Transcranial Motor-evoked Potentials for Intraoperative Nerve Root Monitoring During Adult Spinal Deformity Surgery: A Prospective Multicenter Study

STUDY DESIGN

A prospective, multicenter study.

OBJECTIVE

This study clarified the uses and limitations of transcranial motor-evoked potentials (Tc-MEPs) for nerve root monitoring during adult spinal deformity (ASD) surgeries.

SUMMARY OF BACKGROUND DATA

Whether Tc-MEPs can detect nerve root injuries (NRIs) in ASD surgeries remains controversial.

MATERIALS AND METHODS

We prospectively analyzed neuromonitoring data from 14 institutions between 2017 and 2020. The subjects were ASD patients surgically treated with posterior corrective fusion using multichannel Tc-MEPs. An alert was defined as a decrease of ≥70% in the Tc-MEP's waveform amplitude from baseline, and NRI was considered as meeting the focal Tc-MEP alerts shortly following surgical procedures with postoperative nerve root symptoms in the selected muscles.

RESULTS

A total of 311 patients with ASD (262 women and 49 men) and a mean age of 65.5 years were analyzed. Tc-MEP results revealed 47 cases (15.1%) of alerts, including 25 alerts after 10 deformity corrections, six three-column osteotomies, four interbody fusions, three pedicle screw placements or two decompressions, and 22 alerts regardless of surgical maneuvers. Postoperatively, 14 patients (4.5%) had neurological deterioration considered to be all NRI, 11 true positives, and three false negatives (FN). Two FN did not reach a 70% loss of baseline (46% and 65% loss of baseline) and one was not monitored at target muscles. Multivariate logistic regression analysis revealed that risk factors of NRI were preexisting motor weakness ( P <0.001, odds ratio=10.41) and three-column osteotomies ( P =0.008, odds ratio=7.397).

CONCLUSIONS

Nerve root injuries in our ASD cohort were partially predictable using multichannel Tc-MEPs with a 70% decrease in amplitude as an alarm threshold. We propose that future research should evaluate the efficacy of an idealized warning threshold (e.g., 50%) and a more detailed evoked muscle selection, in reducing false negatives.

Bi-allelic variants in IPO8 cause a connective tissue disorder associated with cardiovascular defects, skeletal abnormalities, and immune dysregulation

Dysregulated transforming growth factor TGF-β signaling underlies the pathogenesis of genetic disorders affecting the connective tissue such as Loeys-Dietz syndrome. Here, we report 12 individuals with bi-allelic loss-of-function variants in IPO8 who presented with a syndromic association characterized by cardio-vascular anomalies, joint hyperlaxity, and various degree of dysmorphic features and developmental delay as well as immune dysregulation; the individuals were from nine unrelated families. Importin 8 belongs to the karyopherin family of nuclear transport receptors and was previously shown to mediate TGF-β-dependent SMADs trafficking to the nucleus in vitro. The important in vivo role of IPO8 in pSMAD nuclear translocation was demonstrated by CRISPR/Cas9-mediated inactivation in zebrafish. Consistent with IPO8's role in BMP/TGF-β signaling, ipo8-/- zebrafish presented mild to severe dorso-ventral patterning defects during early embryonic development. Moreover, ipo8-/- zebrafish displayed severe cardiovascular and skeletal defects that mirrored the human phenotype. Our work thus provides evidence that IPO8 plays a critical and non-redundant role in TGF-β signaling during development and reinforces the existing link between TGF-β signaling and connective tissue defects.

Soft Tissue and Bony Injuries Attributed to the Practice of Yoga: A Biomechanical Analysis and Implications for Management

OBJECTIVE

To analyze injuries that were directly associated with yoga practice and identify specific poses that should be avoided in patients with osteopenia or osteoporosis.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with injuries that were primarily caused by yoga. Patients were seen from January 1, 2006, through December 31, 2018. Injuries were categorized into 3 groups: (1) soft tissue injury, (2) axial nonbony injury, and (3) bony injury. Patients underwent evaluation and were counseled to modify exercise activity.

RESULTS

We identified 89 patients for inclusion in the study. Within the soft tissue group, 66 patients (74.2%) had mechanical myofascial pain due to overuse. Rotator cuff injury was seen in 6 (6.7%), and trochanteric bursopathy was observed in 1 (1.1%). In the axial group, exacerbation of pain in degenerative joint disease (46 patients [51.7%]) and facet arthropathy (n=34 [38.2%]) were observed. Radiculopathy was seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on imaging in 15 patients (16.9%). Spondylolisthesis was present in 15 patients (16.9%). Anterior wedging was seen in 16 (18.0%), and compression fractures were present in 13 (14.6%). The poses that were most commonly identified as causing the injuries involved hyperflexion and hyperextension of the spine. We correlated the kinesiologic effect of such exercises on specific musculoskeletal structures.

