Prevalence of Abnormal Ultrasound Findings in Asymptomatic Posterior Tibial Tendons.

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a pathological condition that can cause failure of the posterior tibial tendon (PTT). Initially, patients with PTTD are often asymptomatic, making early identification and treatment challenging. Certain ultrasound (US) characteristics have been implicated in the presence of tendinopathy, but their frequency has yet to be assessed in the PTT. The purpose of this study was to identify and report on the frequency of incidental, or potentially early subclinical, tendinopathic US characteristics in asymptomatic PTTs. METHODS: Following institutional review board approval, 150 participants underwent a bilateral-comprehensive US assessment. The resulting images were reviewed and assessed to identify the presence of abnormalities demonstrated to represent tendinopathy. RESULTS: Overall, 266 tendons were assessed and 128 (48.1%) were determined to have at least one tendinopathic trait. Specifically, 51 (19.2%) had circumferential fluid, 69 (25.9%) had noncircumferential fluid, 22 (8.3%) had thickening, 31 (11.7%) had heterogenicity, 19 (7.1%) had hyperemia, and 2 (0.8%) had calcification. Additionally, Caucasian participants were found to be nearly 3 times more likely to have tendinopathic findings when compared with African American participants. CONCLUSION: Sixty-seven percent of participants and 48.1% of PTTs evaluated had at least one tendinopathic feature identified on US. The prevalence rates of these findings, observed in participants, were as follows: noncircumferential fluid, circumferential fluid, heterogenicity, and thickening. Knowing the frequency of these traits may help clinicians to identify subclinical tendinopathy in the PTT before it progresses to PTTD. LEVEL OF EVIDENCE: Level IV, case series.

Wernicke's Encephalopathy Presenting as Sensorineural Hearing Loss.

Sleeve gastrectomy is a restrictive-type weight loss surgery that can result in nutritional deficiencies, such as vitamin B1 (thiamine) deficiency. Although Wernicke's encephalopathy is a known complication following bariatric surgery, bilateral sensorineural hearing loss is a rare presenting symptom of this condition. We present a case of a patient two months postoperative following a sleeve gastrectomy whose chief complaint was hearing loss. While initial laboratory evaluation of her complaint showed elevated inflammatory markers, prompting an autoimmune workup, ultimately the diagnosis of Wernicke's encephalopathy was confirmed by a low thiamine level and magnetic resonance imaging findings. A correction of the patient's thiamine deficiency led to an improvement of her symptoms.

Normal Ultrasonographic Parameters of the Posterior Tibial, Peroneal, and Achilles Tendons.

Tendinopathy of the foot and ankle is common and can lead to pain or functional limitations. The most frequently affected tendons in the foot and ankle are the posterior tibial, peroneal, and Achilles. We used ultrasound to determine normal values for these tendons. From 2015 to 2016, a prospective, standardized bilateral lower extremity ultrasound examination protocol was performed by a musculoskeletal ultrasonographer of the 4 tendons and above and below the malleoli as appropriate. A total of 199 patients with 398 extremities were identified, consented, and participated in the study. Most tendons were normally distributed. The average size of the tendons was as follows: Achilles 5.0 mm (range 2.8-11.2 mm); peroneus long above the malleolus 2.1 mm (range 0.7-3.6 mm), below the malleolus 2.9 mm (range 0.8-6.3 mm); peroneus brevis above the malleolus 1.2 cm (range 0.3-4.0 mm), below the malleolus 1.3 mm (range 0.5-4.8 mm); posterior tibial tendon above the malleoli 3.7 mm (range 1.9-8.1 mm), below the malleolus 4.6 cm (range 1.8-11.8 mm). Standard deviations and distribution curves were similarly calculated for each tendon. This baseline data can assist clinicians in their diagnostic ability with ultrasound. Given its low cost, lack of ionizing radiation and dynamic ability along with an improved understanding of normative data it may become an increasingly used diagnostic modality. Levels of Evidence: Level II: Diagnostic.

Triple-Negative Breast Cancer: A Comparison of Race and Survival.

Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer with a high prevalence in blacks. South Carolina demographically has a high percentage of blacks. This study examines survival and recurrence associated with TNBC in black and white women. A retrospective review of breast cancer patients within the Palmetto Health Cancer Registry was performed from 1999 to 2015. Patient demographics and tumor characteristics were collected and correlated with outcomes. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were analyzed. The total number of breast cancer patients in the registry was 1723 (1085-white and 638-black). The median follow-up was 48.4 months. The majority of cancers diagnosed in both cohorts were early stage (I, IIA, IIB, 93.4% vs 90.4% P = NS). We identified 332 patients with TNBC. Of those 332 patients, 144 (43.4%) were whites and 188 (56.6%) were blacks. Older age (P = 0.01), high-grade (P < 0.001), and black race (P < 0.001) were significantly associated with TNBC on multivariate analysis. Five- and 10-year OS was significantly worse in blacks with TNBC (P < 0.001). There was no difference in DSS or RFS between the two cohorts. TNBC disproportionately affects black women and is an aggressive subtype of breast cancer with limited treatment options compared with receptor-positive breast cancer. Black patients with TNBC in our study had statistically worse OS. These findings are similar to what has been reported in the literature and prompts further research in newer targeted therapies.

Urticarial Reaction to Ustekinumab During the Treatment of Plaque Psoriasis in a Hepatitis C-Positive Patient.

A 62-year-old white woman with a history of hepatitis C and type 2 diabetes mellitus developed urticaria during treatment with ustekinumab for plaque psoriasis. The patient received two 45-mg ustekinumab injections in her first 2 months and then one 45-mg injection every 3 months for her psoriasis. After 10 months, she developed a round red rash on her skin diffusely on her body. She also complained of joint pain in her hands. Rheumatology became involved, and investigations revealed that her antinuclear antibody titer was negative, but her rheumatoid factor, erythrocyte sedimentation rate, and liver function enzymes were elevated. She was diagnosed with urticaria, and ustekinumab was discontinued. A Naranjo assessment score of 6 was obtained, indicating a probable relationship between the patient's urticaria and her use of ustekinumab. Ustekinumab was subsequently discontinued, and the patient received a course of Harvoni® (Gilead Sciences, Inc., Forest City, California, United States) (ledispasvir/sofosbuvir) with clearance of the hepatitis C virus. The patient is currently receiving another biologic agent, ixekizumab, and reports no complaints, including that of urticaria.

Trends in the management of pelvic fractures, 2008-2010.

BACKGROUND: Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time. METHODS: The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality. RESULTS: A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001). CONCLUSIONS: AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.