Ultrasound guided treatment of pseudoaneurysm caused by puncture of the common femoral artery

Catheter-induced iatrogenic pseudoaneurysm is a complication on the rise as compared to the past. This is due to the increasingly frequent use of percutaneous endovascular intervention in the diagnosis and treatment of several diseases. We present a case which underlines the diagnostic and therapeutic role of color Doppler ultrasound (US) in this pathology.

New approach for evaluating the public health risk of living near a polluted river

Chemical, physical and microbial analyses were conducted in the Sarno River basin to obtain a comprehensive description of the overall quality of the water bodies. The collection period lasted 12 months, between 2005 and 2006, with high frequency of sampling and analysis. More than 6,000 analytical determinations were performed on samples collected at six sampling points along the Sarno River and two points each on tributaries Solofrana and Cavaiola. The results indicated the presence of inorganic contaminants, which, in most cases, were below the Italian State water quality thresholds. The organic contamination showed an increasing trend, with respect to previous determinations, thus demonstrating the major contribution of untreated urban wastewater to the overall pollution of the river. Moreover, this study was designed to explore the correlation between the presence of microbial indicators of fecal contamination in Sarno River and their presumable presence in the aerosol surrounding the river, thus pointing to the possible environmental hazard associated with the presence of pathogens in the air.

Time-resolved optical spectroscopy of wood

We have proposed and experimentally demonstrated that picosecond time-resolved optical spectroscopy in the visible/near-infrared (NIR) region (700-1040 nm) is a useful technique for noninvasive characterization of wood. This technique has been demonstrated on both softwood and hardwood samples treated in different ways simulating the aging process suffered by waterlogged woods. In all the cases, alterations of absorption and scattering spectra were observed, revealing changes of chemical and structural composition.

Prospective evaluation of the risk of pre-eclampsia using logistic regression analysis

OBJECTIVES

To calculate the risk of developing pre-eclampsia (PET) in a consecutive series of low-risk women at 18-24 weeks' gestation, using recently published logistic regression models.

METHODS

This was a prospective study, with complete follow-up, in a consecutive series of unselected low-risk singleton pregnancies. Uterine artery pulsatility index as well as a combination of maternal factors were recorded at 18-24 weeks' gestation. The distribution of the estimated risks for the 16 PET patients was compared with that obtained for 136 women who had a normal pregnancy, as assessed by routine testing. A receiver-operating characteristics (ROC) curve was plotted to evaluate the detection rate at fixed false-positive rates (FPRs) of 5%, 10% and 20% and the corresponding odds cut-offs.

RESULTS

Just 1/16 (6.2%) women with PET developed the disease before the 34(th) week of gestation. Using the 'All PET' logistic regression model, for 16 PET cases the overall median odds was 1 : 1454, higher compared with that of 1 : 41635 estimated for controls. Using the 'PET >or= 34 weeks' model, the median odds of the 15 women who developed PET late was 1 : 3405, compared with 1 : 40785 for controls. In the case of PET before 34 weeks, the risk was 1 : 426373 vs. 1 : 4159823126 estimated for controls ('PET < 34 weeks' model). Detection rates for the All PET model were 18%, 50% and 62% at a FPR of 5%, 10% and 20%, respectively. For the PET >or= 34 weeks model these detection rates were 6%, 46% and 60%, respectively.

CONCLUSION

Even though the individual odds estimation is too low to represent the real risk of PET, the recently published logistic regression models detected more than 60% of PET at a FPR of 20% for both All PET and PET >or= 34 weeks models. Using these models in clinical practice does not seem to give any significant improvement over Doppler alone in the prediction of PET, but the use of a PET-specific odds instead of an actual Doppler value alone seems to be useful for clinical management.

