation. We describe the case of a patient with early postoperative multidrug-resistant polymicrobial PJI and mixed infection of the surgical wound. Despite the removal of the prosthesis, the positioning of double-stage exchange, and dehiscence debridement of the surgical wound, the infection continued. Positioning of an external fixator, plastic reconstruction with a skin graft, and continuous (two years) multiple antimicrobial therapy led to the resolution of the knee infection; a knee prosthesis was implanted, but a new infection of the extensus apparatus by multidrug-resistant Klebsiella pnumoniae followed. It was complicated by surgical wound dehiscence, forcing us to remove the prosthesis, put a new external fixator, and continue with the antibiotic treatment, with no results, and, finally, proceed to a leg amputation. Fourteen days after, the patient was discharged in good clinical condition but, fifteen days later, during rehabilitation in another hospital, the patient developed a severe Clostridium difficilis infection with profuse, intense diarrhea, toxic megacolon, and septic shock; despite colectomy and treatment in an intensive care unit, he died four months later. Patients affected by polymicrobial PJI are at high risk of treatment failure and, therefore, should be given a warning, in good time and appropriate form, of the likelihood of leg amputation.

Prosthetic joint infection. A relevant public health issue.

Prosthetic joint infection (PJI) is a common complication of the knee and hip arthroplasty and represents a huge challenge for physicians. PJI raises serious social, economic and clinical concerns in the public health that need a comprehensive approach to better focus on proven strategies for disease prevention and treatment. History and clinical signs on joint site are useful means for suspecting PJI that need to be confirmed through major and minor diagnostic criteria. The pathogen isolation and the resulting antibiogram are crucial to guide the correct antibiotic strategy and together with surgical treatment (prosthesis revision and spacer implantation) represent the cornerstones to eradicate the infection before attempting a new arthroplasty. External fixator with removal of the spacer may be an option before performing a new arthroplasty when the infection does not heal. Arthrodesis may also be considered if the arthroplasty is contraindicated. Limb amputation is the last chance when pathogen eradication failed and might lead to life-threatening situations.

Reliability and Agreement of Point and 2-D Shear-Wave Elastography in Assessing the Sciatic Nerve Stiffness.

Information is lacking about the reliability and agreement of different shear-wave elastographic modes in the peripheral nervous system evaluation. The aim of this observational study was to evaluate reproducibility and agreement of two different shear-wave elastographic modes for measuring the sciatic nerve stiffness in patients affected by osteoarthrosis. Two sets of three measurements were conducted bilaterally on the sciatic nerve of 20 patients with point and 2-D shear-wave elastography by a unique expert sonographer. This consecutive case series study was performed in 1 mo. No significant difference was found comparing the first with the second set of evaluations (p = 0.08 for point shear-wave elastography and 0.3 for 2-D shear-wave elastography). Correlation between the two sets of measurements was good and excellent (0.799 with point shear-wave elastography and 0.877 with 2-D shear-wave elastography). Intra-class coefficient correlation between the two sets of measurements was excellent for both shear-wave elastographic modes (0.869 and 0.938, respectively); no agreement between them was demonstrated (analysis of variance [ANOVA] test: p = 0.014).Despite the lack of agreement owing to the different procedures for measuring, both shear-wave elastographic modes allow reliable stiffness measurements of the sciatic nerve and may be used to evaluate stiffness changes.

Portosystemic shunts in a large cohort of patients with liver cirrhosis: detection rate and clinical relevance.

BACKGROUND: This study aimed to determine the detection rate and clinical relevance of portosystemic collaterals. METHODS: We studied 326 cirrhotics. Portosystemic collaterals, portal vein diameter, and splenic area were evaluated by color Doppler sonography; esophageal varices were detected by endoscopy. RESULTS: Of the cirrhotics, 130 had portosystemic collaterals (39.9% total, left gastric vein 11%, paraumbilical vein 7.4%, splenorenal shunts 13.8%, and combined shunts 7.7%). Cirrhotics without portosystemic collaterals or with a paraumbilical vein had a significantly narrower portal vein diameter than cirrhotics with a left gastric vein (P < 0.001). Cirrhotics with a paraumbilical vein had a significantly smaller splenic area than cirrhotics with a left gastric vein (P < 0.001), splenorenal shunts (P < 0.001), combined shunts (P < 0.001), or without portosystemic collaterals (P < 0.05). A significant association between portosystemic collaterals and Child's classes or presence and type of esophageal varices was found (P < 0.0001 and P = 0.0004, respectively). The highest prevalence of Child's class C and large (F-3) esophageal varices was found in cirrhotics with a left gastric vein (41.7% and 36.1%, respectively), whereas esophageal varices were absent in 47.4% of cirrhotics without portosystemic collaterals and in 58.3% of cirrhotics with a paraumbilical vein. CONCLUSIONS: The left gastric vein is associated with some sonographic and clinical markers of disease severity, whereas the absence of portosystemic collaterals or the presence of paraumbilical veins seems to identify cirrhotics with markers predictive of a more favorable clinical course.

