Early Breast Angiosarcoma Development After Radiotherapy: A Cautionary Tale.

This is a short clinical report depicting an exceptionally early presentation of radiation-induced angiosarcoma and overview of the literature. This case highlights the need for a high level of clinical suspicion in those patients presenting with unresolving cutaneous skin changes after radiotherapy for breast cancer.Breast-conserving therapy, comprising breast-conserving surgery and adjuvant radiotherapy, has largely replaced mastectomy in the treatment of early-stage breast carcinoma. Breast angiosarcoma is a rare but severe long-term complication associated with postoperative radiotherapy (Int J Radiat Oncol Biol Phys. 2002;52:1231-1237). It often presents as a bluish/purple skin lesion in a breast previously treated for breast cancer. This case explores an unexpectedly early presentation of radiation-induced breast angiosarcoma, which was initially thought to be benign bruising. Management remains challenging and prognosis is poor because of its aggressive local and regional invasion and early metastasis, commonly to the lungs and liver. Early surgical resection with wide margins is the treatment of choice (J Plast Reconstr Aesthet Surg. 2011;64:1036-1042).

Is the Apprehension Test Sufficient for the Diagnosis of Anterior Shoulder Instability in Young Patients without Magnetic Resonance Imaging (MRI)?

INTRODUCTION: The purpose of this study is to compare the sensitivities and positive predictive values (PPV) of the anterior apprehension test and magnetic resonance imaging (MRI) in the diagnosis of anterior labral tears in young patients with shoulder instability and to determine if surgery could be carried out without this investigation in selected patients. MATERIALS AND METHODS: We undertook a retrospective study of 168 patients aged between 15 and 30 years with a history of shoulder dislocation and compared the sensitivities and the PPV of the apprehension test with both MRI and magnetic resonance arthrograms (MRA) in the diagnosis of a Bankart lesion. The radiological investigations were interpreted by general practice radiologists and specialised musculoskeletal radiologists. All patients had their diagnosis confirmed by shoulder arthroscopy. RESULTS: Our results showed that the apprehension test was highly reliable when it was positive with a PPV of 96%. It was more sensitive than MRI in the diagnosis of a Bankart lesion. The clinical test was significantly better when a musculoskeletal radiologist interpreted the MRI. The MRA interpreted by a musculoskeletal radiologist had the highest rates of sensitivity in detecting Bankart lesions. The figure was similar to that for the apprehension test. There was no difference in the PPVs among the clinical test, the MRI and the MRA read by the 2 categories of radiologists. CONCLUSION: We conclude that a routine MRI may be unnecessary in evaluating a young patient with clinically evident anterior shoulder instability if the apprehension test is positive. A MRA that can be interpreted by a musculoskeletal radiologist will be the next best investigation if the clinical test is negative or equivocal.

Delayed traumatic vertebral body compression fracture; part I: clinical features.

We have described three patient who sustained trauma to their spines followed by persisting pain. Initial radiographs were negative, but on subsequent examinations compression fractures were demonstrated. This sequence of events resembles the clinical picture described by Kümmell in 1895 with significant differences. A plethora of early written description with minimal radiographic documentation suggests that this is a relatively rare condition. It is appropriate, therefore, to present these cases with the suggestion that traumatic injuries with persisting thoracic or upper lumbar back pain should be followed up radiographically in order to demonstrate the occurrence of subsequent compression fractures. These fractures may be treated with simple braces.

Are there deficits in anticipatory postural adjustments in Parkinson's disease?

We studied anticipatory postural adjustments in patients with Parkinson's disease who dropped a load from extended arms while standing. Anticipatory postural adjustments were seen when load dropping was induced by a fast, bilateral shoulder abduction but not when it was induced by pressing a trigger with the right thumb. We conclude that anticipatory postural adjustments in patients with Parkinson's disease can change with the magnitude of an action which is used to trigger a predictable postural perturbation. Thus, the described deficits in anticipatory postural adjustments in patients with Parkinson's disease are likely to be of quantitative rather than qualitative nature.

Contrast sensitivity in one-eyed subjects.

The effects of early monocular form deprivation on the developing mammalian visual system, and the anatomical and physiological consequences of early monocular enucleation, suggest that the remaining eye of human subjects who had the other eye removed early during development might be capable of supernormal performance. To test this inference, the achromatic contrast sensitivity of the remaining eye of subjects who had the other eye removed at different ages after birth was compared with that of normal subjects tested under monocular and binocular conditions. The results show that all subjects who had an eye removed during early development had a higher contrast sensitivity than the better eye of control subjects. Furthermore, the earlier in development that the eye was removed, the lower the spatial frequency at which contrast sensitivity is enhanced compared with measurements made in the better eye of control subjects, and the larger the range of spatial frequencies over which contrast sensitivity is supernormal.

