Decoding pylephlebitis: Tracing the path of infected thrombosis and liver abscesses.

Pylephlebitis, a septic thrombophlebitis of the portal vein, is an uncommon but serious complication following an abdominal site of infection, most frequently diverticulitis or appendicitis. It has a high mortality rate, yet it commonly presents with unspecific abdominal complaints and fever, making diagnosis by clinical and laboratory examinations alone, impossible. This report highlights the extensive computed tomography (CT) findings of pylephlebitis with multiple hepatic abscesses thought to be secondary to diverticulitis, in a patient presenting with septic shock. Radiological characteristics differentiating the liver lesions from malignancy, and showing the ascending pathway of vascular involvement from the inferior mesenteric vein to portal veins is presented, as well as the search for the primary site of infection. Recognizing and understanding the imaging findings in pylephlebitis is crucial for diagnosis and avoiding delay of appropriate treatment for this otherwise often fatal condition.

Carpal tunnel syndrome treatment and the subsequent alterations in tendon and connective tissue dynamics.

BACKGROUND: Carpal tunnel syndrome patients demonstrate diminished motion of the median nerve and fibrotic changes in the subsynovial connective tissue within the carpal tunnel. Currently, there are few prognostic factors to help predict the outcome of commonly performed treatments including surgical carpal tunnel release and corticosteroid injections. This study aimed to non-invasively assess the changes in the dynamic response of the subsynovial tissue relative to tendon motion after the intervention and to correlate this with disease severity. METHODS: A total of 145 patients with carpal tunnel syndrome were recruited into this study. Clinical and demographic data, electrophysiological severity and dynamic ultrasound images were collected before and after treatment, either by injection or surgery. The relative motion of the subsynovial tissue with the underlying middle finger flexor digitorum superficialis tendon was measured using a speckle tracking algorithm and was expressed as a shear index (SI). Baseline and follow-up data, the association between change in SI and severity, and the role of treatment modality were analyzed and statistically compared. FINDINGS: Overall, there was a significant increase (more relative motion) after treatment in the mean shear index from 79.9% (±15.4% SD) to 82.9% (±14.8% SD) (p = 0.03). Secondary analyses showed that this change was mostly present in those with mild disease severity undergoing surgery (p = 0.01). INTERPRETATION: This study shows that the relative subsynovial tissue movement increases in patients after intervention. The present study lays a foundation for future studies to non-invasively assess the role of carpal tunnel dynamics in response to treatment.

Risk of de novo severe carpal tunnel syndrome after bilateral oophorectomy: a population-based cohort study.

OBJECTIVE: The incidence of carpal tunnel syndrome (CTS) is higher in women, and peaks around the age of menopause. Therefore, we investigated whether bilateral oophorectomy is associated with an increased risk of severe CTS. METHODS: We included all of the 1,653 premenopausal women who underwent bilateral oophorectomy for a nonmalignant indication between 1988 and 2007, and a random sample of 1,653 age-matched referent women who did not undergo bilateral oophorectomy in Olmsted County, MN. Diagnoses of CTS assigned to women over their entire lifetime were identified in these two cohorts. The risk of de novo severe CTS after bilateral oophorectomy (or index date) was evaluated using Cox proportional hazards models adjusted for potential confounders. RESULTS: Bilateral oophorectomy was associated with an increased risk of severe CTS (adjusted hazard ratio 1.65, 95% confidence interval 1.20-2.25). The risk was suggestively greater in women with lower body mass index, nulliparity, and with a benign ovarian indication for oophorectomy (nonsignificant interactions). We did not observe a protective effect of estrogen therapy after the oophorectomy. The findings were similar in secondary analyses considering the incidence of CTS of any severity or idiopathic CTS. CONCLUSIONS: The risk of severe CTS, common in perimenopausal women, is increased after bilateral oophorectomy. The association may be causal or due to confounding. Therefore, the precise biological mechanisms explaining the association and the absence of a mitigating effect of estrogen therapy should be further investigated.

