Corticosteroid injections for lateral epicondylitis: a systematic overview.

BACKGROUND: Lateral epicondylitis (tennis elbow) is a common complaint, for which corticosteroid injections are a frequently applied therapy. However, there were no up-to-date reviews available that systematically addressed the effectiveness and adverse effects, including questions concerning optimal timing of injections and composition of the injection fluid. AIM: The aim of the study was to assess the effectiveness of corticosteroid injections in the treatment of lateral epicondylitis (tennis elbow) by systematic review of the available randomized clinical trials. DATA SOURCES: The data sources used were randomized clinical trials identified by literature searches of the MedLine (1966-1994) and Embase (Exerpta Medica) (1980-1994) databases for the keywords epicondylitis, tendinitis and elbow, injection. References given in relevant publications were further examined. STUDY SELECTION: The criteria for selecting studies were as follows: randomized clinical trials (treatment allocation in random or alternate order); one of the treatments to include one or more corticosteroid injections (additional interventions were allowed); participants suffering from lateral epicondylitis; and publication in English, German or Dutch. Abstracts and unpublished studies were not included. DATA SYNTHESIS: Methodological quality was assessed by means of a standardized criteria list (range 1-100 points). The extracted outcomes were the general conclusion drawn by the authors of the reports on the trials, and the success rates at the various follow-up points as (re)calculated by us. The success rates were subsequently graphically displayed and statistically pooled. Separate stratified analyses were conducted according to a predetermined analysis plan. RESULTS: Twelve randomized clinical trials were identified. The median methodological score was 40 points, indicating an overall poor to moderate quality. The pooled analysis indicated short-term effectiveness (2-6 weeks): pooled odds ratio (OR) = 0.15 [95% confidence interval (CI) 0.10-0.23], chi 2 [degrees of freedom (df = 5) = 13.3], indicating statistical heterogeneity. At longer term follow-up, no difference could be detected. The studies of better methodological quality indicated more favourable results than those of lesser methodological quality. The most suitable corticosteroid to use as well as dosage, injection interval and injection volume could not be derived from the various trials. CONCLUSION: The existing evidence on corticosteroid injections for the treatment of tennis elbow is not conclusive. Many trials were conducted in a secondary care setting and clearly had serious methodological flaws, and there was statistical heterogeneity among the trials. Corticosteroid injections appear to be relatively safe and seem to be effective in the short term (2-6 weeks). Although the treatment seems to be suitable for application in general practice, further trials in this setting are needed. As yet, questions regarding the optimal timing, dosage, injection technique and injection volume remain unanswered.     

Irreducible lateral dislocation of the elbow

A rare case of an irreducible post-traumatic lateral dislocation of elbow is presented. The mechanism of injury was fall on a flexed elbow with trauma on its medial aspect resulting in pronation of the forearm. At open reduction, the brachialis muscle was in the form of a tight band which prevented reduction. The ulnar nerve was entrapped in the joint.     

Depression in coronary heart disease. What is the appropriate diagnostic threshold?

The purpose of this study was to determine the threshold at which depression becomes important for the daily functioning of patients with heart disease. Data from a 1-year prospective cohort study of health maintenance organization patients undergoing coronary angiography for coronary heart disease were analyzed for differences in a standardized composite measure of functioning. Patients with major depression (N = 19) and patients with minor depression (N = 28) were significantly more functionally impaired at baseline and at 1-year follow-up than those with no depression (N = 110). The major and minor depression groups did not differ significantly. The significance of the depression group differences was reduced, but not eliminated, when controlling for differences in reported heart symptoms.     

Atheroscleritis is a more rational term for the pathological entity currently known as atherosclerosis

The term "atheroma", a Latin word was first used in 1755 by Albrecht von Halles to designate the plaque deposited on the innermost layer of systemic artery walls. In 1940, however, Félix Marchand suggested the word "atherosclerosis" should be better instead of "atheroma", which is derived from two Greek roots: athéré means gruel or porridge and sclerosis signifies hardening. It is obviously an improvement over the older designation arteriosclerosis. Atherosclerosis is still used up to data because it describes the two components of plaque: the lipid-filled core of atheroma encased in a shell of sclerosis or fibrosis, which presents the feature of atherosclerotic structure. Although atherosclerosis has been considered to be multi-factorial disease in which genetic, environmental, metabolic factors have been implicated, the gaps remain in our knowledge of the etiopathogenesis of atherosclerosis. More recently, there is mounting evidence that inflammation plays an important role in the initiation, development as well as evolution of atherosclerosis. The data from animals as well as humans indicated that an inflammatory process was involved in all stages of atherosclerosis appeared in different clinical settings, including atheromatous development, plaque rupture, restenotic process. The anti-inflammatory approach has been showed as one of the most promising strategies for atherosclerosis, such as statin intervention. Based on evidence and in light of the new understanding that inflammation is an intrinsic part of the process, we would like to propose a further change of nomenclature, call the disease atheroscleritis.     

