A novel grey scale and Power Doppler ultrasonographic score for idiopathic inflammatory myopathies: Siena Myositis Ultrasound Grading Scale.

OBJECTIVES: No clear-cut guidelines exist on the use of diagnostic procedures for idiopathic inflammatory myopathies (IIM) and only minimal and conflicting data report the use of ultrasound (US). In this regard, we aimed to assess if grey-scale (GS) and Power Doppler (PD) US, graded with a 0-3-point scale, may be a reliable tool in a cohort of patients affected by IIM. METHODS: All patients underwent US examination of both thighs in axial and longitudinal scans. Oedema and atrophy, both assessed in GS and PD, were graded with a 0-3-point scale. Spearman's test was used to identify the correlations between US and clinical and serological variables. RESULTS: A total of 20 patients were included. Six and two patients were evaluated twice and three times, respectively. Muscle oedema was found to be directly correlated with physician global assessment (PhGA), serum myoglobin and PD and negatively with disease duration. PD score was positively correlated to PhGA and negatively to disease duration. Muscle atrophy directly correlated with Myositis Damage Index, disease duration and patient's age. The single-thigh sub-analysis evidenced a direct correlation between PD score and Manual Muscle Test. CONCLUSIONS: In our cohort, we found that oedema and PD are strictly related to early, active myositis, suggesting that an inflamed muscle should appear swollen, thickened and with Doppler signal. Conversely, muscle atrophy reflects the age of the patient and the overall severity of the disease. Such findings shed a new, promising, light on the role of US in diagnosis and monitoring of IIMs.

Development and reliability of the revised Patterson Edema Scale.

OBJECTIVE: The Patterson Edema scale was developed in 2007 to address the lack of a reliable, sensitive scale to measure laryngeal and pharyngeal oedema in patients with head and neck cancer. The objective of this study was to revise the existing Patterson scale to improve its reliability and utility. DESIGN: Prospective investigation. SETTING: Academic medical center. PARTICIPANTS: Speech-Language Pathologists, Otolaryngologists, and Radiation Oncologists. MAIN OUTCOME MEASURES: Ratings using the Revised Patterson Edema Scale. METHODS: A consensus group reviewed existing literature regarding the performance of the original Patterson scale and revised the existing scale in regard to items to be included and descriptors for each severity level. The scale was then utilised by 18 speech language pathologists from the US and UK with >2 years-experience working with dysphagia and dysphonia with endoscopy. Each SLP rated a total of eight parameters (epiglottis, vallecula, pharyngoepiglottic folds, aryepiglottic folds, arytenoids, false vocal folds, true vocal folds and pyriform sinuses) using the Revised Patterson Edema Scale. Feedback was solicited from raters regarding areas where clarity was lacking for further scale revision. Scale revisions were completed and additional ratings were completed by otolaryngologists, radiation oncologists and less experienced SLP providers to establish reliability across disciplines. Quadratic weighted Kappa values were obtained to establish interrater reliability. RESULTS: Feedback received from raters included suggestions for clarification of how to rate unilateral oedema, use of a standard task battery to visualise and rate structures consistently, and clarification of true vocal fold oedema rating parameters. Overall interrater reliability was established using quadratic weighted Kappa with good agreement noted for the epiglottis, vallecula, arytenoids and false vocal folds; moderate agreement noted for aryepiglottic folds, pharyngoepiglottic folds and pyriform sinuses; and fair agreement noted for true vocal folds. CONCLUSIONS: The Revised Patterson Edema Scale demonstrates moderate-substantial interrater reliability for most parameters across multiple disciplines and experience levels, with the exception of the true vocal folds where agreement was fair. We believe the Revised Patterson Oedema Scale provides a reliable tool for clinicians and researchers to rate oedema in the supraglottic larynx and pharynx following treatment for head and neck cancer.

Chronic oedema and lymphoedema: what is the difference?