Automated Segmentation of the Median Nerve in the Carpal Tunnel using U-Net.

Nerve area and motion in carpal tunnel syndrome (CTS) are currently under investigation in terms of prognostic potential. Therefore, there is increasing interest in non-invasive measurement of the nerve using ultrasound. Manual segmentation is time consuming and subject to inter-rater variation, providing an opportunity for automation. Dynamic ultrasound images (n = 5560) of carpal tunnels from 99 clinically diagnosed CTS patients were used to train a U-Net-shaped neural network. The best results from the U-Net were achieved with a location primer as initial region of interest for the segmentations during finger flexion (Dice coefficient = 0.88). This is comparable to the manual Dice measure of 0.92 and higher than the resulting automated Dice measure of wrist flexion (0.81). Although there is a dependency on image quality, a trained U-Net can reliably be used in the assessment of ultrasound-acquired median nerve size and mobility, considerably decreasing manual effort.

Carpal Tunnel Syndrome Treatment and the Subsequent Alterations in Median Nerve Transverse Mobility.

OBJECTIVES: The mobility (transverse movement) of the median nerve (MN) is decreased in patients with carpal tunnel syndrome and can be measured noninvasively by ultrasound. To date, there are few prognostic features to help predict the outcome of 2 commonly performed treatments: surgical carpal tunnel release and corticosteroid injection. This study aimed to assess the changes in nerve mobility after the intervention and to correlate this with treatment and the disease severity. METHODS: A total of 181 patients with carpal tunnel syndrome with different electrophysiologic severities were recruited and assessed by dynamic ultrasound scanning of the MN before and after treatment. The dynamic ultrasound images were collected while the patients performed finger and wrist flexion. RESULTS: For both injection and carpal tunnel release, the nerve displacement increased with wrist flexion, from a mean ± SD of 7.0 ± 2.4 to 7.9 ± 2.7 mm (P < .005). Patients who underwent surgery showed greater improvement (P < .005) in nerve mobility compared to those who underwent injection. We also observed that the increase in nerve mobility was predominantly in patients with more nerve damage at baseline. CONCLUSIONS: This study shows that the dynamic behavior of the MN changes in response to treatment and lays a foundation for future studies to assess the prognostic potential of nerve mobility measurement.

An Incision-less Ultrasound-guided Carpal Tunnel Release Technique.

Ultrasound guidance in the operative treatment of carpal tunnel syndrome is gaining in popularity as it noninvasively provides the surgeon with a real-time high-resolution overview of anatomic structures. A new incision-less approach to achieve a division of the transverse carpal ligament has been developed that combines ultrasound guidance with cannulated needles and a thread. Conceptually, an abrasive thread is looped percutaneously around the ligament while avoiding injury to neurovascular structures, the palmar aponeurosis, and skin. The thread is positioned using 2 puncture sites and a contoured Tuohy needle under ultrasound visualization. With a minimal injury to surrounding structures, this approach is designed to minimize recovery time and decrease pillar pain. This article will provide a step-by-step overview of the technique and includes a review of clinical outcomes published so far.

Relative Motion of the Connective Tissue in Carpal Tunnel Syndrome: The Relation with Disease Severity and Clinical Outcome.

Excursion of the median nerve and the surrounding subsynovial connective tissue (SSCT) is diminished in patients with carpal tunnel syndrome (CTS). This study sought to determine if SSCT excursion could be utilized to predict surgical outcome. Idiopathic CTS patients were reviewed with ultrasound and electrodiagnostic tests at baseline. A speckle tracking algorithm was used to determine SSCT relative to tendon motion (shear index). Analysis of variance tests were used to compare SSCT motion with disease severity at baseline. Adjusted linear regressions were used to test the association with patient-reported outcome. A total of 90 CTS patients were analyzed and found to have an average shear index of 79% (95% confidence interval: 76.3%-81.6%). SSCT motion was lower in CTS patients with increasing electrophysiological severity (p = 0.0475). There was no significant association of pre-operative SSCT motion with symptomatic improvement (p = 0.268). Overall, SSCT motion is decreased in CTS patients, but exhibits limited correlation with clinical severity.