CONCLUSION

Yoga potentially has many benefits, but care must be taken when performing positions with extreme spinal flexion and extension. Patients with osteopenia or osteoporosis may have higher risk of compression fractures or deformities and would benefit from avoiding extreme spinal flexion. Physicians should consider this risk when discussing yoga as exercise.

“Semenly” Harmless Back Pain: An Unusual Presentation of a Subcutaneous Abscess

Aims We report, with review of the literature, the case of a patient who developed a subcutaneous abscess after intravenously injecting his own semen in an attempt to treat longstanding back pain. He had devised this “cure” independent of medical advice. Methods A review of EMBASE, PubMed, google scholar and the wider internet was conducted with an emphasis on parenteral semen for the treatment of back pain and for other medical and non-medical uses. Results There were no other reported cases of intravenous semen injection found across the medical literature. A broader search of internet sites and forums found no documentation of semen injection for back pain treatment or otherwise. Conclusion While suicide attempt by intravenous injection of harmful substances is well described, this unique case demonstrates risks involved with innovative treatments prior to clinical research in the form of phased trials inclusive of safety and efficacy assessments.

Recent Advances in Research Regarding Autoantibodies in Connective Tissue Diseases and Related Disorders

Connective tissue diseases (CTDs), also known as systemic autoimmune diseases, involve a variety of autoantibodies against cellular components. An important factor regarding these autoantibodies is that each antibody is exclusively related to a certain clinical feature of the disease type, which may prove useful in clinical practice. Thus far, more than 100 types of autoantibodies have been found in CTDs, and most of their target antigens have been identified. Many of these autoantigens are enzymes or regulators involved in important cellular functions, such as gene replication, transcription, repair/recombination, RNA processing, and protein synthesis, as well as proteins that form complexes with RNA and DNA. This article reviews the autoantibodies for each CTD, along with an assessment of their clinical significance, and provides suggestions regarding their utilization for clinical practice.

[Rheumatoid arthritis as a connective tissue disease]

The available data indicate that seropositive rheumatoid arthritis (RA) develops as a result of systemic, autoimmune reaction directed against a range of "self" peptides/proteins that have undergone specific forms of post-translational modification. The development and progress of autoimmunity may be triggered by non-specific, local inflammatory processes outside the joints, for example in the oral or respiratory mucous membrane. The disease occurs in genetically susceptible individuals under the influence of environmental risk factors that promote autoimmunity and consequently the inflammatory process. Smoking is particularly linked with RA pathogenesis. Synovitis of multiple, symmetrical, peripheral joints is the most typical feature of RA which results in irreversible damage to joints structure and as a consequence in disability of patients. However, the inflammatory process in the course of RA has a systemic, constitutional nature. Therefore, extra-articular symptoms with internal organ involvement may occur additionally to synovitis, what is an unfavorable prognostic factor. Extra-articular manifestations of RA are associated with the high disease activity both inflammatory and immunological. They occur in patients with severe form of the disease and contribute to a significant lifespan reduction. This is usually associated with progressive atherosclerosis and cardiovascular complications. The systemic inhibition of an abnormal immune system activity is the mainstay of the effective RA treatment. The currently used disease modifying antirheumatic drugs affect the activity and function of different constituents of the immune system, including B and T lymphocytes and the main pro-inflammatory cytokines, and contribute to autoimmune and inflammatory processes.

The risk of autoimmune connective tissue diseases in patients with atopy: A nationwide population-based cohort study

BACKGROUND

The relationship between autoimmune connective tissue disease (ACTD) and atopy is controversial.

OBJECTIVES

To investigate the risks of ACTDs in patients with atopic triad diseases, including atopic dermatitis, allergic rhinitis, and asthma, by using a nationwide data base.

METHODS

A cohort of 155,311 patients newly diagnosed with atopic dermatitis, allergic rhinitis, or asthma in 2002-2011 was obtained from the Taiwan National Health Insurance Research Database. An age- and sex-matched control group was selected from the same data base. The association between atopy and ACTD was investigated by using Cox proportional hazards regression analyses.

RESULTS

Atopic dermatitis, allergic rhinitis, and asthma were present in 12.1, 78.6, and 26.3%, respectively, of the patients with atopy. The presence of atopic diseases increased the overall risk of ACTDs (incidence rate ratio 1.85 [95% confidence interval {CI}, 1.52-2.25]). The hazard ratio (HR) for ACTDs remained higher after adjusting for age, sex, urbanization level, socioeconomic status, and comorbidities. Individual risks of systemic lupus erythematosus (HR 1.58 [95% CI, 1.06-2.37]), rheumatoid arthritis (HR 1.74 [95% CI, 1.31-2.33]), and Sjögren syndrome (HR 2.49 [95% CI, 1.71-3.63]) were also higher. The coexistence of atopic triad diseases increased the risk of ACTDs from 1.80 (95% CI, 1.48-2.21) for one atopic disease to 3.29 (95% CI, 1.22-8.88) for three atopic diseases.

