ULTRASONOGRAPHIC PRESENTATION OF NODULAR CYSTIC FAT NECROSIS AFTER A LOW-VELOCITY TRAUMA: A CASE REPORT.

Objective: Morel-Lavallée lesion is a well-known entity after a high-energy, shearing trauma. Another form of lesion in the subcutaneous tissue is fat necrosis, presenting as a palpable mass. The most common presentation of fat necrosis is oil cysts, which occur mainly in the breast. However, in the lower extremities fat necrosis appears as nodular cystic fat necrosis. We report here a case of a patient with multiple injuries after a low-velocity trauma, who developed fat necrosis. Results: Six months after the traumatic event the patient reported multiple subcutaneous lumps on the right knee. On ultrasonography, the probable diagnosis of post-traumatic fat necrosis with consequent development of nodular cystic fat necrosis was seen. The diagnosis was confirmed based on magnetic resonance imaging (MRI). Discussion: Fat necrosis should be included in the differential diagnosis in cases of tissue injuries after a trauma. Fat necrosis can present months or years after the initial injury. It is a benign entity and is the result of an organized haemorrhage, swelling and oedema that progresses with fibrosis. There is no absolute need for surgical treatment.

Distal biceps tendon ruptures: more efficient diagnostics for a better outcome.

Distal biceps tendon ruptures are a rare pathology, but can have significant functional repercussions. Rapid, accurate diagnosis and treatment are essential for a favorable prognosis. During the diagnostic process of distal biceps tendon ruptures, several problems can emerge. An answer to the following clinical questions is given based on an extensive literature review. - Which clinical tests are the most sensitive/ specific for clinical examination? - Can ultrasound evaluation of the distal biceps tendon be optimized? - Is ultrasound an equivalent alternative to MRI in the diagnosis of distal biceps tendon injuries? An extensive literature search was conducted through Pubmed and Embase. The search strategy was developed systematically in the Medline data- base (PubMed interface), using medical subject headings as well as free text words. A standardized clinical examination of the distal biceps tendon consisting of the Hook test, the Passive Forearm Pronation Test and the Biceps Crease Interval test has a high accuracy for correct diagnosis of full-thickness ruptures. Furthermore, Cobra sign, Supinator view and Pronator view give an additional value to the standard ultrasound examination of the distal biceps tendon. Finally, ultrasound can be considered a trustworthy and cost-effective alternative to MRI in evaluation of distal biceps tendon ruptures.

Evidence of rehabilitation therapy in task-specific focal dystonia: a systematic review.

INTRODUCTION: Task-specific dystonias are primary focal dystonias characterized by excessive muscle contractions producing abnormal postures during selective motor activities that often involve highly skilled, repetitive movements. Based on the idea of excessive motor excitability and aberrant sensorimotor integration in the pathophysiology of task-specific dystonia, sensorimotor retraining may hold promise. The purpose of this systematic review was to investigate the available evidence about the role of rehabilitation therapy as a treatment for task-specific dystonia. EVIDENCE ACQUISITION: A systematic review was performed of studies identified through Pubmed and Embase in a structured search strategy by independent author screening. The JBI (Joanna Briggs Institute) Critical Appraisal Checklist and RoB 2 were used to evaluate their methodological quality. EVIDENCE SYNTHESIS: Twenty-one studies were included for qualitative synthesis. Most of the reports are small single group pre-/post-test study designs with a variability in the type of task-specific dystonia and the type of evaluated outcome measures. Rehabilitation interventions were grouped into six categories based upon the underlying theoretical basis of different approaches: 1) movement practice; 2) training with constraint; 3) sensory reorganization; 4) biofeedback training; 5) neuromodulation with training; and 6) compensatory strategies. CONCLUSIONS: Although it appears that a number of task-specific dystonia patients may improve with rehabilitation therapy, no definitive conclusions can be drawn. More research in this field is needed, using standardized approaches and clearly defined outcome measures in larger cohorts of task-specific dystonia patients that are clinically and diagnostically well characterized.

The role of alanine glyoxylate transaminase-2 (agxt2) in ß-alanine and carnosine metabolism of healthy mice and humans.