Chronic oedema is a term that encompasses several causes that lead to oedema formation in any part of the body. This includes lymphoedema and its subcategories. Despite the assumption that these are different, there are more commonalities amongst them. This makes the transfer of knowledge and experience, from chronic oedema conditions to lymphoedema, and vice versa easier to achieve. However, this takes both time and support, to achieve the ultimate patient outcome of self-care, with generalist able to support this process and journey.

Diagnóstico del hidrops endolinfático mediante resonancia magnética de 3T tras administración de gadolinio intratimpánico / Diagnosis of endolymphatic hydrops by means of 3T magnetic resonance imaging after intratympanic administration of gadolinium

Objetivo. Detectar la dilatación del espacio endolinfático o hidrops endolinfático (HE) con resonancia magnética (RM) en pacientes con sospecha de enfermedad de Ménière (EM) o enfermedad inmunomediada del oído interno (EIOI). Material y métodos. Incluimos prospectivamente todos los pacientes con sospecha clínica de EM (seis pacientes) o EIOI (cuatro pacientes) atendidos en el servicio de otorrinolaringología en el último año. En todos los casos se realizó una RM con un equipo de 3T y se adquirió una secuencia 3D real IR tras la inyección de gadolinio intratimpánico en ambos oídos 24-28 horas antes. Dos neurorradiólogos graduaron el volumen del espacio endolinfático según convenio en normal, moderado y significativo en las imágenes obtenidas. Resultados. Se documentó la presencia de HE mediante RM en seis pacientes con EM definida o probable. En dos de los cuatro casos que no presentaban vértigo no se demostró hidrops. En los otros dos casos, con alta sospecha clínica de EIOI, pero con pruebas autoinmunitarias negativas, sí se demostró hidrops. Solo hubo discordancia sobre la presencia de hidrops coclear en dos pacientes. Conclusión. La detección de HE en los pacientes con EM definida o probable sirvió para confirmar el diagnóstico definitivo. Por otro lado, se detectó hidrops en pacientes con sospecha de EIOI, lo cual podría tener repercusión sobre el diagnóstico y el tratamiento de estos pacientes. Por ello, habría que valorar la necesidad de incluir esta prueba en el diagnóstico de dichas enfermedades (AU)

Objective. To detect and graduate endolymphatic hydrops or endolymphatic space dilations in patients with suspected Meniere's disease or immune-mediated inner ear disease by magnetic resonance imaging. Material and methods. A prospective study was performed including all the patients with clinical suspicion of Meniere's disease or immune-mediated inner ear disease treated at the Otolaryngology department during a one year period. In all cases, magnetic resonance imaging (MRI) was performed in a 3T scanner. IR sequence was performed after 24 to 28h prior intratimpanic injection of gadolinium on both ears. Two neurorradiologist graduated endolymphatic space volume as agreed on normal, moderate and significant in the obtained images. Results. The presence of hydrops was documented by MRI in six patients with definite or probable Meniere's disease. In two of the four cases without vertigo hydrops was not demonstrated. In the other two cases with a high clinical suspicion of immune-mediated disease but with negative autoimmune tests hydrops was proved. There was only disagreement on cochlear hydrops presence on two patients. Conclusion. The detection of endolymphatic hydrops in patients with definite or probable Meniere's disease served to confirm the final diagnosis. Moreover, hydrops was detected in patients with suspected immune-mediated inner ear disease, which could have an impact on the diagnosis and treatment of these patients. Therefore, we suggest that this test could be included for the diagnosis of these inner ear diseases (AU)

Hierarchical Classification and System Combination for Automatically Identifying Physiological and Neuromuscular Laryngeal Pathologies.