CONCLUSION

The presence of atopic triad diseases is significantly associated with risks of systemic lupus erythematosus, rheumatoid arthritis, and Sjögren syndrome, and their coexistence exacerbates this risk. To our knowledge, this was the first study that reported an increased risk of Sjögren syndrome among patients with atopy.

Endoplasmic Reticulum Stress and Unfolded Protein Response in Cartilage Pathophysiology; Contributing Factors to Apoptosis and Osteoarthritis

Chondrocytes of the growth plate undergo apoptosis during the process of endochondral ossification, as well as during the progression of osteoarthritis. Although the regulation of this process is not completely understood, alterations in the precisely orchestrated programmed cell death during development can have catastrophic results, as exemplified by several chondrodystrophies which are frequently accompanied by early onset osteoarthritis. Understanding the mechanisms that underlie chondrocyte apoptosis during endochondral ossification in the growth plate has the potential to impact the development of therapeutic applications for chondrodystrophies and associated early onset osteoarthritis. In recent years, several chondrodysplasias and collagenopathies have been recognized as protein-folding diseases that lead to endoplasmic reticulum stress, endoplasmic reticulum associated degradation, and the unfolded protein response. Under conditions of prolonged endoplasmic reticulum stress in which the protein folding load outweighs the folding capacity of the endoplasmic reticulum, cellular dysfunction and death often occur. However, unfolded protein response (UPR) signaling is also required for the normal maturation of chondrocytes and osteoblasts. Understanding how UPR signaling may contribute to cartilage pathophysiology is an essential step toward therapeutic modulation of skeletal disorders that lead to osteoarthritis.

[Interstitial pneumonia with autoimmune features]

Some patients with idiopathic interstitial pneumonias (IIPs) have clinical features that suggest autoimmune process but not fulfill established criteria for connective tissue disease (CTD). Different terms and criteria have been proposed to describe these patients, which includes undifferentiated connective tissue disease (UCTD), lung dominant connective tissue disease (LD-CTD), and autoimmune-featured interstitial lung disease (AIF-ILD). To marshal these ununiform classification criteria, the "European Respiratory Society/American Thoracic Society Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease" proposed a consensus regarding the nomenclature and classification criteria for patients with IIP and features of autoimmunity with the term "interstitial pneumonia with autoimmune features" (IPAF). It was reported that patients with IPAF accounted for 7.3%∼34.1% of patients with interstitial lung disease (ILD). Survival, rate of progressing to CTD, appropriate treatment, and treatment response are not yet elucidated. Furthermore, it is not determined whether IPAF is a distinct category of ILD or simply a part of IIP. These questions should be elucidated by future prospective cohort studies. Hopefully, rheumatologists should participate in not only clinical trials but also in multidisciplinary discussions for IPAF.

[The gastrointestinal tract microbiom in connective tissue diseases]

Factors such as genetics, the environment, infections, and the human body microbiota, mainly gastrointestinal tract microbiota may play a role in the pathogenesis of autoimmune disorders. There is an increasing evidence that suggest an association between gastrointestinal tract dysbiosis, and in particular gut dysbiosis, and connective tissue diseases but it still remains unclear whether alterations in the microbiome are a pathogenic cause or an effect of autoimmune disease. Given the strong variability and abundance of microbes living in close relation with human host, it becomes a difficult task to define what should be considered the normal or the favorable microbiome. Further studies are needed to establish how the human microbiome contributes to disease susceptibility, and to characterize the role of microbial diversity in the pathogenesis of connective tissue diseases and their clinical manifestations. The identification of dysbiosis specific for certain connective tissue diseases may help in the development of an individualized management for each patient. This review aims to summarize current data on the role of the gastrointestinal tract microbiome in connective tissue diseases.

Adipokines in connective tissue diseases

Adipokines, pleiotropic molecules produced by white adipose tissue (WAT) have attracted the attention of scientists since 1994. The role of adipokines in metabolic syndrome is known and fixed. Adipokines exerting a variety of metabolic activities have contributed to the ethiopathogenesis and the consequences of metabolic syndrome. Furthermore, adipokines are involved in the regulation of inflammatory processes and autoimmunity in the light of pathogenesis of connective tissue diseases. Given some evidence for the influence of adipokines in metabolic syndrome, there may be a link between CVDs and rheumatic diseases. This review provides an overview of the literature focusing on the role of adipokines in rheumatic diseases by putting special emphasis on the potential role of leptin, resistin, adiponectin, chemerin, visfatin and novel adipokines in connective tissue diseases.

[ROLE OF FACTORS OF THE ENVIRONMENT OF EDUCATION AND TRAINING IN THE FORMATION OF THE DYSPLASIA OF THE CONNECTIVE TISSUE IN TEENAGE YEARS]

Negative trends of indices of the incidence in children and teenagers in the Russian Federation are caused by essential changes in the system of training and medical care of school students. In cases of connective tissue dysplasia (CTD) when the gene defect is remains to be unascertained, there is a great role of environmental factors contributing to the implementation of pathology and hygienic measures of the prevention of complications. There was performed the hygienic assessment of sanitary-epidemiologic welfare (SEW) of the educational institutions (EI) of the city of Omsk (n = 76), including the study of environmental factors, health and performance of adolescents. For the correction priority factors for SEW were "medical care", "mode and organization of the educational-training process", "conditions and organization of nutrition", "conditions and organization of physical education." There are determined the most important for the occurrence of CTD indices lifestyle factors and "indicators" of the risk for the progression of pathological processes in adolescents.