Anatomy of the ulnar part of the lateral collateral ligament of the elbow

The lateral ulnar collateral ligament (LUCL) of the elbow has been illustrated variably in anatomy texts. The purpose of this investigations was to determine the percentage of specimens in which this structure is present, and to describe its anatomy and function. The LUCL was identified as part of the lateral capsulo-ligamentous complex in 17 of 17 fresh frozen cadaver elbows (P <.0001). The LUCL originates on the lateral epicondyle, blends with the fibers of the annular ligament as it arches superficial to it, then curves to insert on the tubercle of the supinator crest of the ulna. It is distinct at its insertion, but not at its origin where its fibers blend with those of the common extensor origin. The insertion is exposed in the interval created between (the deep surface of) the fascia of the supinator and its muscle fibers. The insertion can be palpated by applying a varus stress to the elbow. Cutting the ulnar fibers permitted posterolateral rotatory subluxation of the ulno-humeral joint and varus subluxation of the elbow. © 1992 Wiley-Liss, Inc.     

The anconeus, an active lateral ligament of the elbow: new anatomical arguments

Purpose  

As there are a few detailed anatomical studies of the active function of anconeus muscle in stabilizing the elbow, we aimed to look for anatomical features confirming its role as an active stabilizer of the humero-ulnar joint.     

AMACR is not applicable as a diagnostic tool in hepatocellular carcinoma

Willemoe GL, Vainer B. AMACR is not applicable as a diagnostic tool in hepatocellular carcinoma. APMIS 2010; 118: 85–90. α‐methylacyl coenzyme A racemase (AMACR or P504S) is a mitochondrial and peroxisomal protein present in a variety of human cells. Demonstration of increased expression is used diagnostically in prostatic adenocarcinoma. AMACR is also produced by normal hepatocytes and it has been postulated that the demonstration of AMACR expression or its pattern of distribution is useful in the diagnosis of hepatocellular carcinoma (HCC) (Jiang et al., Hum Pathol 2003;34, Guzman et al., Appl Immunohistochem Mol Morphol 2006;14, Li et al., J Exp Clin Cancer Res 2008;27). The aim of the present study was to evaluate whether immunohistochemical staining for AMACR can be used in a routine histopathologic setting. Immunohistochemical staining for AMACR was performed on paraffin‐embedded tissue from livers resected for HCC during 1980–2006 at Rigshospitalet, Copenhagen, Denmark (n = 44). Tumor sections as well as surrounding non‐neoplastic tissues were studied. In both tumor and non‐tumor tissues, intracellular localization and staining pattern were assessed and the staining intensity of AMACR was graded. The fraction of stained tumor cells was not significantly different from that of stained non‐tumor cells in the same patients (p = 0.97). A significantly lower staining intensity was observed in clear cell areas (p = 0.005), but the AMACR expression did not correlate with the HCC type and could not distinguish neoplastic from non‐neoplastic liver cells. AMACR is not applicable as a tool in the histopathologic diagnosis of HCC.     

The lateral collateral ligament complex and related muscles act as a dynamic stabilizer as well as a static supporting structure at the elbow joint: an anatomical and experimental study

Among 71 osteoligamentous elbow joint specimens from Japanese subjects, 66% of the lateral ulnar collateral ligaments (LUCLs) were in an incomplete form, such as a fibrous intermuscular septum lying between the anconeus, supinator and extensors, and terminated on the annular ligament. The 'typical' complete ligament, extending from the lateral epicondyle and over the radial collateral ligament (RCL) to the crista spinatoris, appeared in only 20% of the elbows examined. This observation suggests that, in Japanese subjects, the LUCL is not usually a simple ligamentous static stabilizer, but acts as a dynamic stabilizer, together with its related muscles. In addition, when the elbow was flexed by more than 90 degrees, the distance between the lateral epicondyle and the radial head became almost 1.5 mm larger than the distance from the epicondyle to the annular ligament. We therefore consider that, in the overflexed position, the radial head moves slightly distal while the length of the RCL remains almost constant. This morphometrical observation suggests that the annular ligament needs to be supported by the LUCL-muscle complex from the distal side, as well as by the RCL from the proximal side. This extended definition of the lateral collateral ligament complex and its associated muscular function is discussed.     

An appropriate in vitro culture condition for the induction of human TCR gamma delta + cells by heat-killed bacteria.