OBJECTIVES: Speech signal processing techniques have provided several contributions to pathologic voice identification, in which healthy and unhealthy voice samples are evaluated. A less common approach is to identify laryngeal pathologies, for which the use of a noninvasive method for pathologic voice identification is an important step forward for preliminary diagnosis. In this study, a hierarchical classifier and a combination of systems are used to improve the accuracy of a three-class identification system (healthy, physiological larynx pathologies, and neuromuscular larynx pathologies). METHOD: Three main subject classes were considered: subjects with physiological larynx pathologies (vocal fold nodules and edemas: 59 samples), subjects with neuromuscular larynx pathologies (unilateral vocal fold paralysis: 59 samples), and healthy subjects (36 samples). The variables used in this study were a speech task (sustained vowel /a/ or continuous reading speech), features with or without perceptual information, and features with or without direct information about formants evaluated using single classifiers. A hierarchical classification system was designed based on this information. RESULTS: The resulting system combines an analysis of continuous speech by way of the commonly used sustained vowel /a/ to obtain spectral and perceptual speech features. It achieved an accuracy of 84.4%, which represents an improvement of approximately 9% compared with the stand-alone approach. For pathologic voice identification, the accuracy obtained was 98.7%, and the identification accuracy for the two pathology classes was 81.3%. CONCLUSIONS: Hierarchical classification and system combination create significant benefits and introduce a modular approach to the classification of larynx pathologies.

Limitation of previous Allen classification and subaxial cervical spine injury classification (SLIC) system in distractive-extension injury of cervical spine: proposal of modified classification system.

PURPOSE: To verify the clinical applicability of a modified classification system in distractive-extension cervical spine injury that reflects the degrees of soft tissue damage and spinal cord injury while complementing previous Allen classification and subaxial cervical spine injury classification (SLIC) system. METHODS: A total of 195 patients with cervical spine distraction-extension (DE) injury were retrospectively classified. We added stages IIIA (with concomitant spinal cord injury without bony abnormalities) and IIIB (with concomitant additional soft tissue swelling) to the existing stages I and II of the Allen classification. We also supplemented the SLIC system by refining and assigning scores to bony morphology and soft tissue damage. The previous and proposed classification systems were compared by analyzing their scoring performances in terms of clinical features and prognosis. RESULTS: The Allen classification yielded 153 and 42 patients with stage 1 and 42 stage 2 injuries, respectively. Patients classified according to the proposed system were stratified as follows: stage I, 58; stage II, 27; stage IIIA, 33; and stage IIIB, 77. Regarding neurological symptoms and prognosis, stages IIIA and IIIB were poorer than stage I but significantly better than stage II (P < 0.05). On the SLIC system, 146 patients scored ≥5; and 37 and 12 patients scored 4 and ≤3 points, respectively, whereas the numbers of patients who scored ≥5, 4, and ≤3 points on the modified SLIC system were 170, 21, and 4, respectively. CONCLUSIONS: The proposed classification and scoring system to complement the Allen classification and SLIC system with respect to the degrees of soft tissue damage and spinal cord injury is considered effective for diagnosing and determining therapeutic directions and prognosis in cases of cervical spine extension injury.

Functioning in lymphoedema from the health professionals' perspective using the international classification of functioning, disability and health as a reference.

PURPOSE: To capture the views of different health care providers involved in the treatment of patients with lymphoedema from various countries around the world on the functioning of lymphoedema patients and the factors influencing functioning of these patients using the international classification of functioning, disability and health (ICF). METHOD: A worldwide e-mail survey with questions based on components of the ICF. RESULTS: In total, 142 health professionals from seven different health professions and 20 different countries answered the questions. The aspects of functioning that were named by the health professionals could be linked to 359 different ICF categories. Of these categories, 109 belonged to body functions (30.4%), 55 to body structures (15.3%), 121 to activities and participation (33.7%) and 74 to environmental factors (20.6%). Overall, the most mentioned items were health services, systems and policies, immunological system functions, looking after one's health, products and technology for personal use in daily life and dressing. CONCLUSIONS: The ICF provided a valuable reference for identifying concepts in statements from international health care professionals experienced in the treatment of lymphoedema patients. The results of this research will be used in the development of ICF core sets for lymphoedema.

A glossary of terms to assist the recognition and diagnosis of skin conditions associated with lower-limb chronic oedema.