Subsynovial connective tissue development in the rabbit carpal tunnel.

The carpal tunnel contains the digital flexor tendons and the median nerve, which are embedded in a unique network of fibrovascular interconnected subsynovial connective tissue (SSCT). Fibrous hypertrophy of the SSCT and subsequent adaptations in mechanical response are found in patients with carpal tunnel syndrome (CTS), but not much is known about the development of the SSCT. This observational study describes the morphological development of SSCT using histology and ultramicroscopy in an animal model at four time points between late-term fetuses through adulthood. A transition is seen between 3 days and 6 weeks post-partum from a dense solid SSCT matrix to a complex multilayered structure connected with collagenous fibrils. These preliminary data show a developmental pattern that matches an adaptive response of the SSCT to loading and motion. Understanding the anatomical development aids in recognizing the pathophysiology of CTS and supports research on new therapeutic approaches.

Ultrasound-Guided Hydrodissection With Corticosteroid Injection in the Treatment of Carpal Tunnel Syndrome: A Pilot Study.

OBJECTIVES: Corticosteroid injections can provide (temporary) relief in patients with mild to moderate carpal tunnel syndrome (CTS). Hydrodissection as part of an injection has been associated with positive clinical outcomes but data for CTS so far has been scarce. This study is designed to assess patient tolerance and secondarily provide pilot data on the added effect of hydrodissection. METHODS: Twenty CTS patients were randomized to an ultrasound-guided betamethasone injection with hydrodissection (5 mL) or without (2 mL). Patient tolerance was assessed directly after intervention and patient-reported outcome after 4 and 24 weeks. Intra-group data were compared using Wilcoxon Signed Rank and inter-group with Wilcoxon rank-sum tests. RESULTS: Tolerance and pain scores did not differ between the two groups. Symptom scores decreased in both groups, but to a lesser extent in the hydrodissection group with a mean difference of -0.8 versus -1.5 in the control group at 4 weeks (P = .02). At 6 months, this difference was no longer present (P = .81). No statistically significant differences were found between the hydrodissection and control groups in the function or pain scores at follow-up at either time point. CONCLUSION: After injection, both symptomatic and functional scores improved, but the hydrodissected group did not show additional improvement. Data presented can be used to support larger studies to assess the value of hydrodissection in CTS management.

Shear wave elastography of the median nerve: A mechanical study.

BACKGROUND: Shear wave elastography (SWE) shows promise in peripheral neuropathy evaluation but has potential limitations due to tissue size and heterogeneity. We tested SWE sensitivity to elasticity change and the effect of probe position in a median nerve cadaver model. METHODS: Ten specimens were used to measure median nerve elasticity under increasing loads using SWE and indentation. Measurements were compared using repeated-measures analysis of variance. RESULTS: Indentation and SWE-based longitudinal nerve elasticity increased with tensile loading (P < .01), showing a similar relationship. Acquisition in a transverse plane showed lower values compared with longitudinal measurements, mostly under higher loads (P = .03), as did postdissection elasticity (P = .02). Elasticity did not change when measured proximal to the carpal tunnel. CONCLUSIONS: Longitudinal SWE is sensitive to changes in median nerve elasticity. Measuring elasticity of peripheral nerves noninvasively could elucidate intra-neural pathology related to compression neuropathies, and proof to be of added value as a diagnostic or prognostic tool.

Arthrodesis of the Carpometacarpal Thumb Joint for Osteoarthritis; Long-Term Results Using Patient-Reported Outcome Measurements.