[Not allergic dermatitis as occupational diseases: a suggestion for an evaluation method]

Aim of the study was to propose a method to define the relationship of not allergic contact dermatitis with chemical risk factors in workplace. This method evaluates the skin response to simultaneous chemical and mechanical stimulation, made with a soft bristle brush. The method has been used on 9 cases of not allergic skin diseases, observed from 2000 to 2006 in Occupational Medicine Division of "Federico II" University of Naples. The greatest part of pathologies had the polymorphous pattern of skin inflammation, characterized by subintrant erythema, suspected of occupational origin. In 6 cases a stronger reaction to both chemical and mechanical stimulation was highlighted, confirming a possible occupational etiology. In 1 case the occupational origin was excluded, while in 2 cases the skin response was uncertain. The method does not define all cases of occupational skin pathologies, but it seems to be very useful to diagnostic and insurance needs.

[Burden of COPD on health profiles in different work activities]

According to WHO, COPD will be the 5th cause of disability and the 3rd cause of mortality by 2020. Even cigarette smoking represents the main cause of COPD recent studies demonstrated positive association with occupational exposure. In Europe costs of COPD were estimated at about 38,8 billion Euros in 2000; its burden is also expected to increase. Aim of the study is to evaluate the burden of COPD on health profiles in a sample of workers of Campania region. Prevalences were calculated in a sample of 908 male workers, employed in industrial (479) and tertiary (429) sectors. Results were compared with population data of ISTAT database. Higher prevalence of COPD was found in industrial workers (23.4%) than general population (3.5%) and tertiary workers (2.1%). Analysing smoking habits, higher prevalence of smokers in the industrial sector (75.9%) than tertiary (66.4%) was found, but this difference cannot explain the big difference of COPD prevalence between the two groups and suggest a positive interaction between smoking and occupational exposure. In conclusion, the results analysis underlines the burden of COPD on workers' health status, particularly in some work activities. Specific health promotion programs are necessary in these activities.

[Chronic-degenerative diseases in health care activities: data from health surveillance of Federico II University General Hospital in Naples]

Recent average life increase, as well as new habits and lifestyles assumption, has determined a change in population health profiles, as a result of progressive increase in chronic-degenerative diseases prevalence. Among these latter; musculoskeletal and cardiovascular diseases are the most frequent ones. Health care workers also suffered from this change in health profiles. This study, performed thanks to the extension of Health Surveillance to all health care workers, aimed at evaluating chronic-degenerative diseases risk among three main welfare activities (medical, nursing and auxiliary). In conclusion, data showed that nurses, mainly the shift workers, are exposed to a higher risk of chronic-degenerative diseases. All other health care workers have not significant work risk factors, because of a greater burden of aging and lifestyles effects.

Measurement of mRNA of trophoblast-specific genes in cellular and plasma components of maternal blood

BACKGROUND

Placental mRNA in maternal plasma is suitable for quantitative analysis regardless of fetal gender and genetic polymorphism status.

METHODS

We obtained 155 blood samples from pregnant women to compare human placental lactogen (hPL) and beta-subunit of human chorionic gonadotropin (beta hCG) mRNA and protein levels between the cellular and plasma components of maternal blood. To assess clearance of hPL mRNA expression, we obtained blood samples from nine women immediately before and after delivery by caesarean section. mRNA was extracted from the cellular and plasma components of all samples, and hPL and beta hCG mRNA expression was analysed by reverse transcription-PCR assay.

RESULTS

The concentration of beta hCG mRNA in the cellular component positively correlated with the plasma concentration of beta hCG protein and beta hCG mRNA (p = 0.001 for both). The concentration of hPL protein in the plasma correlated with the hPL mRNA concentration of the cellular component (p<0.05). For both hPL and beta hCG, the mRNA concentration of the cellular component was greater than that of the plasma component (22.9-fold higher for hPL and 4.3-fold higher for beta hCG). The half life of hPL mRNA clearance was significantly longer for the cellular fraction (mean half life = 203.8 min, range 150-3465 min) than for the plasma fraction (mean half life = 32.2 min, range 15-385 min) (p = 0.008).

CONCLUSION

The present findings indicate that the concentration of hPL and beta hCG mRNA is significantly higher in the cellular component of maternal blood samples than in the plasma component. Cellular mRNA in maternal blood is useful for non-invasive evaluation of placental function.