[The Information Flows System as an instrument for preventing technological illness]

This paper describes the project "Information Flows", its contents of INAIL data about accidents and occupational diseases reported and recognized and its usefulness for programs of preventive initiatives undertaken by INAIL and by the responsible structures in the single italian regions. We propose some processings of data and suggest how their collection, according to criteria based on occupational medicine, industrial hygiene and epidemiology and a careful analysis and processing of data from more sources could lead to an extension of the workers protection, relatively to "unrecognized" occupational diseases, diseases caused by the "old" risks and the identification of occupational diseases caused by "new" risks.

Subcutaneous abscess secondary to xanthogranulomatous cholecystitis

One of the known complications of gallstones consists in gallbladder perforation with cholecystocutaneous abscesses or external fistulas formation. Nowadays these types of complications are uncommon, having been more frequent. The authors report the case of an 86 year-old woman, bedridden and dependent, referred to our institution by presenting a tumefaction with inflammatory signs in the right upper quadrant. The radiological investigation revealed it to be a subcutaneous abscess associated with a perforated gallbladder, whose histological analysis revealed xanthogranulomatous cholecystitis.

[MRI investigations in patients with problems due to metal-on-metal implants]

Until recently, metal-on-metal (MoM) hip implants were commonly used for joint replacement and resurfacings. Their use has rapidly declined following reports of Frühversagen and soft tissue disease caused by the release of metal debris from the prosthesis. Detection of these soft tissue lesions has proven difficult using conventional imaging techniques and blood metal ion tests. Current guidelines recommend the use of imaging modalities including metal artefact reduction sequence (MARS) magnetic resonance imaging (MRI), computed tomography and ultrasound but provide little indication which is best. MARS significantly reduces the susceptibility artefact induced by the presence of metal objects, thereby producing diagnostic quality images that can be shared with other physicians and compared over time. The clinical interpretation of MRI findings of solid pseudotumours and severe muscle atrophy is straightforward: revision is usually recommended. However, the most common MRI findings are of a cystic pseudotumour and minor muscle wasting. In these cases decision-making is difficult and we currently use multi-disciplinary and multi-colleague based meetings to make decisions regarding patient management. This article presents a comparison of imaging modalities and an update on the interpretation of MARS MRI for the investigation of patients with MoM hip implants.The English full-text version of this article is available at Springer Link (under "Supplemental").

Raynaud's phenomenon: from molecular pathogenesis to therapy

Raynaud's phenomenon (RP) is a well defined clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical/chemical or emotional stress. RP has been classified as primary or secondary, depending on whether it occurs as an isolated condition (pRP) or is associated to an underlying disease, mainly a connective tissue disease (CTD-RP). In both cases, it manifests with unique "triple" (pallor, cyanosis and erythema), or "double" color changes. pRP is usually a benign condition, while sRP can evolve and be complicated by acral digital ulcers and gangrene, which may require surgical treatment. The pathogenesis of RP has not yet been entirely clarified, nor is it known whether autoantibodies have a role in RP. Even so, recent advances in our understanding of the pathophysiology have highlighted novel potential therapeutic targets. The aim of this review is to discuss the etiology, epidemiology, risk factors, clinical manifestations, recently disclosed pathogenic mechanisms underlying RP and their correlation with the available therapeutic options, focusing primarily on pRP and CTD-RP.

[Features of fluor intoxication development in patients with nondifferentiated connective tissue dysplasia and physical therapy methods for these patients]

The article covers results of studies concerning time of fluorosis development in patients with signs of connective tissue dysplasia syndrome (CTDS). if compared with patients without CTDS, and of studies concerning hyperostosis coefficient in accordance with presence or absence of CTDS. Efficiency of physical therapy and balneotherapy for these patients are also reported by the authors.

Late appearance and exacerbation of primary Raynaud's phenomenon attacks can predict future development of connective tissue disease: a retrospective chart review of 3,035 patients

To assess the prognostic value of the age at onset of Raynaud's (RP) and of a history of exacerbation of RP attacks for the development of connective tissue disease (CTD) in patients initially found to have primary Raynaud's. 3,035 patients with primary RP (2,702 women and 333 men) were followed for an average of 4.8 years (range from 1 to 10 years). At baseline and every 6 months, they were screened for signs and symptoms of CTD. At 4.8 years of follow-up, 54.7 % patients remained as primary RP, 8.1 % had developed suspected secondary RP, and 37.2 % had developed a definite CTD. Primary RP patients had an earlier onset of RP (mean age of 32.2 years) than those with suspected (mean age 36.5 years, P = .007) or definite secondary RP associated with CTD (mean age of 39.8 years, P = .004). RP beginning before the age of forty was not significantly associated with the development of CTD. Conversely, the appearance of RP after the age of 40 was significantly associated with the development of CTD (P = .00001). Worsening of RP attacks predicted the development of CTD, especially systemic sclerosis (relative risk [RR] of 1.42), scleroderma overlap syndrome (RR of 1.18), and mixed CTD (RR of 1.18). Patients whose onset of RP occurred past 40 years of age and those with worsening RP attacks were at risk for the future development of CTD.