Background Results following carpometacarpal (CMC) arthrodesis of the thumb for osteoarthritis vary widely in literature. Data on long-term patient-reported outcome measurements (PROMs) after thumb CMC joint arthrodesis for osteoarthritis are scarce. Purpose We report the long-term outcomes of PROMs (function, pain, and satisfaction) after arthrodesis of the thumb CMC joint. We evaluated the correlation of function and pain with patient satisfaction. Methods Long-term PROMs after thumb CMC arthrodesis for osteoarthritis were evaluated using a retrospective cohort (1996-2015). Three different PROM questionnaires (Disabilities of the Arm, Shoulder, and Hand Questionnaire, Dutch Language version [DASH-DLV], the Patient-Related Wrist and Hand Questionnaire Dutch Language version [PRWHE-DLV], and a questionnaire concerning satisfaction) were sent to all patients. Results Twenty-five arthrodeses (21 patients) were available for long-term follow-up. The median follow-up time was 10.8 years (interquartile range [IQR]: 9.7-13.0). The median DASH score was 29.2 (IQR: 14.4-38.3), median PRWHE score was 25.0 (IQR: 12.5-44.3). The median satisfaction after the operation and satisfaction with outcome of the operation was 10 for both (on a Likert's scale with 1 worse and 10 excellent satisfaction). There was a statistically significant correlation between the PRWHE total score and PRWHE pain score and satisfaction with surgery and satisfaction with the result. There was no correlation between PRWHE function score and satisfaction or DASH and satisfaction. Results after hardware removal showed no significant differences compared with patients without hardware removal. Conclusion Patients who underwent arthrodesis for thumb CMC osteoarthritis showed high satisfaction at long-term follow-up, despite moderate results as measured using the DASH and PRWHE. The PRWHE total and PRWHE pain scores correlated significantly with satisfaction with surgery and satisfaction with the result, respectively, whereas no correlation was observed with the PRWHE function score or DASH and satisfaction. This therapeutic study reflects level of evidence IV.

Median Nerve Transverse Mobility and Outcome after Carpal Tunnel Release.

Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a novel approach in which nerve movement and the association with short-term patient-reported outcome are assessed. Ultrasound images at the carpal tunnel inlet were acquired during finger and wrist flexion. Linear regression models were used with the Boston Carpal Tunnel Questionnaire as main outcome. Eighty-five patients were included; 93% completed the 3-mo follow-up. Pre-surgical mean nerve area was 14.5 ± 4.2 mm2 and decreased to 13.3 ± 3.8 mm2 (p < 0.001). Displacement in dorsal direction with wrist flexion increased from 1.9 ± 1.3 to 2.4 ± 1.3 mm (p < 0.01). A pre-surgical larger nerve area was associated with more functional improvement (ß = -0.024, p = 0.02), but baseline mobility was not. Change in excursion with finger flexion was associated with symptomatic improvement, but with a small effect (ß = -0.05, p = 0.01). This indicates that there is limited prognostic potential for dynamic transverse ultrasound in carpal tunnel syndrome.

Better Patient-Reported Experiences with Health Care Are Associated with Improved Clinical Outcome after Carpal Tunnel Release Surgery.

BACKGROUND: In hand surgery, and specifically carpal tunnel syndrome, it is currently unknown whether experiences with health care influence surgical outcome. To investigate whether there is an association between patient-reported experience measures and symptom relief, data were gathered using a cohort of patients undergoing surgical treatment for carpal tunnel syndrome. METHODS: Patient-reported experience measures and patient-reported outcome measures were registered in a national database of 16 hand surgery practices. The experience measure data were gathered at 3 months after surgery and included six subscales on different health care delivery aspects (e.g., provided information, communication, facility, operative care). The outcome measure data were acquired before and 3 months after surgery with the Boston Carpal Tunnel Assessment Questionnaire. The association was tested using linear regression analyses. RESULTS: A total of 1607 patients were included in the analysis. The experience measure scores were good to excellent, with a median value between 8.0 and 8.5 on a 10-point scale. Regression analyses showed a significant (p < 0.001) association with the Boston Carpal Tunnel Assessment Questionnaire for all individual patient-reported experience measure subscales. The greatest effects were found in physician communication and treatment information. Patient-reported experience measures accounted for more than 5 percent of the explained variance, with patient characteristics explaining an approximately additional 3 percent. CONCLUSIONS: In this large data set of carpal tunnel syndrome patients who underwent surgical release, a significant impact of health care experiences on self-reported clinical outcome was found. This is relevant information, not only for directing care providers in improving health care experiences as a quality-of-health care measure but now also potentially to achieve better clinical outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reliability of ultrasound speckle tracking with singular value decomposition for quantifying displacement in the carpal tunnel.

