What tendon pathology is seen on imaging in people who have taken fluoroquinolones? A systematic review

Modified Pulvertaft on Weave Technique Restores Full Active Knee Extension in Patients With Large Chronic Quadriceps Tendon Rupture: A Case Series

PURPOSE

We aimed to investigate the clinical and functional outcomes, including maximal and explosive strength, after chronic quadriceps tendon rupture repair with Modified Pulvertaft on Weave (MPW) technique METHODS: Knee joint range of motion (ROM), patella height, thigh circumference, and Lysholm and International Knee Documentation Committee (IKDC) scores were assessed preoperatively and postoperatively. The knee extensors maximal (isokinetic peak torque and isometric maximal voluntary contraction (MVC) torque) and explosive strength-rate of torque development (RTD) early [RTD₅₀ and RTD₁₀₀] and late [RTD₂₅₀]-were performed. We assessed the thigh circumference and vastus lateralis muscle thickness (MT) as indicators of quadriceps muscle mass, and the voluntary quadriceps activation using surface electromyography (EMG₅₀).

RESULTS

Nine patients (mean age: 53 ± 11 years) took part in the study. We observed a significant increase in the knee active ROM and a decreased extension deficit (both, P < .001), but not for pain (P = .07), IKDC (P = .07), and Lysholm (P = .21) after the surgery. We did not observe a difference between involved (n = 8) and uninvolved (n = 10) limbs for ROM, thigh circumference, and MT. We observed differences for extensors peak torque, MVC torque, and late RTD (all, P < .05). However, we did not observe differences for early RTD and EMG₅₀. Significant positive correlations were observed for RTD₅₀ (ρ = .80) and RTD₁₀₀ (ρ = .81) vs EMG₅₀. Both the IKDC and Lysholm were better correlated with the early than with later RTD.

CONCLUSIONS

The MPW reestablished the active knee extension. The same level of quadriceps muscle mass was observed in both limbs, suggesting a lack of hypotrophy due to the injury. Although the involved limb had demonstrated lower knee extensors maximal strength, they demonstrate an equivalent early RTD when compared to the uninvolved limb. The early RTD seems to be better correlated with the patient's functionality than the later RTD and maximal strength.

LEVEL OF EVIDENCE

IV, case series.

Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities

INTRODUCTION

Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics.

AREAS COVERED

In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units.

EXPERT OPINION

Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.

Toxicity induced by ciprofloxacin and enrofloxacin: oxidative stress and metabolism

Ciprofloxacin (CIP) (human use) and enrofloxacin (ENR) (veterinary use) are synthetic anti-infectious medications that belong to the second generation of fluoroquinolones. They have a wide antimicrobial spectrum and strong bactericidal effects at very low concentrations via enzymatic inhibition of DNA gyrase and topoisomerase IV, which are required for DNA replication. They also have high bioavailability, rapid absorption with favorable pharmacokinetics and excellent tissue penetration, including cerebral spinal fluid. These features have made them the most applied antibiotics in both human and veterinary medicine. ENR is marketed exclusively for animal medicine and has been widely used as a therapeutic veterinary antibiotic, resulting in its residue in edible tissues and aquatic environments, as well as the development of resistance and toxicity. Estimation of the risks to humans due to antimicrobial resistance produced by CIP and ENR is important and of great interest. Moreover, in rare cases due to their overdose and/or prolonged administration, the development of CIP and ENR toxicity may occur. The toxicity of these fluoroquinolones antimicrobials is mainly related to reactive oxygen species (ROS) and oxidative stress (OS) generation, besides metabolism-related toxicity. Therefore, CIP is restricted in pregnant and lactating women, pediatrics and elderly similarly ENR do in the veterinary field. This review manuscript aims to identify the toxicity induced by ROS and OS as a common sequel of CIP and ENR. Furthermore, their metabolism and the role of metabolizing enzymes were reported.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

The Physiology and Biomechanics of the Master Runner

The Master runner (age 35 y and above) represents a unique athletic patient. Lifelong participation in endurance running slows the inevitable age-related decline in aerobic function and muscular strength. Still, the Master runner does not escape the inevitable effects of aging. Master runners experience a steady decline in running performance, that is, typical and maximal running speeds, after the age of 50 years of age. Age-related declines in running performance are driven by a host of factors, including declining cardiovascular function, reduced muscular capacity, altered biomechanics, and greater susceptibility to running-related injury. This review discusses age-related changes in physiology, biomechanics, and running injury susceptibility and practical strategies to maximize running participation in the Master runner.

The Relative Risk of Achilles Tendon Injury in Patients Taking Quinolones

OBJECTIVE

To examine the association between quinolone use and Achilles tendon injury, comparing well-matched cohorts of users of quinolone and nonquinolone antibiotics, and well-matched cohorts of quinolone users and patients not using any nonquinolone antibiotics.

PATIENTS AND METHODS

This retrospective cohort study used Clinformatics data from 2008-2014. Using the propensity score, we matched quinolone users with other antibiotic users and quinolone users with nonusers. The primary outcome was Achilles tendon injury within 6 months. Bivariate analyses determined risk factors for Achilles tendon injury, and conditional logistic regression assessed the impact of quinolone use on these injuries.

RESULTS

A total of 716,522 fluoroquinolone users were matched with other antibiotic users, and 645,034 fluoroquinolone users were matched with nonusers. Rates of Achilles tendon injury were less than 0.5% in all groups. Quinolone use increased the risk of Achilles tendon injury compared with other antibiotic users (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.17-1.31) and nonusers (OR 1.54, 95% CI 1.44-1.64). Interaction with age did not significantly impact the relationship between quinolone use and Achilles injury; however, older quinolone users had a slightly higher relative risk of injury than nonusers versus younger patients. Furthermore, the youngest group of patients had similarly elevated relative risk for injury with quinolone use as did the elderly.