Paraneoplastic syndromes with connective tissue involvement. "It's not always lupus!"

Paraneoplastic syndromes (PNS) are remote effects of cancer that are, by definition, caused neither by invasion of the tumor or its metastases nor by infection, ischemia, metabolic and nutritional deficits, surgery or other forms of tumor treatment. The purpose of the current review was to present the challenging elements of differential diagnosis in oncology, as they may represent the main clinical problem in a patient diagnosed with cancer, even though the complete knowledge of both their clinical aspects and pathogenesis remain quite poor. This review focuses on the paraneoplastic syndromes related to dermatology and rheumatology, as the most frequent manifestations come from connective tissues that might determine a patient to ask for consultation by a general practitioner.

[Morphological diagnosis of connective tissue dysplasia in patients, suffering postoperative abdominal hernia]

The results of treatment of 122 patients, to whom alloplasty for postoperative abdominal hernia (POAH) was performed, were analyzed. In 76 patients a connective tissue dysplasia (CTD) was diagnosed.Determination of a various types of collagen content in connective tissue of patients, suffering CTD, may confirm or exclude this diagnosis. Diagnostic significance has the enhancement of a collagen type III content in comparison with such of a type I by three times and more. The method of lectinohistochemical investigation of connective tissue was applied as a precision-enhancing method of a CTD diagnosis. Mosaic or diffuse loss of SNA, LABA, ConA receptors of lectins by collagen fascicles, which reflect carbohydrate determinants of dense and strong collagen fascicles, made of collagen type I, witness the CTD presence. Along with this, there was observed a lectin WGA receptors expression increase, which constitutes a marker of fascicular structures, made of collagen, predominantly type III and a lectin PNA receptors, which are revealed around vessels.

[Symptomatic foot shortening with subacute soft tissue swelling of the right tibia]

A 13-year-old girl presented with load-dependent pain of the medial part of the right foot. The medical history revealed no trauma and no sports-related injury. X-ray examinations of the foot and lower leg showed subcortical increased sclerosis at the medial part of the tibia, the medial tarsal bones and of a bunion. Magnetic resonance imaging revealed corresponding findings with localized edema of the bone marrow within the increased subcortical sclerosis but no indications of subcutaneous fibrosis. The constellation is indicative of melorheostosis, a rare benign sclerosis of bones and soft tissue. Subcutaneous fibrosis and limb shortening are also common.

ReviewSilicone Gel Breast Implants and Connective Tissue Disease—A Comprehensive Review

Silicone breast implants have been in use for breast reconstruction and breast augmentation for a long time. In the late 80's anecdotal reports describing a possible association between silicone-gel filled breast implants, and autoimmune diseases was accumulating. Due to the growing concern about the safety of silicone-gel implants, the Food and Drug administration (FDA) restricted their use to participants in controlled clinical trials, including women having reconstructive surgery. However, in recent years, large meta-analyses were unable to establish an association between silicone-gel breast implants and autoimmune disease. We review the current literature, emphasizing the most important epidemiologic studies.

[Targeted therapies including monoclonal antibodies for connective tissue diseases]

Recent advance of targeted therapies including monoclonal antibodies and fusion proteins has allowed effective strategies in the treatment of rheumatoid arthritis. And now, TNF inhibitors are broadly used for rheumatoid arthritis and prevent the disease progression. Meanwhile, B cell targeted therapies and anti-interleukin-6 receptor antibody treatment are not only used for second line biological agents for rheumatoid arthritis, but also expected for the treatments of various autoimmune diseases. Recent year, some of novel small molecules, which inhibit the signal transduction of various surface receptors of immune cells, are in clinical trials. These drugs will be a breakthrough for the treatment of some autoimmune disorders.