Inhibited movement patterns of carpal tunnel structures have been found in carpal tunnel syndrome (CTS) patients. Motion analysis on ultrasound images allows us to non-invasively study the (relative) movement of carpal tunnel structures and recently a speckle tracking method using singular value decomposition (SVD) has been proposed to optimize this tracking. This study aims to assess the reliability of longitudinal speckle tracking with SVD in both healthy volunteers and patients with CTS. Images from sixteen healthy volunteers and twenty-two CTS patients were used. Ultrasound clips of the third superficial flexor tendon and surrounding subsynovial connective tissue (SSCT) were acquired during finger flexion-extension. A custom made tracking algorithm was used for the analysis. Intra-class correlation coefficients (ICCs) were calculated using a single measure, two-way random model with absolute agreement and Bland-Altman plots were added for graphical representation. ICC values varied between 0.73 and 0.95 in the control group and 0.66-0.98 in the CTS patients, with the majority of the results classified as good to excellent. Tendon tracking showed higher reliability values compared to the SSCT, but values between the control and CTS groups were comparable. Speckle tracking with SVD can reliably be used to analyze longitudinal movement of anatomical structures with different sizes and compositions within the context of the carpal tunnel in both a healthy as well as a pathological state. Based on these results, this technique also holds relevant potential for areas where ultrasound based dynamic imaging requires quantification of motion.

Wide Awake Surgery as an Opportunity to Enhance Clinical Research.

Wide Awake surgery under Local Anesthesia with No Tourniquet (WALANT) has revolutionized clinical hand surgery, improving clinical outcomes and reducing postoperative pain and morbidity. It can also be used to deepen scientific knowledge, because the unsedated patient, with sensation intact and without the adverse effects of tourniquet neurapraxia or paralysis, can follow commands and actively move the limb after tendon and nerve surgery. These movements can be correlated with fingertip force, tendon tension, nerve conduction and amplitude, and muscle sarcomere length measurements to develop new insights into the effectiveness of many different tendon and nerve procedures in the hand.

Task shifting in active management of the third stage of labor: a systematic review.

BACKGROUND: Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). In low- and middle-income countries, implementation of AMTSL is hampered by shortage of skilled birth attendants and a high percentage of home deliveries. Task shifting of specific AMTSL components to unskilled birth attendants or self-administration could be a strategy to increase access to potentially life-saving interventions. This study was designed to evaluate the effect, acceptance and safety of task shifting of specific aspects of AMTSL to unskilled birth attendants. METHODS: A systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Quality of studies was evaluated with an adapted Cochrane Collaboration assessment tool. RESULTS: Of 2469 studies screened, 21 were included. All studies assessed implementation of uterotonics (misoprostol tablets or oxytocin injections), administered by community health workers (CHWs), auxiliary midwives, traditional birth attendants (TBAs) or self-administration at antenatal (home) visits or delivery. Task shifting for none of the other AMTSL components was reported. Task shifting of provision of uterotonics reduced the risk of PPH (RR 0.16 to 1) compared to standard care (13 studies, n = 15.197). The correct dose and timing was reported for 83.4 to 99.8% (5 studies, n = 6083) and 63 to 100% (9 studies, n = 8378) women respectively. Uterotonics were recommended to others by 80 to 99.7% (7 studies, n = 6445); 80 to 99.4% (5 studies, n = 2677) would use the drug at next delivery. Willingness to pay for uterotonics varied from 54.6 to 100% (7 studies, n = 6090). CONCLUSION: Task shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users. In order to increase AMTSL coverage in low-staffed health facilities, task shifting of uterine massage or postpartum tonus assessment to unskilled attendants or delivered women could be considered. Task shifting of controlled cord traction is currently not recommended.