Impaired compensation for mechanical loads in a patient with hemiballismus following stroke.

Flexion movements of the wrist were studied in a patient who showed signs of hemiballismus following a unilateral infarction, which damaged the region neighboring the subthalamic nucleus. The experiments were designed to test whether a lesion of this nature impairs load compensation and, specifically, whether antagonist activity can be appropriately suppressed when initiating a movement. The latency between movement onset and agonist EMG onset changed from the normal relationship where agonist onset precedes movement to one where agonist onset followed movement when an extensor load was placed on the affected limb. This was found to result from the inability to inhibit tonic activity in the antagonist and simultaneously activate the agonist muscle. The results suggest that the indirect pathway through the basal ganglia may be necessary to compensate for mechanical loads and to suppress antagonist activity when a movement is initiated.

Motor control research in rehabilitation medicine.

Progress in rehabilitation medicine requires an understanding of the basic rules of motor coordination, as well as of the contribution of adaptive processes within the central nervous system to the patterns of impaired movements. We assume that patterns of voluntary movements reflect rules of coordination that are used by the intact central nervous system of healthy persons. In pathological conditions that may include cognitive, central neurological, and peripheral disorders, the central nervous system may reconsider these rules leading to different peripheral patterns of voluntary movements. In such conditions, changed motor patterns may be considered adaptive to a primary disorder. They may even be viewed as optimal for a given state of the system of movement production. We suggest that the emphasis of therapeutic approaches must be placed not on restoring the motor patterns to 'as close to normal as possible', but on assisting the central nervous system to develop optimal adaptive reactions to the original underlying problem.

Metastatic cancer in Paget's disease of bone. A case report.

A 50-year-old white male presented with concurrent Paget's disease of bone and metastatic adenocarcinoma. Our review of the literature and our clinical experience suggests that carcinoma coexisting at the site of bone involved with Paget's disease occurs more commonly than has been recognized. The paucity of reports of tumor metastatic to sites of Paget's disease of bone may be due to an artifact of data collection. The differentiation of metastatic from de novo tumors must be accomplished by biopsy, and the diagnosis is essential for appropriate treatment. Commonly a correlation of known tumor types with Paget's disease is made, and metastatic tumors are excluded.

Physical modalities in rheumatological rehabilitation.

Physical modalities continue to be a part of the rehabilitation treatment of patients with arthritis. Databases Medline (1980-1992) and National Rehabilitation Information Center, Rehabdata (1956-1992), were searched for "arthritis" and (1) diathermy, (2) massage, (3) transcutaneous electrical nerve stimulation (TENS), (4) hydrotherapy, (5) counter-irritants, (6) topical ointments, (7) compression gloves, (8) superficial heat, and (9) acupuncture. The results suggest that scientific publication related to the treatment of arthritis with physical modalities has been recently less frequent. The literature reviewed suggested that ablative diathermy may be fruitful for wider trials for persistently inflamed joints, and TENS and capsaicin can provide pain relief in osteoarthritis if it is possible to deliver the treatment fully and persistently.

Rehabilitative rheumatology content in current rehabilitation medicine training programs.

The Council on Rehabilitative Rheumatology of the American Rheumatism Association, through the Education Subcommittee, surveyed directors of 69 approved rehabilitation medicine residency training programs to assess the nature of training in rehabilitative-rheumatology and whether the directors believed this training to be adequate. Sixty-one directors responded, with 84% of the respondents reporting a rheumatology department in their hospitals and 43% reporting a formal rotation for their residents in rheumatology. Fifty-nine (97%) reported their residents received lectures in rheumatology. Fifty-five (90%) reported lectures given by a physiatrist in the rehabilitative management of rheumatic diseases. Only 21 (34%) reported a physiatrist-attended rheumatology outpatient clinic. Fifty-one (82%) desired a closer liaison with the rheumatology department. Thirty-seven (61%) indicated their residents received adequate training on the diagnosis of rheumatic diseases, and 46 (75%) adequate training in rehabilitative management, while 59 (97%) desired a concise handbook which emphasizes the rehabilitative management of rheumatic diseases. A previous survey of 100 arthritis fellowship programs approved by the American Medical Association brought 81 responses, of which only 43% considered that their Fellows had adequate training in rehabilitative rheumatology. Physiatrists attended clinics 21% of the time and patient care rounds 19%. Ninety-four percent desired a syllabus. Both surveys indicated limited interaction between the two specialties and leads us to conclude that a rehabilitative-rheumatology handbook would be desirable, closer liaison of rehabilitation faculty with rheumatology faculty is needed to respond to individual training needs, more active participation by a physiatrist in patient care conferences may be necessary for adequate education in rehabilitative-rheumatology.