Cord insertion into the lower third of the uterus in the first trimester is associated with placental and umbilical cord abnormalities

OBJECTIVES

To assess the feasibility of detecting the cord insertion site during the late first trimester, and to investigate the possible association between perinatal complications and a cord insertion in the lower third of the uterus in the first trimester.

METHODS

This was a prospective cohort study in which the positional relationship between the uterus and the cord insertion site was examined using gray-scale transvaginal sonography at 9-11 weeks of gestation. The distance between the internal os and the fundus was divided equally into three parts. Cord insertions located in the upper or middle thirds were defined as normal (controls), and those located in the lower third were defined as cases, regardless of their relationship to the chorion villosum. Third-trimester sonography and pathological examination of the placenta and cord at delivery were performed to check for placental/cord abnormalities. The univariate association between the location of the cord insertion in the first trimester and placental and umbilical cord abnormalities and perinatal complications was assessed.

RESULTS

The cord insertion site was identified in 318/340 (93.5%) cases at 9-11 weeks of gestation and it was in the lower third of the uterus in 35 (11.0%) cases. Of these 35, the cord insertion was found at delivery to be low in nine cases (26%) and the placenta was low-lying at delivery in eight (23%). None of the 283 cases with a normal cord insertion in the first trimester was found to have a low-lying placenta at delivery (P < 0.0001). Ten (29%) of the cases with a low cord insertion and four (1.4%) with a normal cord insertion in the first trimester had a velamentous or marginal cord insertion at delivery (P < 0.0001). At delivery, five (14%) of the low cord insertion cases and four (1.4%) of the normal cord insertion cases (P < 0.0001) had some form of placental malformation, including accessory placenta and infarction of the placenta. An emergency Cesarean section was performed in four (11%) and six (2.1%) of the low and normal cord insertion cases, respectively (P = 0.003).

CONCLUSION

Developmental abnormalities of the placenta and umbilical cord occur frequently in cases in which the cord insertion is in the lower third of the uterus in the first trimester. We suggest that screening for the cord insertion site at 9-11 weeks of gestation may have clinical significance for predicting abnormalities of the cord and the placenta at delivery.

Stimulation of osteoblast growth by an electromagnetic field in a model of bone-like construct

The histogenesis of bone tissue is strongly influenced by physical forces, including magnetic fields. Recent advances in tissue engineering has permitted the generation of three dimensional bone-like constructs. We have investigated the effects of electromagnetic stimulation on human osteoblast cells grown in a hydrophobic polyurethane scaffold. Bone-like constructs were stimulated by pulsed electromagnetic fields in a bioreactor. Proliferation, bone protein expression and calcified matrix production by osteoblasts were measured using histochemical methods. In stimulated cultures, the number of cells was significantly higher compared to static (control) cultures. In both stimulated and control cultures, cells were immunoreactive to osteoblast markers, including type-I collagen, osteocalcin and osteopontin, thus suggesting that the expression of bone-related markers was maintained throughout the in vitro experiments. Morphometric analysis of von Kossa-stained sections revealed that stimulation with electromagnetic field significantly increased matrix calcification. The data lend support to the view that the application of a magnetic field can be used to stimulate cell growth in bone-like constructs in vitro. This finding may be of interest for the production of biomaterials designed for clinical applications.

Velamentous cord insertion into the lower third of the uterus is associated with intrapartum fetal heart rate abnormalities

OBJECTIVES

To evaluate the accuracy of sonographic identification of the site of umbilical cord insertion (CI) at 18-20 weeks of gestation, to compare the sensitivities for detection of a velamentous cord insertion (VCI) secondary to a CI into the anterior, posterior or fundal wall, and to compare the intrapartum complications secondary to VCI into the upper, middle or lower third of the uterus.

METHODS

As part of the routine ultrasound scan at 18-20 weeks' gestation we evaluated abnormal CI (VCI and marginal CI) and the location of the CI in the uterus in 3446 pregnancies. In cases of abnormal CI, the location of the CI was further classified as being in the upper, middle or lower third of the uterus. After delivery, the placenta and the umbilical cord were examined and intrapartum complications were compared with the location of the CI.