PURPOSE: Chronic ß-alanine supplementation leads to increased levels of muscle histidine-containing dipeptides. However, the majority of ingested ß-alanine is, most likely, degraded by two transaminases: GABA-T and AGXT2. In contrast to GABA-T, the in vivo role of AGXT2 with respect to ß-alanine metabolism is unknown. The purpose of the present work is to investigate if AGXT2 is functionally involved in ß-alanine homeostasis. METHODS: Muscle histidine-containing dipeptides levels were determined in AGXT2 overexpressing or knock-out mice and in human subjects with different rs37369 genotypes which is known to affect AGXT2 activity. Further, plasma ß-alanine kinetic was measured and urine was obtained from subjects with different rs37369 genotypes following ingestion of 1400 mg ß-alanine. RESULT: Overexpression of AGXT2 decreased circulating and muscle histidine-containing dipeptides (> 70% decrease; p < 0.05), while AGXT2 KO did not result in altered histidine-containing dipeptides levels. In both models, ß-alanine remained unaffected in the circulation and in muscle (p > 0.05). In humans, the results support the evidence that decreased AGXT2 activity is not associated with altered histidine-containing dipeptides levels (p > 0.05). Additionally, following an acute dose of ß-alanine, no differences in pharmacokinetic response were measured between subjects with different rs37369 genotypes (p > 0.05). Interestingly, urinary ß-alanine excretion was 103% higher in subjects associated with lower AGXT2 activity, compared to subjects associated with normal AGXT2 activity (p < 0.05). CONCLUSION: The data suggest that in vivo, ß-alanine is a substrate of AGXT2; however, its importance in the metabolism of ß-alanine and histidine-containing dipeptides seems small.

Alcohol-related emergency department admissions in an elderly population.

OBJECTIVE: Alcohol abuse remains a major health concern. This study aimed to describe the characteristics of alcohol-related emergency department (ED) admissions in an elderly population. METHODS: Between 1 September 2013 and 31 August 2014, we retrospectively analyzed patient charts of patients admitted with a blood alcohol concentration (BAC) of at least 0.5 g/L to the EDs of all five hospitals in two distinct areas. We focused on the population ≥65 years, divided in three subgroups (65-74, 75-84 and ≥85, respectively) and compared them to the 55-64 year group. RESULTS: Of the 3918 included patients 645 (16.5%) were between 55 and 64, and 406 (10.4%) were ≥65 years (65-74: 267, 6.8%; 75-84: 128, 3.3%; ≥85: 11, 0.3%). The male-to-female ratio ranged between 2.1:1 and 2.7:1. BACs decreased with increasing age. In all age groups the majority of patients (71.0-77.8%) were transported by emergency medical services. The chief presenting complaint was trauma and its relative importance increased with age. Contextual factors consisted mostly of chronic abuse (43.1-57.8%). Most frequently patients could be discharged within 24 h, although hospital admission rates increased with age. CONCLUSION: Our study shows that alcohol-related ED admissions in the elderly are common, but less frequent than in younger age groups. More (preferentially prospective) studies are needed to give more insight in the living environment, prescription medication, socioeconomic cost, etc. Nonetheless, it is clear that a national action plan should be developed to tackle the alcohol abuse problem in all age groups.

Repeated stereotactic body radiotherapy for oligometastatic prostate cancer recurrence.

PURPOSE: To assess the outcome of prostate cancer (PCa) patients diagnosed with oligometastatic disease at recurrence and treated with stereotactic body radiotherapy (SBRT). METHODS: Non-castrate patients with up to 3 synchronous metastases (bone and/or lymph nodes) diagnosed on positron emission tomography - computed tomography, following biochemical recurrence after local curative treatment, were treated with (repeated) SBRT to a dose of 50 Gy in 10 fractions or 30 Gy in 3 fractions. Androgen deprivation therapy-free survival (ADT-FS) defined as the time interval between the first day of SBRT and the initiation of ADT was the primary endpoint. ADT was initiated if more than 3 metastases were detected during follow-up even when patients were still asymptomatic. Secondary endpoints were local control, progression free survival (PFS) and toxicity. Toxicity was scored using the Common Terminology Criteria for Adverse Events. RESULTS: With a median follow-up from time of SBRT of 2 years, we treated 50 patients with 70 metastatic lesions with a local control rate of 100%. The primary involved metastatic sites were lymph nodes (54%), bone (44%), and viscera (2%). The median PFS was 19 mo (95% CI: 13-25 mo) with 75% of recurring patients having ≤3 metastases. A 2nd and 3rd course of SBRT was delivered in 19 and 6 patients respectively. This results in a median ADT-FS of 25 months (20-30 mo). On univariate analysis, only a short PSA doubling time was a significant predictor for both PFS (HR: 0.90, 95% CI: 0.82 - 0.99) and ADT-FS (HR: 0.83; 95% CI: 0.71 - 0.97). Ten patients (20%) developed toxicity following treatment, which was classified as grade I in 7 and grade II in 3 patients. CONCLUSION: Repeated SBRT for oligometastatic prostate cancer postpones palliative androgen deprivation therapy with 2 years without grade III toxicity.