Spinal pain made worse by recumbency: a clue to spinal cord tumors.

In the absence of physical findings, pain in the low back, cervical or thoracic spine, or the extremities presents a diagnostic problem. On occasion the pain is present or made worse only when the patient lies down. We have attended four patients with underlying extradural tumors of the spinal canal. A 75-year-old woman with chronic back pain was treated for multiple myeloma with intravenous dexamethasone and 400 rads of x-ray irradiation to the lumbar spine and experienced marked pain relief in 24 hours. A 76-year-old woman with neck pain had complete pain relief after a vascular, calcified meningioma was removed surgically from under the 2nd and 3rd cervical nerve roots. A 38-year-old male with constant pain in the lumbar area and right leg and foot experienced marked relief from pain after a neurolemmoma of the cauda equina was surgically removed. A 57-year-old woman with knee pain became pain free 24 hours after radiation therapy to an enlarged nodular cauda equina. These four cases illustrate a diagnostic clue rarely mentioned in the literature.

Cylinder splints: their use in the treatment of arthritis of the knee.

Cylinder knee splints afforded significant relief of pain and were not associated with loss of range of motion or muscle strength in 13 of 15 patients. Splints help patients who demonstrate persistent synovitis of the knee, who do not respond to intraarticular injection of steroids, and for whom surgery is not immediately appropriate. The fiberglass polymer used in this study has several advantages over plaster for splints.

Lower extremity amputation in scleroderma.

Scleroderma or Systemic Sclerosis (SSC) is a disorder characterized by fibrosis of the skin and multiple internal organs. The pathological lesion is a triad of small artery intimal proliferation, medial thinning and adventitial scarring. Autoamputation of fingers and toes is often seen, but only a few cases of limb amputation in scleroderma patients have been reported. The Pittsburgh Scleroderma databank includes 1,030 patients with SSC. Among these were seven patients who sustained lower limb amputation. There were four patients with the CREST variant of SSC, two with diffuse scleroderma, and one who had SSC/rheumatoid arthritis/polymyositis overlap who sustained limb amputation. Of the seven, three were male and five had a significant smoking history. Ages ranged from 46 to 71 years. All patients underwent amputation for nonhealing ulcerations. No problems with postoperative wound healing were seen. Pathologic changes typical of SSC in addition to atherosclerotic peripheral vascular disease were described in one case. Three patients were successfully fitted with prostheses and became independent ambulators. Four patients could not be fitted with prostheses. No skin problems were reported related to prosthetic use. Our review demonstrates that SSC patients who undergo amputation can become successful prosthetic users and should be considered for prosthetic prescription.

Anticipatory postural adjustments during standing in below-the-knee amputees.

OBJECTIVE: We studied the role of adaptive changes within the central nervous system in anticipatory postural adjustments seen in unilateral below-the-knee amputees. DESIGN: Changes in electromyographic and mechanical variables were compared during standardized tasks performed by standing subjects. BACKGROUND: Anticipatory postural adjustments represent an important mechanism of postural control which was expected to be changed in amputees because of both mechanical and secondary, neurological reasons. METHODS: Six patients after a below-the-knee amputation and six control subjects stood on a force platform and performed fast bilateral shoulder movements and also dropped or caught a load from (into) extended hands. Anticipatory changes in the background activity of postural muscles were analysed. RESULTS: In amputees, there were cases of marked asymmetry in anticipatory changes of the background muscle activity which were larger on the intact side of the body but were commonly small or absent on the side of the amputation. This asymmetry could lead to larger mediolateral forces and displacements of the centre of pressure. CONCLUSIONS: We suggest that asymmetrical patterns of anticipatory postural adjustments reflect central adaptive changes secondary to the amputation. Rehabilitation approaches would benefit from understanding and taking advantage of the adaptive changes within the central nervous system. RELEVANCE: We demonstrated asymmetries in patterns of anticipatory postural adjustments during voluntary arm movements and load manipulations by standing unilateral amputees. This finding is of potential importance for rehabilitation of amputees and their prosthetic training.