RESULTS

The values for antenatal detection of VCI were: sensitivity, 25 of 40 (62.5%); positive predictive value, 25 of 25 (100%); and negative predictive value, 3406 of 3421 (99.6%). The sensitivity for cases in which the CI was located on the anterior wall was 12 of 13 (92.3%); when it was located on the posterior wall, the sensitivity was 11 of 22 (50.0%); and when it was fundal the sensitivity was 2 of 5 (40.0%). Variable decelerations were frequently observed with a VCI. In lower VCI cases, non-reassuring fetal heart rate patterns and emergency Cesarean sections occurred with a higher frequency than in cases with upper or middle VCI (P < 0.01). After delivery, the length of the aberrant vessels in cases of VCI by pathologic examination was 3.9 +/- 3.3 cm in the upper third, 4.7 +/- 4.6 cm in the middle third, and 10.6 +/- 6.8 cm in the lower third; thus, the aberrant vessel length was significantly greater when the CI was in the lower third of the uterus (P = 0.024).

CONCLUSION

We have demonstrated that VCI with a lower CI site and with longer aberrant vessels is associated with various intrapartum complications. This finding has the potential for improving perinatal outcome.

Regulation of the expression of the Epstein-Barr virus early gene BFRF1

The switch from latency to lytic phase of Epstein-Barr virus (EBV) is coordinated by the expression of two viral transactivators known as ZEBRA and RTA. The BFRF1 gene has been shown to be transcribed during the early phases of EBV lytic cycle. Here, we characterized the BFRF1 promoter showing that ZEBRA transfection stimulated BFRF1 expression, whereas RTA induced BFRF1 only after the transfection of an amount of plasmid largely in excess than that sufficient to stimulate the expression of other RTA-responsive genes. However, a co-operative effect between ZEBRA and RTA in the expression of BFRF1 is evident since the transfection of RTA can rescue the transactivating capacity of a mutant of the ZEBRA protein, known as Z(S186A), that has a substitution affecting the DNA binding region. Moreover, we identified one ZEBRA-responsive element (ZRE) and one RTA-responsive element (RRE) within the BFRF1 promoter region.

Clinical experience with retrievable vena cava filters: results of a prospective observational multicenter study

BACKGROUND

Retrievable inferior vena cava (IVC) filters offer the attractive possibility to be definitive or to be removed when they become unnecessary.

OBJECTIVE

The purpose of this study was to evaluate the efficacy and the likelihood to remove the retrievable IVC filter ALN.

METHODS

A total of 30 patients (13 males and 17 females, mean age 57 +/- 15 years) underwent placement of ALN filters. Indications for implantation were acute venous thromboembolism (VTE) with a contraindication to anticoagulation in 26 cases (86%), primary prophylaxis after major trauma in two cases (7%) or before surgery in two patients with very high thromboembolic risk (7%).

RESULTS

The filter was successfully placed in all patients. After a median follow-up of 18.2 months, there were three cases (10%) of trapped emboli within the filter, one case (3%) of asymptomatic migration of the filter toward the heart and two patients (7%) had deep vein thrombosis (DVT) recurrences. ALN retrieval was attempted through transjugular approach in 18 patients (60%) and the maneuver was successful in 14 of them (78%); when the decision of removal was taken more than 3 months after the implantation, the retrieval was possible only in four of eight patients (50%). The median implantation period was 123 days (range: 30-345).

CONCLUSIONS

The present study shows the efficacy of ALN filter; it also demonstrates the feasibility and safety of retrieval after a medium-term period of placement. Removal after 3 months after implantation can be unsuccessful and maximum implantation time requires further studies.

Velamentous cord insertion and atypical variable decelerations with no accelerations

OBJECTIVES

To examine intrapartum fetal heart rate (FHR) patterns in the presence of velamentous cord insertion (VCI).

METHODS

The site of cord insertion was determined in 1460 women on antenatal ultrasonographic and postnatal examinations. Each of 24 women with pregnancies complicated with VCI was matched at the onset of labor with 10 women who had a normal pregnancy, and FHR patterns were analyzed for both cases and controls.