There are a number of recognised skin conditions associated with chronic oedema, but the lack of agreed definitions and terminology often leads to poor recognition and a delay in treatment. Many patients are given a diagnostic 'label' (e.g. varicose eczema) that often turns out to be incorrect, leading to an interruption in the patient pathway. Every skin condition can be described in a variety of ways and each professional group adheres to certain phrases and words that, within each discipline, are recognised, but when making onward referral or working between professions, it helps to have clear and concise definitions. This article aims is to standardise the terminology used to describe skin conditions of the lower limbs among health professionals, removing some of the discrepancy, and to develop a glossary to aid recognition, definition and hence diagnosis to ensure prompt and appropriate management is implemented.

Woody hardness - a novel classification for the radiotherapy-treated neck.

The term 'woody neck' is widely used by surgeons and oncologists to describe the fibrosis that can occur following radiotherapy for head and neck malignancy. These soft tissue and skin changes can be compounded by neck dissection, either before or after radiotherapy. To our knowledge, there is no classification published in the literature to describe the degree of woody hardness following treatment. We propose a simple ABC classification for varying degrees of indurated oedema and neck fibrosis secondary to radiotherapy or long-standing pathology, using the hardness of different woods to enable a suitable description to be made of severity.

[Study on the heterogeneity of edema in severe preeclampsia].

OBJECTIVE: The aim of this study was to analysis the clinical edema forms and explore the heterogeneity of edema in severe preeclampsia (PE) . METHOD: From February 2002 to February 2009, Peking University Third Hospital admitted with severe preeclampsia 228 cases who were enrolled in this study. The form is divided into no edema (A-type), pure interstitial edema (B-type), a simple cavity gap edema (C-type) and mixed interstitial edema that coexist with lacunar edema (D-type). Analysis and comparison of various types of edema in patients with different clinical manifestations of prenatal care models, laboratory parameters, the incidence of gestational age, complications and obstetric and perinatal outcomes, and analyze the relationship between different types of edema and albumins and the peak value of proteinuria. RESULTS: Edema was seen in 86% (197/228) of all of cases. Compared the cases who have regular prenatal care with those who have irregular care, differences were statistically significant in edema type composition ratio (P < 0.01) and the incidence of serious complications (P < 0.01), and serum albumin levels (P < 0.01), but not in the peak value of proteinuria (P > 0.05); Compared early-onset PE and late-onset PE patients, differences were statistically significant in edema type composition ratio (P < 0.01) and peak value of proteinuria (P < 0.01), but not in serum albumin levels and the incidence of serious complications (P > 0.05). Comparison between the various types of edema, differences were statistically significant in serum albumin levels and peak value of proteinuria and incidence of serious complications and the gestational week at PE onset and the incidence of treatment preterm labor (P < 0.05).Occurrence of placental abruption, heart failure and HELLP syndrome had statistical significance in different types of edema(P < 0.05). The varying degrees of interstitial edema were correlated with serum albumin levels (r = -0.19, P < 0.05) and serious complication occurrence (r = -0.232, P < 0.05), but no correlation displayed with the peak value of urinary protein (P > 0.05). CONCLUSIONS: The manifestations of edema were diverse in severe preeclampsia. The forms of edema were related to the PE onset of gestational age and serious complication involving in different organs.Strengthen prenatal care and early detection of edema may improve adverse obstetric outcomes.

Influence of kinesiologic tape on postoperative swelling, pain and trismus after zygomatico-orbital fractures.