Accuracy and performance of a new handheld ultrasound machine with wireless system.

We verified the accuracy and performance of a new handheld ultrasound machine, in comparison to a high-end sonographic machine. We performed bilateral measurements of the following tendon districts (supraspinatus, flexor of the middle finger, patellar and Achilles) and of the cross sectional area of the median nerve in 21 patients using a musculoskeletal ultrasound linear scanner of a handheld sonographic machine and a high-end sonographic machine. Two tail T test was used to evaluate whether there were differences in the measurements between the two sonographic machines. Agreement was evaluated by Pearson's correlation. The mean time requested for the examinations was 18 and 9 minutes for the handheld and high-end sonographic machines, respectively. No significant differences were found between the measurements obtained with the handheld ultrasound machine and those with the high-end sonographic machine (p value ranging between 0.31 and 0.97, according to the examined district), whereas, a moderate correlation was found (r coefficient ranging between 0.43 and 0.77, according to the examined district). Although the examination with the handheld ultrasound machine took more time, it showed adequate accuracy and performance; this palmar tool might be also useful in operating rooms.

Reliability of quantitative point shear-wave ultrasound elastography on vastus medialis muscle and quadriceps and patellar tendons.

AIM: The aim of this work was to evaluate the reliability of pSWE in assessing the stiffness of the vastus medialis muscle and of the quadriceps and patellar tendons. MATERIAL AND METHODS: For this purpose, 18 subjects (9 males and 9 females of 57±22 years) in good clinical conditions were included in this study. pSWE examination was conducted by a unique expert operator with more than ten years of experience in musculoskeletal ultrasound. Two sets of five measurements for each muscle and tendon district were bilaterally performed at the same manner, at least fifteen minutes apart. The mean value of the measurements of each set was statistically compared with that of the other set. RESULTS: No significant differences were found comparing the mean value of the measurements of the two sets of evaluation performed in muscle and tendon areas (vastus medialis muscle: p=0.285; quadriceps tendon: p=0.979; patellar tendon: p=0.187). The intraclass correlation coefficient was excellent for all areas (vastus medialis muscle: 0.969; quadriceps and patellar tendons: 0.995 and 0.989, respectively). CONCLUSION:  The pSWE technique demonstrated that it was a reliable method for measuring stiffness in vastus medialis muscle and quadriceps and patellar tendon in subjects who had undergone orthopedic surgery. This opens the possibility of many applications in monitoring stiffness before and after surgery and during rehabilitation.

Postmeal portal flow variations in HCV-related chronic hepatitis and liver cirrhosis with and without hyperdynamic syndrome.

BACKGROUND: Doppler ultrasonography (US) of portal blood flow and portal flow volume (PFV) are useful to define changes in portal hemodynamics of patients with chronic liver diseases. The meal test with postmeal PFV measurements is generally accepted as a reproducible noninvasive test to evaluate the severity of portal hypertension. The aim of this study was to evaluate whether monitoring PFV changes after ingestion of a standard meal would be useful to characterize patients with chronic hepatitis or liver cirrhosis in the presence or absence of hyperdynamic syndrome (HS) characterized by elevated PFV, splenomegaly, systemic hypotension and/or increased cardiac output. PATIENTS AND METHODS: Thirty-seven patients (22 men and 15 women, median age 53 years) with hepatitis C virus infection and 20 healthy age- and sex-matched volunteers (Controls) were enrolled in the study. There were 19 (51.4%) patients with chronic hepatitis (Group A) and 18 (48.6%) with ultrasonographic evidence of liver cirrhosis (Child-Pugh class B), 9 of whom had an HS (Group B) while the remainder (Group C) did not. Each patient underwent liver color Doppler US and the test was repeated 30, 60 and 90 minutes after administration of a standard meal (300 kcal fluid meal containing 12 g of proteins, 11.6 g of lipids and 36.8 g of carbohydrates). RESULTS: The baseline PFV did not differ (p=NS) between Controls and both Groups A and C, while the PFV of Group B patients was significantly (p<0.01) higher. After 30 minutes, the PFV increased (p<0.01) both in Controls and Group A patients, while the differences were not significant in cirrhotic patients (Groups B and C). Our study confirmed that the postmeal PFV increases in both healthy individuals and in patients with chronic hepatitis, while in cirrhotic patients no significant changes occur. In conclusion, monitoring the portal blood flow in cirrhotic patients before and after administration of a standard meal might be a suitable test to evaluate potential disturbances of the flow itself. Moreover, the test could be useful to determine optimal pharmacological or surgical interventions aimed at restoring a better flow to the liver by reducing or favouring the occurrence of spontaneous mesenteric-systemic venous shunts.