TCR gamma delta + cells proliferated when MNC were stimulated with various heat-killed bacteria. We investigated here the culture conditions for their maximum proliferation. MNC were cultured for 6 days with Streptococcus pyogenes, and for 3 days with T cell mitogens, PHA and anti-CD3 mAb, in medium supplemented with various concentrations (0.05-50%) of human sera. TCR gamma delta + and TCR gamma delta- CD2+3- double negative cells induced by Str. pyogenes required high concentrations of sera (greater than 6%) for their proliferation. Moreover, increased sera (up to 50%) greatly augmented their proliferation. On the other hand, TCR alpha beta + cell proliferation induced by T cell mitogens was supported by a small concentration (even 0.1%) of the sera, and the addition of high concentrations of sera (greater than 6%) somewhat suppressed responses. Similar serum requirement patterns were evident for the induction of cytotoxic cells. These results clearly demonstrated the existence of an appropriate culture condition for the proliferation of TCR gamma delta + cells induced in vitro.     

Preliminary observations on the presence of sustained tendon strain and eccentric contractions of the wrist extensors during a common manual task: implications for lateral epicondylitis

Lateral epicondylitis (LE) is hypothesized to occur as a result of repetitive, strenuous and abnormal postural activities of the elbow and wrist. There is still a lack of understanding of how wrist and forearm positions contribute to this condition during common manual tasks. In this study the wrist kinematics and the wrist extensors' musculotendon patterns were investigated during a manual task believed to elicit LE symptoms in susceptible subjects. A 42-year-old right-handed male, with no history of LE, performed a repetitive movement involving pushing and turning a spring-loaded mechanism. Motion capture data were acquired for the upper limb and an inverse kinematic and dynamic analysis was subsequently carried out. Results illustrated the presence of eccentric contractions sustained by the extensor carpi radialis longus (ECRL), together with an almost constant level of tendon strain of both extensor carpi radialis brevis (ECRB) and extensor digitorum communis lateral (EDCL) branch. It is believed that these factors may partly contribute to the onset of LE as they are both responsible for the creation of microtears at the tendons' origins. The methodology of this study can be used to explore muscle actions during movements that might cause or exacerbate LE.     

Dopamine in the lateral caudate-putamen of the rat is essential for somatosensory orientation

The present study examined the possible localization of somatosensory orientation in the caudate-putamen (CP) of the rat. In the first experiment, 6-hydroxydopamine (6-OHDA) was injected into either the anterodorsal (AD), anteroventral (AV), posterodorsal (PD), or posteroventral (PV) CP. Only rats with PV-CP 6-OHDA injections showed impaired orientation scores. However, these PV injections often caused widespread CP dopamine (DA) depletions, and no specific CP region appeared to be particularly associated with somatosensory orientation. In the second experiment, multiple injections of 6-OHDA were directed toward the medial or lateral halves of the CP to assess their relative contributions directly. DA depletions confined to the lateral (but not medial) CP resulted in orientation deficits; these deficits were greater than would be predicted from the volume of CP/DA loss. Furthermore, the magnitude of the DA fluorescence loss in the lateral CP was more highly correlated with the orientation impairment than was the medial CP fluorescence loss. Thus the lateral CP contributes to sensorimotor functions to a greater extent than does the medial CP, but the volume of CP/DA depletion also appears important.     

Validation of 31 of the most commonly used immunohistochemical antibodies in cytology prepared using the cellient® automated cell block system

The Cellient^® cell block system has become available as an alternative, partially automated method to create cell blocks in cytology. We sought to show a validation method for immunohistochemical (IHC) staining on the Cellient cell block system (CCB) in comparison with the formalin fixed paraffin embedded traditional cell block (TCB). Immunohistochemical staining was performed using 31 antibodies on 38 patient samples for a total of 326 slides. Split samples were processed using both methods by following the Cellient^® manufacturer's recommendations for the Cellient cell block (CCB) and the Histogel method for preparing the traditional cell block (TCB). Interpretation was performed by three pathologists and two cytotechnologists. Immunohistochemical stains were scored as: 0/1+ (negative) and 2/3+ (positive). Inter‐rater agreement for each antibody was evaluated for CCB and TCB, as well as the intra‐rater agreement between TCB and CCB between observers. Interobserver staining concordance for the TCB was obtained with statistical significance (P < 0.05) in 24 of 31 antibodies. Interobserver staining concordance for the CCB was obtained with statistical significance in 27 of 31 antibodies. Intra‐observer staining concordance between TCB and CCB was obtained with statistical significance in 24 of 31 antibodies tested. In conclusions, immunohistochemical stains on cytologic specimens processed by the Cellient system are reliable and concordant with stains performed on the same split samples processed via a formalin fixed‐paraffin embedded (FFPE) block. The Cellient system is a welcome adjunct to cytology work‐flow by producing cell block material of sufficient quality to allow the use of routine IHC. Diagn. Cytopathol. 2014;42:1024–1033. © 2014 Wiley Periodicals, Inc.