RESULTS

Compared with controls, cases of variable decelerations with no accelerations (VDNA) during the first and second stages of labor were more frequent in women with VCI (first stage: 25% vs. 5.1%, second stage: 65.0% vs. 21.7%, P < 0.001). The adjusted odds ratio associated with VDNA occurrence in women with VCI was 3.83 (95% confidence interval [CI]: 1.51-9.72, P = 0.005). The mean odds ratio associated with length of aberrant vessels in women with VCI plus VDNA was 1.38 (95% CI: 1.04-1.83, P = 0.026).

CONCLUSION

Pregnancies complicated with VCI are associated with a higher rate of VDNA.

Gene expression profile analysis in human T lymphocytes from patients with Down Syndrome

Down Syndrome (DS) is caused by the presence of three copies of the whole human chromosome 21 (HC21) or of a HC21 restricted region; the phenotype is likely to have originated from the altered expression of genes in the HC21. We apply the cDNA microarray method to the study of gene expression in human T lymphocytes with trisomy 21 in comparison to normal cells. Two patients with DS were investigated, along with two normal subjects as a control, all being tested in independent, duplicated cell culture experiments. The most consistent finding was the overexpression of the superoxide dismutase gene (SOD1), located on 21q, and of MHC DR beta 3 (HLA-DRB3), GABA receptor A gamma 2 (GABRG2), acetyltransferase Coenzyme, A 2 (ACAT2) and ras suppressor protein 1 (RSU1) genes. When the data were clustered according to chromosome localization, the HC21 gene set showed, on average, the highest expression in DS cells in all the experiments. Moreover, separate clustering of patients and controls was obtained when analysis was restricted to HC21 gene expression values. These findings reinforce the specific gene dosage theory for the pathogenesis of the DS phenotype, and show a consistent overexpression of the SOD1 gene on 21q.

Characterization and intracellular localization of the Epstein-Barr virus protein BFLF2: interactions with BFRF1 and with the nuclear lamina

We have reported in the accompanying paper that the BFRF1 protein of Epstein-Barr virus (EBV) is important for efficient primary viral envelopment and egress (A. Farina, R. Feederle, S. Raffa, R. Gonnella, R. Santarelli, L. Frati, A. Angeloni, M. R. Torrisi, A. Faggioni, and H.-J. Delecluse, J. Virol. 79:3703-3712). Here we describe the characterization of the product of the EBV BFLF2 gene, which belongs to a family of conserved herpesviral genes which include the UL31 genes of herpes simplex virus and of pseudorabies virus and whose products are known to interact with UL34, the positional homolog of BFRF1. BFLF2 is an early transcript and is expressed in a variety of cell lines upon EBV lytic cycle activation. Western blotting of purified virion preparations showed that BFLF2 is a component of intracellular virions but is absent from mature extracellular virions. Coimmunoprecipitation experiments indicated that BFLF2 interacts with BFRF1, which was confirmed by immunofluorescence confocal microscopy showing that the two proteins colocalize on the nuclear membrane not only upon cotransfection in epithelial cells but also during viral replication. In cells carrying an EBV mutant with the BFRF1 gene deleted (293-BFRF1-KO cells) BFLF2 expression was low, and it was restored to wild-type levels upon treatment of the cells with the proteasome inhibitor MG132. Furthermore, recomplementing the 293-BFRF1-KO cells by BFRF1 transfection restored BFLF2 expression to the wild-type level. In addition, when expressed alone BFLF2 was localized diffusely inside the nucleus, whereas in the presence of BFRF1 the two proteins colocalized at the nuclear rim. Finally, 293 epithelial cells transfected with either protein or cotransfected were analyzed by electron microscopy to investigate potential alterations in the morphology of the nuclear membrane. The ultrastructural analysis revealed that (i) BFRF1 caused duplications of the nuclear membrane, similar to those reported to occur during the course of herpesviral replication, and (ii) while BFLF2 alone did not cause any apparent alteration, coexpression of the two proteins dramatically induced profound convolutions of the duplicated nuclear membrane. Both biochemical and morphological analysis showed association of the BFRF1-BFLF2 complex with a component of the nuclear lamina, lamin B. Taken together, these results and those of the accompanying paper (Farina et al., J. Virol. 79:3703-3712) indicate an important role of BFRF1 and BFLF2 in the early steps of EBV maturation at the nuclear membrane.