Diagnostic approach to neuropsychiatric lupus erythematosus: what should we do?

Neuropsychiatric systemic lupus erythematosus is a diagnostic challenge due to the multifarious neurological and psychiatric manifestations that define it but, when suspected, diagnostic imaging can give a fundamental help. The advancements and variety of neuroimaging techniques allow us to perform more and more accurate evaluations of structure, perfusion, and metabolism of the brain and to detect cerebral and spinal lesions. Moreover, vascular districts of the neck and the brain, as well as the electrical brain and peripheral muscle activity may be accurately investigated, thus giving us a wide panoramic view. Although magnetic resonance is recognized as a fundamental neuroimaging technique to reach a correct diagnosis, the juxtaposition of other diagnostic techniques has improved the possibility to make diagnoses but has also increased the confusion about deciding which of them to use and when. Our aim was to combine the number of available techniques with the need to simplify the diagnostic path. Therefore, through the construction of an algorithm from an evidence based approach, we believe we are providing some added improvements to facilitate and expedite the diagnosis of NPSLE.

Differences in carotid atherosclerosis between patients with ankylosing spondylitis treated with tumor necrosis factor-α antagonists and healthy matched controls.

An increased vascular risk is present in patients with ankylosing spondylitis (AS). In this report, we evaluate the presence and grade of atherosclerosis in patients with AS, uninterruptedly treated with tumor necrosis factor-α (TNF-α) antagonists for 2 years, in comparison to that in a nontreated group of healthy controls.Fourteen patients with AS and 14 healthy controls underwent carotid sonography to measure intima-media thickness (IMT) and to evaluate the presence of plaque. Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Metrology Index, Bath Ankylosing Spondylitis Functional Index scores, erythrocyte sedimentation rate, C-reactive protein, glycemia, total cholesterol, and triglyceride levels were also recorded.Patients with AS showed significantly lower values of mean and maximum IMT at the level of the common carotid (P = .02 and .04, respectively) and the carotid bulb (P = .0006 and .0005, respectively) compared to those of healthy controls. They also had a number of carotid plaques significantly lower than that of healthy controls (P = .02). No differences were found in IMT values at the level of internal carotid between the 2 populations.The significantly lower carotid atherosclerosis found in patients with AS treated with TNF antagonists than in healthy controls shows the important complementary role of this treatment in reducing vascular disease progression probably by decreasing inflammation.

An ultrasound automated method for non-invasive assessment of carotid artery pulse wave velocity.

To validate the clinical applicability and feasibility of an automated ultrasound (US) method in measuring the arterial stiffness of patients with chronic inflammatory rheumatic diseases, comparing automated measurements performed by a rheumatologist without experience in vascular sonography with those obtained by a sonographer experienced in vascular US, using a standardized manual method. Twenty subjects affected by different chronic inflammatory rheumatic disorders were consecutively recruited. For each patient, the arterial stiffness of both common carotids was manually calculated. Subsequently, the measure of the pulse wave velocity (PWV) was obtained using an US device called Radio Frequency - Quality Arterial Stiffness (RF-QAS), provided by the same US system (ie, My Lab 70 XVG, Esaote SpA, Genoa, Italy) equipped with a 4-13 MHz linear probe. The reliability comparison between the two US methods was calculated using the intraclass correlation coefficient (ICC). ICC between the values obtained with the two methods for calculating the arterial stiffness resulted 0.789. A significant positive correlation between the two methods was also established with Pearson's (r=0.62, p<0.0001) and Spearman's analysis (r=0.66, p=0.001). A significant performance comparison was seen using Bland-Altman plot. The acquisition of the arterial stiffness parameter with the automated method required about 2 min for each patient. Clinical applicability of this US automated method to assess PWV at common carotid level by a rheumatologist is reliable and feasible in comparison with a conventional manual method.