Serum proteins and paraproteins in women with silicone implants and connective tissue disease: a case-control study

Prior studies have suggested abnormalities of serum proteins, including paraproteins, in women with silicone implants but did not control for the presence of connective-tissue disease (CTD). This retrospective case–control study, performed in tertiary-care academic centers, assessed possible alterations of serum proteins, including paraproteins, in such a population. Seventy-four women with silicone implants who subsequently developed CTD, and 74 age-matched and CTD-matched women without silicone implants, were assessed in the primary study; other groups were used for additional comparisons. Routine serum protein determinations and high-sensitivity protein electrophoresis and immunofixation electrophoresis were performed for detection of paraproteins. Women with silicone implants, either with or without CTD, had significantly lower serum total protein and α₁-globulin, α₂-globulin, β-globulin, γ-globulin, and IgG levels compared with those without silicone implants. There was no significant difference, however, in the frequency of paraproteinemia between women with silicone implants and CTD (9.5%) and age-matched and CTD-matched women without silicone implants (5.4%) (odds ratio, 1.82; 95% confidence interval, 0.51–6.45). Paraprotein isotypes were similar in the two groups, and the clinical characteristics of the 13 women with paraproteinemia were comparable with an independent population of 10 women with silicone breast implants, CTD, and previously diagnosed monoclonal gammopathies. In summary, this first comprehensive study of serum proteins in women with silicone implants and CTD found no substantially increased risk of monoclonal gammopathy. Women with silicone implants, however, had unexpectedly low serum globulin and immunoglobulin levels, with or without the subsequent development of CTD. The causes and clinical implications of these findings require further investigation.

Abscess of the deep cervical fascial space in adults: a report of 3 cases and review of anatomy

Deep cervical space abscess is a disease with the potential for grave consequences if not managed properly. Even though since the antibiotic era it has been on the decline, it still occurs. Better imaging techniques have made the management of this disease better such that it is possible to treat the abscesses conservatively reserving surgical drainage for cases that fail to respond to treatment. We present 3 cases of deep cervical space abscess that were surgically drained and wide spectrum antibiotic administered. In one of the patients, there was coexisting pulmonary tuberculosis.

Exogenous factors in connective tissue diseases

Exogenous factors implicated in or suspected of precipitating connective tissue diseases are reviewed. These include environmental agents, such as ultraviolet light, drugs, chemicals, pesticides, heavy metals, infectious viruses, and bacteria. The possible roles of occupational exposures and the environmental factors early in life are discussed as well.

A Nationwide Study of Connective Tissue Disease and Other Rheumatic Conditions Among Danish Women With Long-Term Cosmetic Breast Implantation

PURPOSE

Numerous epidemiologic studies have demonstrated that breast implants are not associated with connective tissue diseases (CTDs). However, many CTDs are rare, and continued follow-up of women with breast implants is warranted.

METHODS

We extended by 5 years the follow-up of our earlier population-based cohort study of Danish women with cosmetic breast implants (n = 2761) and comparison groups of women with other types of cosmetic surgery (n = 8807). All women were followed from January 1977 through December 2001. Hospitalization and outpatient data for CTD and ill-defined and other rheumatic conditions in the implant and comparison groups were compared with those in the general Danish population. Additionally, CTDs and fibromyalgia were confirmed through medical chart review, and direct comparisons of the breast implant cohort with the comparison cohort were performed.

RESULTS

When compared with general population rates, CTDs were not statistically significantly elevated in either the implant or the comparison cohorts. However, unspecified rheumatism was similarly increased in the implant (standardized rate ratio = 1.9; 95% confidence interval = 1.6 to 2.2) and comparison (standardized rate ratio = 1.5; 95% confidence interval = 1.4 to 1.7) cohorts. In analyses of diagnoses validated by chart review, women with cosmetic breast implants compared with those having other types of plastic surgery or consultation for plastic surgery had no statistically significant excess for any specific confirmed CTD or combined CTDs (hazard ratio = 1.3; 95% CI = 0.9 to 1.9). In addition, there was no relation between breast implants and confirmed fibromyalgia (hazard ratio = 1.2; 95% CI = 0.6 to 2.1).

CONCLUSIONS

This extension of our earlier cohort study further supports the consensus of epidemiologic research that breast implants are unrelated to the development of CTD.

Autoimmune disease etiology—a perplexing paradox or a turning leaf?

Autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma have been considered to represent disorders associated with reaction of the patient's own immune system against self-antigens or body systems. In many such disorders, tissues involved show lesions or morphology indicating destructive inflammatory or reactive features clearly produced by or associated with cell-mediated or antibody-driven reactions of the patient against his own tissues. After an exhaustive search which has stretched back in time for at least the last five decades, we seem to understand how the immune system works better than previously. However, despite the fact that we now understand molecular mechanisms of antibody selection and structure, how the cell-mediated and humoral antibody system is activated in terms of signal peptides and in the context of HLA molecules, we have not yet exactly identified inciting antigens which clearly cause these diseases. The focus recently has shifted towards being able to down-modulate potentially harmful parts of a self-directed inflammatory process by abrogating harmful messenger molecules participating in tissue injury. Following such a path, we may actually alleviate or cure these diseases before eventually identifying their original cause.

Bullous solar elastosis

Solar elastosis (SE) is a well-recognized manifestation of chronic sun exposure, mainly affecting white patients. Well-established clinical manifestations of SE include Favre-Racouchot syndrome, cutis rhomboidalis nuchae, actinic comedonal plaques, elastomas, elastotic nodules of the ears, elastotic bands, collagenous plaques of the hands and colloid millia. Bullous SE is a very unusual presentation of SE, which consists clinically of tense bullae on chronically sun-damaged skin and is characterized histopathologically by a dermal cleft within a dermis with severe SE. Bullous SE is a rare but characteristic clinical expression of SE.