Surgical treatment of zygomatico-orbital (ZO) fractures is a common procedure in maxillofacial surgery. Often accompanied by pain, trismus and swelling, postoperative morbidity is a major disadvantage, affecting patients' quality of life. The appliance of kinesiologic tape (KT) improves the blood and lymph flow, removing congestions of lymphatic fluid and haemorrhages. The aim of this study was to find out if the application of kinesiologic tape prevents or improves swelling, pain and trismus after zygomatico-orbital fracture surgery, improving patients' postoperative quality of life. A total of 30 patients were assigned for treatment of zygomatico-orbital fractures and were randomly divided into treatment either with or without kinesiologic tape. Tape was applied directly after surgery and maintained for at least 5 days postoperatively. Facial swelling was quantified using a five-line measurement at six specific time points. Pain and degree of mouth opening was measured. Patient's subjective feeling and satisfaction was queried. The results of this study show that application of kinesiologic tape after zygomatico-orbital surgery significantly reduced the incidence of swelling with an earlier swelling maximum, and decreased the maximum turgidity for more than 60% during the first 2 days after surgery. Although, kinesiologic tape has no significant influence on pain control and trismus, mouth opening increased earlier after operation in the kinesiologic tape group compared to the no-kinesiologic tape group. Furthermore, patients with kinesiologic tape felt significantly lower morbidity than those without kinesiologic tape. Therefore kinesiologic tape is a promising, simple, less traumatic, economical approach, which is free from adverse reaction and improves patients' quality of life.

Derivation of the Genital Injury Severity Scale (GISS): a concise instrument for description and measurement of external female genital injury after sexual intercourse.

INTRODUCTION: Inconsistencies abound in the current forensic literature regarding the definition, and as a result, the significance of female genital injury after sexual intercourse. These definitions are based on variables related to the anatomic locations that are examined, the actual physical findings types, and the methods used to detect the findings. PURPOSE: To derive and perform initial clinimetric analyses on a simple instrument that defines, and based on severity, quantifies external genital injury after sexual intercourse. The scale utilizes standard injury definitions and a standardized examination method. METHODS: After empirical investigation, it was determined that the application of the tool would require the use of magnification and toluidine blue in order to have the sensitivity to detect the majority of injuries that occur after sexual intercourse. Separate matrices were constructed based on anatomic locations and injury types from data collected from sexual assault genital injury examination forms. Principal Components Analyses were applied. A clinical model was constructed from the resultant variables, utilizing operational definitions and forming a template for the instrument. RESULTS: A twelve-factor instrument measuring five variables along five "types" of severity and two "classes" of severity ensued. The resultant instrument was tested for internal consistency and differential validity. Very good internal consistency was attained (Cronbach's Coefficient α = 0.8). In a pilot study, the scale was able to distinguish a cohort of sexual assault patients from one of consensual intercourse subjects based on type and class of injury (p < 0.0001). CONCLUSION: The findings presented demonstrate that while employing a standardized examination method, the Genital Injury Severity Scale has utility in defining and measuring external genital injury after sexual intercourse.

The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment.

An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.

[Bone (marrow) edema in magnetic resonance imaging - finding or only signal? A brief look behind the mirror]. / Knochen(mark)ödem in der MRT - Befund oder nur Signal? Ein kurzer Blick hinter den Spiegel.

An ill-defined area of increased signal intensity in bone marrow seen on water-sensitive magnetic resonance (MR) sequences (e. g. T2, short TI inversion recovery STIR) is usually referred to as "bone marrow edema". It may be observed with traumatic (e.g. bone bruise), inflammatory, osteoarthritic as well as neoplastic processes. Therefore, it can be confusing if the term "bone marrow edema" is used to describe a clinicoradiologic condition or diagnosis. Addressing these imaging findings as "edema equivalent" or "edema-like increased signal intensity" helps to restrict this phenomenon to a magnetic resonance sign and to avoid using it as a radiologic diagnosis. To illustrate this three case examples with corresponding MR images are presented to point out the intention of this article.

[Bone marrow edema in magnetic resonance imaging. A misleading term?]. / Knochenmarködem in der Magnetresonanztomographie. Ein irreführender Begriff?

Magnetic resonance imaging (MRI) is a mainstay in musculoskeletal imaging. The term"bone marrow edema" is frequently used for describing the radiological findings, especially with respect to rheumatic diseases. The referring physician should be aware that this term has a purely descriptive character and the pathophysiology of signal alterations in MRI shows a broad spectrum certainly not always corresponding to increased liquid contents. The recommendations therefore tend towards the use of the neutral terms"osteitis","bone marrow edema-like lesion" or"bone marrow lesion" instead of the misleading term"bone marrow edema".