BFRF1 of Epstein-Barr virus is essential for efficient primary viral envelopment and egress

The molecular mechanisms that underlie maturation and egress of Epstein-Barr virus (EBV) virions are only partially characterized. We have recently shown that the BFRF1 gene, the EBV positional homolog of herpes simplex virus type 1 and pseudorabies virus UL34, is expressed early during EBV lytic replication and that it is found predominantly on the nuclear membrane (A. Farina, R. Santarelli, R. Gonnella, R. Bei, R. Muraro, G. Cardinali, S. Uccini, G. Ragona, L. Frati, A. Faggioni, and A. Angeloni, J. Virol. 74:3235-3244, 2000). These data suggest that the BFRF1 protein might be involved in viral primary envelopment. To precisely determine the function of this protein, we have constructed an EBV mutant devoid of the BFRF1 gene (BFRF1-KO). 293 cells carrying BFRF1-KO showed no differences in comparison with wild-type EBV in terms of DNA lytic replication or expression of late viral proteins upon induction of the lytic cycle. However, binding assays and infection experiments using cell lines or human cord blood lymphocytes showed a clear reduction in the viral mutant titers. Complementation experiments with BFRF1-KO and a BFRF1 expression vector restored viral titers to levels similar to those for the wild-type control, showing that the modifications that we introduced were limited to the BFRF1 gene. Electron microscopic observations showed that the reduction in viral titers was due to sequestration of EBV nucleocapsids in the nuclei of lytically induced cells. This suggests that BFRF1 is involved in transport of the maturing virion across the nuclear membrane. This hypothesis was further supported by the observation that BFRF1 is present in maturing intracellular virions but not in their extracellular counterparts. This implies that BFRF1 is a key protein for EBV maturation.

16-year follow-up study of Vena Cava Filters Group

AIM

The prevalence of venous thromboembolic disease (VTED) is between 0.05% and 0.1% whereas its incidence is approximately 0.1%. Out of 100 patients with deep vein thrombosis (DVT), 5 will develop clinically serious pulmonary embolism (PE), one of which will be fatal. It is well known from the literature that surgical interventions carried out without antithrombotic prophylaxis have a 30% incidence of DVT, which can be halved with adequate prophylaxis. The aim of this study is to evaluate the immediate, middle- and long-term complications of caval filters by identifying any of the problems connected with or independent of the presence of the filter, also in relation to international literature data.

METHODS

In view of the evolution of VTED surgical prevention methods, we have analyzed our case record composed of 821 patients (October 1984-October 2002), treated with different surgical solutions for VTED, with indications for the placement of 634 caval filters.

RESULTS

The 30-day follow-up of all the 634 filters placed (100%) shows no mortality from the procedure and any of its immediate complications. The middle-term follow-up (from 1 month to 5 years) of 361 filters (57%) shows 0.55% mortality from PE while the long-term follow-up (5-16 years) of 105 filters (17%) shows a percentage decrease in all complications and no mortality from PE. The results also show a progressive annual decrease in the number of filters placed.

CONCLUSIONS

The lower incidence of complications, compared to that reported in the literature, can be attributed to both improved operator dexterity in the placement of the filter and correct management of the complications. The lower number of filters used can be explained by improved therapeutic possibilities with new low molecular weight heparins (LMWH) and by current diagnostic as well as instrumental and biochemical monitoring methodologies.