[Formation of a pseudocyst following abdominoplasty]

A 49-year-old woman presented for follow-up examination after an abdominoplasty performed in Germany. She complained of pain in the abdomen and was not satisfied with the final result. The patient presented with a bulging, painful abdomen. The symptoms disappeared for a few weeks after puncture of the seroma, but then returned. Neither haematoma, seroma nor neuroma were found at the first exploration, but a second abdominoplasty revealed a large pseudocyst extending from the epigastric to the supra-pubic area. The pseudocyst was extirpated. Seroma formation is a frequently occurring complication after abdominoplasty, but is ultimately reabsorbed spontaneously. Pseudocyst formation following abdominoplasty is a rare complication, which has been described in the literature only when liposuction was done as well. Liposuction creates multiple channels that result in an open abdominoplasty cavity. Seroma and blood clots provoke an inflammatory response, resulting in a pseudocyst after the formation of a thick capsule. The prevention of seroma and haematoma formation is of essential importance in preventing this rare complication. Sharp dissection, prolonged drainage with high vacuum and a compressive bandage are very important in this connection.

Soft tissue calcifications in the lower extremities of severely diabetic patients simulating venous stasis or collagen vascular disease

The purpose of this work is to report soft tissue calcifications in severely diabetic patients that simulate venous stasis or scleroderma, without other stigmata of these diseases. Findings from lower extremity radiographs were reviewed on two patients with severe diabetes mellitus and abnormal soft tissue calcifications. Findings were correlated with clinical history, physical exam findings, and laboratory values. Both patients in this study demonstrate radiographic findings of lower extremity soft tissue calcifications similar to those seen in venous stasis or scleroderma. Clinical history, physical examination, and laboratory values support severe diabetes mellitus, with no evidence of these other disease entities. Patients with severe diabetes mellitus may exhibit soft tissue calcifications of their lower extremities that may simulate the changes of venous stasis or scleroderma. This association has not been previously described.

"Normal" prevertebral soft tissue swelling following elective anterior cervical decompression and fusion

INTRODUCTION

Prevertebral soft tissue swelling (PSTS) has been evaluated in the setting of traumatic cervical spine injuries. However, no study to date has quantified the PSTS following elective anterior cervical decompression and fusion or the time course to resolution of that swelling.

METHODS

From May 2002 to May 2005 the senior author performed 193 elective 1- or 2-level anterior cervical decompression and fusions. Patients who underwent corpectomies and anterior cervical fusions for trauma or tumor were excluded. Preoperative, 2-week postoperative and 6-week postoperative radiographs were available on 100 patients. The prevertebral soft tissue stripe was measured on the neutral lateral radiographs for the 3 time points. The mean swelling (mm) for each time point was calculated and stratified by cervical level. Repeated measures analysis of variance with the Tukey-Kramer multiple comparisons test was used to compare the measured swelling at the various time points.

RESULTS

The average PSTS was calculated for each cervical level, for each of the 3 time points, preoperative, 2- and 6-week postoperative. There was a significant increase in PSTS between the preoperative and 2-week postoperative measurements at all levels. There is a significant decrease in PSTS between 2- and 6-week postoperatively at all cervical levels. There is no significant change in PSTS at C2, C3, and C5, when comparing the preoperative and 6-week postoperative measurements. There is significant PSTS at C4, C6, and C7, when comparing preoperative and 6-week postoperative measurements.

CONCLUSIONS

The "normal" range for PSTS at 2 weeks and at 6 weeks after elective 1- and 2- level anterior cervical decompression and fusions is described. Our data demonstrates that edema persists at the 2-week follow-up. By 6 weeks postoperative, the increased PSTS has greatly dissipated.

Elastosis perforans serpiginosa in a patient with trisomy 21

A 12-year-old girl with trisomy 21 (Downs syndrome) presented with an approximate 2-year history of an asymptomatic eruption on the right upper arm and left lateral neck that was clinically and histologically diagnostic of elastosis perforans serpiginosa (EPS). EPS is a perforating dermatosis affecting the face, ear, neck, extremities, or trunk. It occurs with greater frequency in persons with trisomy 21, as well as some other genetic syndromes and after D-penicillamine therapy. It has also been reported as a sporadic, presumably unrelated disorder in several acquired diseases.

Ophthalmologic manifestations of cutaneous conditions

Many cutaneous conditions have associated ophthalmologic findings, which are important to recognize for both dermatologists and ophthalmologists. This review highlights some important ophthalmologic manifestations associated with neurocutaneous syndromes and inherited connective tissue diseases.

