A Novel Two-Step Ultrasound-Guided Technique for Anesthesia and Postsurgery Analgesia in Gluteal Augmentation Surgery.

In recent years, there has been an increase in demand for gluteal augmentation and reshaping surgeries with intramuscular implants which are becoming increasingly popular. Until now, this surgery was mainly performed under general anesthesia, but recently locoregional anesthesia techniques, such as tumescent local anesthesia, are being applied more and more. Today, the use of ultrasound for locoregional anesthesia and analgesia allows us to perform techniques that are increasingly precise and burdened with lower risks. In this report, we present a novel two-step ultrasound-guided technique combining a botox injection in the gluteus maximus four weeks before surgery and tumescent anesthesia with a cluneal nerve block. Furthermore, the combination of anesthetic and analgesic techniques can guarantee a better result both in terms of surgical execution of the intervention and in reducing pain and improving patient comfort in the postoperative period.

Ultrasound-Guided Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analyses.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.

Scanning before injection for costochondritis: A case report of ultrasound imaging of Hodgkin's lymphoma with chest wall invasion.

Non-traumatic costochondritis, which manifests as pain and tenderness over the anterior chest wall, may be associated with inflammatory arthritis affecting the upper costochondral and sternocostal joints. Local corticosteroid injection is helpful for recalcitrant cases and ultrasound guidance may not be routinely used by experienced rheumatologists. We report a female patient with pain over the right upper parasternal area with gradual swelling near the first costosternal junction. The ultrasound examination revealed a hyper-vascular mass, which was proven to be Hodgkin's lymphoma. We want to emphasize the importance of using ultrasound for guiding injection for costochondral lesions which facilitated the detection of a tumor invading the chest wall in our case.

Postoperative Analgesia and Palliative Care of Peng Block for Terminal Osteosarcoma.

Palliative care involves patients with a high incidence of chronic pain and inadequate treatment related to opioid abuse. In terminal patients, the side effects of opioids may result in lower quality of life due to their deleterious immunosuppression and gastrointestinal effects. In our routine clinical practice, we consider the ultrasound-guided PENG block as a palliative analgesic technique to improve end-of-life care to terminal patients.

Indications and Future Perspectives of a Minimally Invasive Ultrasound-guided Double-needle Joint Lavage.

Arthroscopic joint lavage was proposed as a treatment option for different joint conditions such as septic or inflammatory arthritis. Ultrasound (US) is today considered a fundamental tool in musculoskeletal diseases as for diagnostic and guide for interventional procedures such as synovial fluid sampling and drug injections. To enable faster recovery and to have an alternative to surgery, to reduce risks and costs, we performed an US-guided double-needle lavage of the shoulder joint. Here, we present two different clinical cases, the first with septic arthritis and the second with recalcitrant gouty arthritis, successfully treated with this technique.

Women With Primary Sjögren Syndrome and With Non-Sjögren Sicca Syndrome Show Similar Vulvar Histopathologic and Immunohistochemical Changes.

The goal of this study was to evaluate the characteristics and the prevalence of histopathologic and immunohistochemical changes in vulvar biopsies, in women with Primary Sjögren Syndrome (pSS) and non-Sjögren Sicca Syndrome (nS-SS). Twenty-one women with pSS and 11 with nS-SS (investigated by xerophtalmia and xerostomia tests, biopsy of minor salivary glands, gynecological history, and gynecologic symptoms score) underwent vulvar biopsies, evaluated for histopathologic and immunohistochemicalchanges, and compared with those obtained from 26 patients with lichen sclerosus. An inflammatory infiltrate was present in 31/32 biopsies (96.9%); biopsies from pSS patients showed a mild infiltrate in 10 cases and a moderate infiltrate in 11 cases; and patients with nS-SS had a mild infiltrate in 8 biopsies and moderate infiltrate in the other 2 biopsies. By immunohistochemistry, the infiltrate was composed predominantly of T lymphocytes (CD3), CD20 B cells were sparse and mean CD4:CD8 T-cell ratio was 1.5. No differences were observed between the grading of the inflammatory infiltrate in nS-SS and pSS; no correlation was shown between vulvar inflammatory infiltrate score (mild or moderate) and salivary glands inflammatory score. No differences were found in gynecologic symptoms, as well as in clinical and demographical characteristics between patients with mild and those with moderate vulvar inflammatory score. A higher prevalence of moderate inflammatory infiltrate was observed in biopsies from women with lichen sclerosus than in pSS and nS-SS patients (61.5% vs. 27.5%, P=0.02). Women with pSS and nS-SS show a high and similar prevalence of vulvar inflammatory infiltrate. A gynecologic evaluation is needed both in pSS and nS-SS to assess genital involvement and, eventually, to address a therapy targeted to genital symptoms.

Premedication prevents infusion reactions and improves retention rate during infliximab treatment.