Influence of a pedicle flap design on acute postoperative sequelae after lower third molar removal.

Pain, swelling, trismus, and alveolar osteitis often occur after removal of impacted third molar teeth. To minimize these complications a number of mucoperiosteal flap designs have been advocated, but, to date, a pedicle flap design has not been evaluated. In a randomized prospective split mouth study, 52 participants had bilateral symmetrically impacted mandibular third molars removed over two sessions. A buccal envelope or pedicle flap was randomly assigned to the left or right third molar site. Pre-and postoperative pain and swelling were recorded using a standardized visual analogue scale, trismus was measured as the maximum inter-incisal opening distance in millimetres and dry socket was assessed clinically. Greater continuous pain, pain on maximum opening, and oro-facial swelling were recorded with the pedicle flap design. Continuous pain resolved significantly faster with this flap design (p<0.05). Trismus was similar for both flap designs (p>0.05). Five cases of alveolar osteitis occurred with the envelope flap whilst no cases developed with the pedicle flap, but the incidence was too small for statistical analysis. The pedicle flap improved some aspects of postoperative pain experience and reduced the incidence of alveolar osteitis, but further investigation with a larger sample size is required to evaluate its significance.

Comparison of the roles of serratiopeptidase and dexamethasone in the control of inflammation and trismus following impacted third molar surgery.

INTRODUCTION: Surgical extraction of lower 3 rd molar is the most frequent intervention in oral surgery. This procedure is often associated with significant post operative swelling that may have both biological and social implications. Various studies have been done using different anti inflammatory drugs to study their impact on inflammation. MATERIAL AND METHODS: This study was conducted on 110 patients who had undergone surgical removal of mandibular third molar. The subjects were divided into two groups by double blind method. In addition to post operative swelling and pain , trismus was evaluated using two different groups of drugs. RESULTS: One group was administered 1 mg of dexamethazone every 8 hours for 3 days post operatively. The other group was administered 10 mg of serratiopaptidase every 8 hours for 3 days post operatively. Swelling, pain and trismus were assessed on the 1 st , 3 rd , 5 th and 7 th post operative days. The results of the studies were statistically analysed. CONCLUSION: The results showed dexamethazone was more effective in reduction of swelling and pain in comparison with serratiopaptidase. Both dexamethazone and serratiopaptidase had the same effect on trismus.

Evaluation of the muscle relaxant cyclobenzaprine after third-molar extraction.

BACKGROUND: Pain, swelling and trismus are undesirable effects of extraction of impacted mandibular third molars. The authors conducted a study to evaluate the effectiveness of the muscle relaxant cyclobenzaprine when used as a supplement to cryotherapeutic, antibiotic and steroidal anti-inflammatory treatment with the aim of reducing undesirable consequences after third-molar extraction. METHODS: The authors conducted a prospective, randomized, double-masked, placebo-controlled clinical trial involving 50 participants aged 18 to 29 years randomly assigned to receive cyclobenzaprine or the placebo. The authors used a split-mouth design, so each participant acted as his or her own control. For each participant, the authors extracted one impacted mandibular third molar on each side of the mouth at different times. Participants received 10 milligrams of cyclobenzaprine or a placebo once per day the day before surgery, the day of surgery and the first day after surgery. The authors assessed the participants' postoperative pain by means of a visual analog scale at four, six, eight, 12, 24 and 48 hours. They measured the participants' swelling and maximal interincisor distance at 48 hours and seven days. RESULTS: The authors assessed both sides of each participant's mouth for differences in pain, swelling and trismus. They found no statistically significant differences between sides of the mouth regarding these three variables. CONCLUSIONS: The results of this trial indicate that the influence of cyclobenzaprine over pain, swelling and trismus does not justify prescribing additional medication for patients undergoing third-molar extraction. CLINICAL IMPLICATIONS: The muscle relaxant cyclobenzaprine was ineffective in reducing pain, swelling and trismus after third-molar extraction.