CONCLUSION

Although quinolone use increases the risk of Achilles tendon injury, the absolute risk increase is minimal, especially when compared with similar morbidity patients taking other nonquinolone antibiotics. In relatively healthy populations, such as the one studied here, quinolone use may not make a clinically significant contribution to risk of Achilles tendon injury, at any age range, among those in need of such drugs.

Delafloxacin: an improved fluoroquinolone developed through advanced molecular engineering

The emergence of antimicrobial resistance threatens current clinical practice across a range of infection types. Delafloxacin, a non-zwitterionic fluoroquinolone recently approved by the US FDA for the treatment of acute bacterial skin and skin structure infections, has been developed to address some of these challenges. Uniquely delafloxacin has increased intracellular penetration and enhanced antibacterial activity under acidic conditions, an environment seen in many infection sites including abscesses. Delafloxacin is active against a wide range of Gram-positive and -negative species including methicillin-resistant Staphylococcus aureus and many fluoroquinolone-resistant strains. Additionally, according to preclinical and clinical trial data, well-known adverse events related to fluoroquinolone class do not appear to occur with this new molecule. Delafloxacin has been studied in acute bacterial skin and skin structure infections with >1400 patients exposed to both intravenous and oral formulation for up to 14 days and has shown noninteriority to vancomycin with or without aztreonam. For its interesting microbiological and pharmacokinetic/pharmacodynamics characteristics and for its safety profile, delafloxacin represents a very promising option for the treatment of infections caused by multidrug-resistant pathogens.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.

Bacterial Pneumonia in Older Adults

The incidence of pneumonia increases with age, and is particularly high in patients who reside in long-term care facilities (LTCFs). Mortality rates for pneumonia in older adults are high and have not decreased in the last decade. Atypical symptoms and exacerbation of underlying illnesses should trigger clinical suspicion of pneumonia. Risk factors for multidrug-resistant organisms are more common in older adults, particularly among LTCF residents, and should be considered when making empiric treatment decisions. Monitoring of clinical stability and underlying comorbid conditions, potential drug-drug interactions, and drug-related adverse events are important factors in managing elderly patients with pneumonia.

Two Unique Cases of Ciprofloxacin-Associated Avulsion of Ligament and Tendon

Ciprofloxacin is recognized to have a deleterious relationship with tendons, particularly Achilles tendinopathy, which makes up most case reports. Tendinopathy seems to occur because of induction of collagen-degrading enzymes causing damage and ischemia of the poorly vascularized regions preventing repair. The focus on the relationship of ciprofloxacin and the Achilles tendon leaves patients on fluoroquinolones with non-Achilles tendinopathy symptoms at risk of misdiagnosis. There have not been any documented instances of ligament damage with ciprofloxacin administration in the literature, although ligament and tendon compositions are similar and should have similar susceptibility. This report includes two cases, one presenting with right lateral thumb pain and a medical history of gastroenteritis treated with ciprofloxacin. Physical examination showed swelling of the right metacarpophalangeal joint and ultrasound confirmed disruption of the radial collateral ligament at insertion on first metacarpal; the second case is of a woman presenting with right hip pain in setting of chronic recurrent diverticulitis treated with ciprofloxacin. She received work-up for lumbar disc disease and spondylosis. After standard therapy with pharmacotherapy and physical therapy for radiculopathy failed, magnetic resonance imaging was performed showing near complete avulsion of the right hamstring tendons from the ischial tuberosity.

Antibacterial small molecules targeting the conserved TOPRIM domain of DNA gyrase

To combat the threat of antibiotic-resistant Gram-negative bacteria, novel agents that circumvent established resistance mechanisms are urgently needed. Our approach was to focus first on identifying bioactive small molecules followed by chemical lead prioritization and target identification. Within this annotated library of bioactives, we identified a small molecule with activity against efflux-deficient Escherichia coli and other sensitized Gram-negatives. Further studies suggested that this compound inhibited DNA replication and selection for resistance identified mutations in a subunit of E. coli DNA gyrase, a type II topoisomerase. Our initial compound demonstrated weak inhibition of DNA gyrase activity while optimized compounds demonstrated significantly improved inhibition of E. coli and Pseudomonas aeruginosa DNA gyrase and caused cleaved complex stabilization, a hallmark of certain bactericidal DNA gyrase inhibitors. Amino acid substitutions conferring resistance to this new class of DNA gyrase inhibitors reside exclusively in the TOPRIM domain of GyrB and are not associated with resistance to the fluoroquinolones, suggesting a novel binding site for a gyrase inhibitor.

Rehabilitation and Prevention of Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy (PHT) comprises a small but significant portion of hamstring injuries in athletes, especially runners. PHT is a chronic condition that is clinically diagnosed but can be supported with imaging. The main presenting complaint is pain in the lower gluteal or ischial region that may or may not radiate along the hamstrings in the posterior thigh. There is little scientific evidence on which to base the rehabilitation management of PHT. Treatment is almost always conservative, with a focus on activity modification, addressing contributing biomechanical deficiencies, effective tendon loading including eccentric training, and ultrasound-guided interventional procedures which may facilitate rehabilitation. Surgery is limited to recalcitrant cases or those involving concomitant high-grade musculotendinous pathology. The keys to PHT management include early and accurate diagnosis, optimal rehabilitation to allow for a safe return to preinjury activity level, and preventative strategies to reduce risk of reinjury.