The prognostic value of nailfold capillary changes for the development of connective tissue disease in children and adolescents with primary raynaud phenomenon: a follow-up study of 250 patients

To assess the prognostic value of capillaroscopy findings for the development of connective tissue disease in children and adolescents with Raynaud phenomenon, we followed up a group of 250 (mean age 15 years) for 1 to 6 years after the first capillaroscopy was performed. Every 6 months they were screened for signs and symptoms of connective tissue disease. Analysis was performed on capillary changes registered 6 months before the development of connective tissue disease. Capillary changes were classified into three types: normal, nonspecific, and sclerodermatous. At the end of the follow-up period, 191 (76%) subjects had primary Raynaud phenomenon, 27 (10.8%) were diagnosed as having undifferentiated connective tissue disease, and 32 (12.8%) fulfilled the criteria for a diagnosis of a specific connective tissue disease. Systemic lupus erythematosus was found in nine (3.6%) patients, rheumatoid arthritis in 10 (4%) patients (six of them with juvenile onset rheumatoid arthritis), and scleroderma spectrum disorders in 13 (5.2%). The mean time for the evolution of Raynaud phenomenon into undifferentiated connective tissue disease or a form of the disease was 2 years. Most of the subjects with primary Raynaud phenomenon (173/191, 91%), undifferentiated connective tissue disease (22/27, 81%), juvenile onset rheumatoid arthritis/rheumatoid arthritis (7/10, 70%), and systemic lupus erythematosus (6/9, 67%) had normal capillary findings. Nonspecific capillary changes occurred in 3 of 10 (30%) patients with rheumatoid arthritis, 2 of 9 (22%) with systemic lupus erythematosus, 4 of 27 (15%) with undifferentiated connective tissue disease, and 18 of 191 (9%) with primary Raynaud phenomenon. Of all the subjects, only 10 (4%) showed sclerodermatous disease type capillary changes 6 months before the expression of a particular disease: eight (62%) of these developed scleroderma spectrum disorders, one expressed systemic lupus erythematosus, and one had undifferentiated connective tissue disease. We concluded that there were no specific capillary changes predictive for future development of systemic lupus erythematosus, juvenile onset rheumatoid arthritis/rheumatoid arthritis, and undifferentiated connective tissue disease in children and adolescents with Raynaud phenomenon. Most of our study subjects with Raynaud phenomenon who developed these diseases had normal capillary findings or nonspecific changes. Children and adolescents who developed scleroderma spectrum disorders showed a sclerodermatous type of capillary changes 6 months before the expression of the disease, indicating that this type of capillary changes in children and adolescents with Raynaud phenomenon highly correlated with further development of scleroderma spectrum disorders.

[Bilateral orbital fat prolapse associated with pterygium: case report]

Orbital fat prolapse is an uncommon benign entity that can cause esthetic defects. The authors present a 63-year-old patient with bilateral temporal orbital fat prolapse associated with a bilateral nasal pterygium. Clinical and surgical features are described. The clinical, imaging and histopathological diagnoses are discussed.

Comparison of Polypropylene and Silicone Ahmed Glaucoma Valves

PURPOSE

To evaluate and compare the clinical outcomes after implantation of the silicone plate and the polypropylene plate Ahmed Glaucoma Valves.

DESIGN

Prospective, multicenter, comparative series.

METHODS

A total of 132 patients with uncontrolled glaucoma were treated with either the silicone or polypropylene Ahmed Glaucoma Valve implant.

MAIN OUTCOME MEASURES

Success was defined according to 2 criteria: (1) intraocular pressure (IOP) of 6 mmHg or more or 21 mmHg or less, and (2) IOP reduction of at least 30% relative to preoperative values. Eyes requiring further glaucoma surgery, including cyclophotocoagulation, or showing loss of light perception were classified as failures.

RESULTS

Average follow-up was 12.8 months (range, 6-30 months) for the silicone plate group and 14.5 months (range, 6-30 months) for the polypropylene plate group (P = 0.063). At the last follow-up examination, the mean IOP was 13.8+/-3.9 mmHg and 17.3+/-6.5 mmHg (P<0.0001) and the mean number of antiglaucoma medications was 1.9+/-1.3 and 2.1+/-1.4 (P = 0.48) in the silicone plate and polypropylene plate groups, respectively. The life-table success rates for the silicone plate and polypropylene plate groups were 94.2% and 83.2% at 12 months and 82.4% and 56.7% at 24 months by definition 1, respectively (P = 0.035). When an IOP reduction of at least 30% was used for success criterion (definition 2), probabilities of success were 89.5% and 71.7% at 12 months and 78.3% and 68.5% at 24 months in the silicone and the polypropylene plate groups, respectively (P = 0.012). Visual outcomes were comparable between the 2 groups. However, complications including Tenon's cyst were observed more frequently in the polypropylene plate than in the silicone plate group (P<0.05).

CONCLUSIONS

The silicone Ahmed Glaucoma Valve (model FP7) showed improved IOP reduction compared with the polypropylene (model S2) implant. Differences observed in mean IOP, success rate, and complications suggest that plate material may influence clinical outcome.