Chiral investigation of midodrine, a long-acting alpha-adrenergic stimulating agent

Midodrine hydrochloride is a peripheral alpha(1)-adrenoreceptor agonist that induces venous and arterial vasoconstriction. Midodrine, after oral or intravenous administration, undergoes enzymatic hydrolysis and releases deglymidodrine, a pharmacologically active metabolite. Midodrine and deglymidodrine have a chiral carbon in the 2-position. To investigate the bioactivity of racemates and enantiomers of the drug and metabolite, three chromatographic chiral stationary phases, Chiralcel OD-H, Chiralcel OD-R, and alpha(1)-AGP, were evaluated for enantiomeric resolution. Good enantioseparation of midodrine racemate was obtained using the Chiralcel OD-H column. This stationary phase was then used to collect separately the midodrine enantiomers. By alkaline hydrolysis of rac-midodrine and each separated enantiomer, rac-deglymidodrine and its enantiomers were prepared. The control of the enantiomeric purity was carried out by alpha(1)-AGP stationary phase, while the hydrolysis of rac-midodrine and its enantiomers was controlled by capillary electrophoresis using trimethyl-beta-cyclodextrin as chiral selector. The pharmacological activity of the two racemates and the two enantiomeric pairs was tested in vitro on a strip of rabbit descending thoracic aorta. The tests continued that the activity of the drug and metabolite is due only to the (-)-enantiomer because neither of the (+)-enantiomers is active.

Grey scale and power Doppler sonographic changes induced by intra-articular steroid injection treatment

OBJECTIVE

To investigate the ability of high resolution grey scale sonography (GSS) and power Doppler sonography (PDS) to assess short term soft tissue changes induced by intra-articular steroid injection in the small joints of patients with chronic synovitis.

METHODS

20 patients with clinically active synovitis of a small joint unresponsive to systemic drug treatment underwent a sonographic guided intralesional injection with triamcinolone acetonide. Clinical examinations were carried out by a trained rheumatologist. GSS and PDS examinations were performed independently by two examiners unaware of the results of the clinical examination. Joint cavity widening and power Doppler signal were evaluated and graded on a semiquantitative scale ranging from 1 to 4. Clinical and sonographic follow up examinations were carried out 2 weeks after the injection with triamcinolone acetonide.

RESULTS

All intra-articular injections were successfully carried out and documented under sonographic guidance. In 19/20 patients, baseline sonographic examinations clearly detected morphological and perfusional signs of synovitis. At follow up examinations, clinical and sonographic scores had improved significantly.

CONCLUSION

GSS and PDS appear to be a useful adjunctive tool for assessing short term soft tissue changes induced by intra-articular injection treatment with triamcinolone acetonide in small joints of patients with chronic arthritis.

[Levofloxacin-induced bilateral rupture of the Achilles tendon: clinical and sonographic findings]

The fluoroquinolones are antibiotics widely used in the clinical practice. The concomitant use of corticosteroids and fluoroquinolones in elderly patients is recognised as a risk factor for developing clinically relevant tendon lesions. Fluoroquinolone-induced tendinopathy is underreported in the literature. A 67-year-old man, came to our observation complaining of 5 days history of bilateral heel pain. The patient had a medical history of sarcoidosis and was treated with a daily dose of 5 mg of prednisone. He was initially given oral levofloxacin (500 mg/die) for 10 days, because of an acute respiratory infection. Two days before the end of the antibiotic therapy, he developed bilateral heel pain. He denied any history of trauma. Physical examination revealed swelling and marked tenderness with mild palpation of the Achilles tendons at the calcaneal insertion. The ultrasound evaluation of the Achilles tendons revealed the following main abnormalities: diffuse thickening, loss of the "fibrillar" echotexture, blurred margins, and bilateral partial tendon tears. Bilateral Achilles tendon pain and rupture has been described as a rare adverse effect of fluoroquinolone treatment. Most of the fluoroquinolone-induced tendinopathies of the Achilles tendon are due to ciprofloxacin. To the best of our knowledge, this is the first description of bilateral Achilles tendon rupture due to levofloxacin. The risk/benefit ratio of the fluoroquinolones should be carefully considered and these drugs should be prescribed cautiously in elderly patients treated with corticosteroids. This case can be regarded as a representative example of the potential clinical efficacy of sonography in daily rheumatological practise.