Infliximab (IFX) is an anti-tumor necrosis factor-alpha antibody used to treat inflammatory joint diseases. Infusion reactions (IR) can occur during and after intravenous administration and often require discontinuation of IFX therapy. This retrospective study aimed at evaluating the incidence of IR in patients with joint inflammatory diseases receiving IFX with and without premedication. Clinical charts of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis patients receiving IFX from January 2002 to December 2014 were reviewed. Patients receiving only one premedication protocol over time were enrolled and clustered based on the type of premedication as follows: group 1 received no premedication; group 2 received paracetamol, esomeprazole, hydrocortisone, and chlorpheniramine maleate; group 3 received paracetamol, hydoxyzine, ranitidine, and 6-methylprednisolone. Adverse events were recorded during the infusion, in the following hours and at control visits. The charts of 105 patients treated with IFX were selected. IR were observed in 23/51 patients of group 1, in 7/35 patients of group 2, and none of 19 patients in group 3. IR incidence was significantly lower in the second (p = 0.021) and third (p < 0.001) compared to the first group. The incidence of IR was significantly lower in group 3 than group 2 (p < 0.043). Moreover, patients in group 1 had a relative risk of developing an IR 2.5 times higher than group 2. In our experience, the use of premedication significantly reduced the number of IR to IFX. In particular, the combination of paracetamol, hydroxyzine, 6-methylprednisolone and ranitidine was more efficacious than paracetamol, esomeprazole, hydrocortisone, and chlorpheniramine maleate combination protocol.

Assessment, Definition, and Classification of Lower Limb Ulcers in Systemic Sclerosis: A Challenge for the Rheumatologist.

OBJECTIVE: To evaluate pathogenesis and clinical features of lower limb ulcers in systemic sclerosis (SSc) and to propose a classification that could be used in clinical practice. METHODS: Charts of 60 patients with SSc who had lower limb cutaneous lesions were reviewed. All patients had videocapillaroscopy and arterial and venous lower limb color Doppler ultrasonography (US). Arteriography was performed if occlusive peripheral arterial disease was suspected. RESULTS: The 554 lesions were classified as hyperkeratosis, ulcers, and gangrenes. There were 341 (61.6%) hyperkeratoses, 208 (37.5%) ulcers, and 5 (0.9%) gangrenes. Ulcers were divided into pure ulcers, ulcers associated with hyperkeratosis, and ulcers secondary to calcinosis. Involvement of arterial and venous macrocirculation as determined by color Doppler US was observed in 17 (18.3%) and 18 (30%) patients, respectively. Seventeen out of 37 patients with pure ulcers (45.9%) presented neither venous insufficiency nor hemodynamically significant macrovascular arterial disease. In these patients, pure ulcers were most likely caused by isolated SSc-related microvascular involvement (pure microvascular ulcers). The only significant risk factor for development of pure microvascular ulcers in the multivariate analysis was the history of lower limb ulcers (OR 26.67, 95% CI 2.75-259.28; p < 0.001). CONCLUSION: Results of our study indicate that lower limb ulcers in SSc often have a multifactorial pathogenesis that may be difficult to manage. Further studies are needed to validate the proposed classification and to assess the most appropriate management of lower limb ulcers in SSc.

Is an intervention with a custom-made splint and an educational program useful on pain in patients with trapeziometacarpal joint osteoarthritis in a daily clinical setting?

AIM: Custom-made splints may be useful in the conservative treatment of osteoarthritis (OA) of trapeziometacarpal (TMC) joint OA. Our aim was to evaluate usefulness of a custom-made splint and educational program in patients with symptomatic TMC joint OA in daily clinical practice. METHODS: Fifty patients with symptomatic TMC joint OA, not treated with surgery, were enrolled in a open prospective study in a clinical day setting and treated with a 'butterfly' custom-made thermoplastic short opponens splint to be worn 16 h/day for 30 days and then when needed, for 12 months. Patients were evaluated at enrolment (T0), at the first month (T1) and at the 12th month (T2) since splint application for pain (main outcome measure) by numeric rating scale 0-10. At T0 and T1, a Jamar dynamometer (kg) was used to assess hand strength, a pinch gauge to evaluate pinch strength (kg) and Dreiser test to assess hand disability (secondary outcome measures). RESULTS: The comparison between T0 and T1 showed a significant improvement in all the outcome measures (P < 0.0001 for pain, muscle and pinch strength; P = 0.001 for Dreiser test). Moreover, at the end of 12 months follow-up, patients maintained the reduction of pain (T2 vs. T1, P = NS) and showed a reduced consumption of analgesics (P < 0.05). CONCLUSIONS: A custom-made thermoplastic short opponens splint for 30 consecutively days for at least 16 h/day, followed by occasional use on pain outbreak is an useful conservative treatment in symptomatic TMC joint OA.

Digital ulcers in scleroderma: staging, characteristics and sub-setting through observation of 1614 digital lesions.

OBJECTIVE: To evaluate in SSc, the frequency of digital lesions and the morphology, characteristics, natural course and time to healing of 1614 digital ulcers (DUs). METHODS: One hundred SSc patients were followed up for 4 years. In the first step, the digital lesions were observed and classified at the time of presentation [digital pitting scar (DPS); DU; calcinosis; gangrene]. In the second step, DUs were divided into subsets according to their origin and main features. In the third step, the time to healing was recorded for each DU and the influence of DU main characteristics on time to healing was also evaluated. RESULTS: In the first step, 1614 digital lesions were observed: DPS, 712 (44.1%) lesions; DU, 785 (48.6%); calcinosis, 110 (6.8%); and gangrene, 7 (0.8%). In the second step, DUs were subsetted as follows: DU developed on DPS (8.8%), pure DU; DU developed on calcinosis (60%); DU derived from gangrene. In the third step, the mean time to healing was 25.6 (15.6) days in DPS, 76.2 (64) days in pure DU, 93.6 (59.2) days in calcinosis ulcers and 281.1 (263.3) in gangrene. CONCLUSIONS: In SSc, digital lesions are represented by DPS, DU, calcinosis and gangrene, and provide an evidence-based DU subsetting according to their origin and main characteristics. Subsetting may be helpful for a precise DU evaluation and staging, and in randomized controlled trials for a precise identification of those DUs that are to be included in therapeutic studies.