The association between HIV, antiretroviral therapy, and gestational diabetes mellitus.

OBJECTIVES: The widespread, chronic use of antiretroviral therapy raises questions concerning the metabolic consequences of HIV infection and treatment. Antiretroviral therapy, and specifically protease inhibitors, has been associated with hyperglycemia. As pregnant women are vulnerable to development of hyperglycemia, the objective of this study was to explore existing literature on the relationship between HIV infection, HIV treatment, and gestational diabetes mellitus (GDM). METHODS: A systematic search was conducted in six databases for articles providing data on HIV-positivity, protease inhibitor exposure, and GDM or glucose intolerance development in pregnancy. The quality of articles was evaluated using an adapted Cochrane Collaboration bias assessment tool. Risk ratios were generated from pooled data using meta-analysis by the Mantel-Haenszel method. RESULTS: Of 891 references screened, six studies on the role of HIV-positivity, 10 on protease inhibitor use, and two on both were included. Meta-analysis showed no significant relationship between HIV infection and the development of GDM [risk ratio 0.80, 95% confidence interval (CI): 0.47-1.37, I = 0%]. Meta-analysis of protease inhibitor exposure showed increased GDM in studies using first-generation protease inhibitors (risk ratio 2.29, 95% CI: 1.46-3.58) and studies using the strictest diagnosis criteria, the National Diabetes Data Group criteria for 3-h oral glucose tolerance test (risk ratio 3.81, 95% CI: 2.18-6.67). CONCLUSION: Meta-analysis showed no significant association between HIV-positivity and GDM. Significance of protease inhibitor use was limited to studies using the strictest diagnostic criteria for GDM. Results are limited by high risk of bias. Well designed prospective studies are needed to further clarify this relationship and its consequences for clinical practice.

HIV, Antiretroviral Therapy, and Hypertensive Disorders in Pregnancy: A Systematic Review and Meta-analysis.

BACKGROUND: There are data to suggest that infection with HIV or use of highly active antiretroviral therapy increases the risk of hypertensive disorders in pregnancy. This systematic review and meta-analysis aims to provide an overview of the research hitherto. METHODS: A systematic review of EMBASE, PubMed, and The Cochrane Library databases was conducted to obtain articles about the association between HIV in pregnancy and/or HIV therapy and the risk of developing pregnancy-induced hypertension (PIH), pre-eclampsia, eclampsia, or Hemolysis Elevated Liver enzymes Low Platelet count syndrome. Quality of articles was evaluated with an adapted Cochrane Collaboration bias assessment tool. Relative risks (RRs) were pooled with a random-effects meta-analysis weighted by the inverse of their variance. RESULTS: Of the 2136 articles screened, 28 studies were eligible for inclusion; 15 studies reported on the association with PIH, 16 on pre-eclampsia, 5 on eclampsia, and 3 articles on HIV therapy regimens. All articles had a high risk of bias, and between-study heterogeneity was considerable. Based on the meta-analysis, there does not seem to be an association between HIV and PIH [RR 1.26, 95% confidence interval (CI): 0.87 to 1.83, I = 78.6%], pre-eclampsia (RR 1.01, 95% CI: 0.87 to 1.18, I = 63.9%), or eclampsia (RR 1.61, 95% CI: 0.14 to 18.68, I = 97.0%). A meta-analysis of the association with HIV therapy and risk of hypertensive disorders in pregnancy could not be performed. CONCLUSIONS: This meta-analysis shows no significant association between HIV positivity and PIH, pre-eclampsia, or eclampsia. However, the high risk of bias within most studies limits the strength of conclusions and well-designed studies are necessary to confirm or refute these findings.