Subungual squamous cell carcinoma presenting with minimal nail changes: A factor in delayed diagnosis?

Squamous cell carcinoma of the nail bed is a relatively uncommon tumour that may be diagnosed only after considerable delay. The first case presented is a 79-year-old man with a history of discomfort and discoloration affecting the right thumbnail of 3 years duration. The second case is a 70-year-old man who presented with a recurrent, offensive discharge from beneath the left thumbnail of 40 years duration. Clinical examination of the affected digits revealed minor nail abnormalities. The presence of tumour was fully apparent only after removal of the nail plate and inspection and biopsy of the nail bed. The cases demonstrate that subungual squamous cell carcinoma may present with prolonged symptoms and a deceptively benign appearance. The importance of consideration of the possibility of malignancy, removal of the nail plate for inspection of the nail bed and appropriate biopsy is emphasized.     

Identification of aortic thrombus by magnetic resonance imaging

The unique properties of magnetic resonance imaging result in the potential to differentiate various components of the diseased arterial wall. In this article four cases are presented in which magnetic resonance imaging showed mural aortic thrombus and its anatomic relationship to the visceral and renal arteries. Once thrombus is identified and localized specific operative strategies can be undertaken to prevent recurrent embolic events and/or avoid perioperative thromboembolic complications.     

Quantitation in gated perfusion SPECT imaging: the Cedars-Sinai approach.

Cedars-Sinai's approach to the automation of gated perfusion single photon emission computed tomography (SPECT) imaging is based on the identification of key procedural steps (processing, quantitation, reporting), each of which is then implemented, in completely automated fashion, by use of mathematic algorithms and logical rules combined into expert systems. Our current suite of software applications has been designed to be platform- and operating system-independent, and every algorithm is based on the same 3-dimensional sampling scheme for the myocardium. The widespread acceptance of quantitative software by the nuclear cardiology community (QGS alone is used at over 20,000 locations) has provided the opportunity for extensive validation of quantitative measurements of myocardial perfusion and function, in our opinion, helping to make nuclear cardiology the most accurate and reproducible modality available for the assessment of the human heart.     

Nocturia: a risk factor for falls in the elderly.

OBJECTIVE: To determine if nocturia is a risk factor for reported falls and bone fractures in older persons. DESIGN: Cross-sectional study comparing falls in men and women with and without nocturia. SETTING: Longitudinal health screening program of ambulatory elderly participants. PARTICIPANTS: Participants included 988 (65.5%) women and 520 (34.5%) men who had completed their tenth annual visit to the program. MAIN OUTCOME MEASURES: Reported falls in the past year and reported bone fractures in the past 5 years. RESULTS: Participants who reported nocturia at least twice during the night were at significantly greater risk to report falls (Odds Ratio = 1.84; 95% CI = 1.05-3.22), and the risk increased in subjects reporting more than three nocturia events (Odds Ratio = 2.15; 95% CI = 1.04-4.44). The significant increase in falls reported by nocturia participants did not result in an increase in reported bone fractures in the past 5 years (P < 0.4360). CONCLUSIONS: Nocturia is an important risk factor for falls in ambulatory elderly persons. Preventive measures should be taken to decrease nocturia events and to decrease the risk of falling during these nocturia events.     

Increased Ligament Thickness in Previously Sprained Ankles as Measured by Musculoskeletal Ultrasound

Context:Lateral ankle sprains are among the most common injuries in sport, with the anterior talofibular ligament (ATFL) most susceptible to damage. Although we understand that after a sprain, scar tissue forms within the ligament, little is known about the morphologic changes in a ligament after injury.Objective:To examine whether morphologic differences exist in the thickness of the ATFL in healthy, coper, and unstable-ankle groups.Design:Cross-sectional study.Setting:Laboratory.Results:A group-by-limb interaction was evident (P = .038). The ATFLs of the injured limb for the coper group (2.20 ± 0.47 mm) and the injured limb for the unstable group (2.28 ± 0.53 mm) were thicker than the ATFL of the “injured” limb of the healthy group (1.95 ± 0.29 mm) at P = .015 and P = .015, respectively. No differences were seen in the uninjured limbs among groups.Conclusions:Because ATFL thicknesses of the healthy group''s uninjured ankles were similar, we contend that lasting morphologic changes occurred in those with a previous injury to the ankle. Similar differences were seen between the injured limbs of the coper and unstable groups, so there must be another explanation for the sensations of instability and the reinjuries in the unstable group.Key Words: ankle instability, anterior talofibular ligament, morphology

Key Points

• The anterior talofibular ligament can be viewed using musculoskeletal ultrasound imaging.
• The anterior talofibular ligaments of previously sprained ankles were thicker than those of uninjured ankles.
• Although coper ankles were more functionally similar to healthy ankles than to unstable ankles, they were structurally different. Only further research can determine the relationship between ligament damage and functional stability of the ankle.

Musculoskeletal ultrasound (MSUS) imaging is a new technique being used in the sports medicine setting. Compared with other imaging techniques, such as radiographic or magnetic resonance imaging (MRI), MSUS offers a safer, more time-efficient, and more cost-effective alternative. A real-time image can be captured via MSUS by using a transducer to send high-frequency sound waves into the body and recording the echo of the sound waves reflecting back, providing an image of the internal structure.^1,2 This method has been found to be effective in imaging upper extremity, lower extremity, and joint injuries.^1,3,4Oae et al³ reported greater than 90% accuracy for both MSUS and MRI in identifying injuries to the ankle. Lateral ankle sprains (LASs) are among the most common injuries in sport.⁵ An estimated 850 000 new ankle sprains occur each year in the United States,⁷ which does not include a 70% reinjury rate at the ankle.⁶ Ankle stability plays an important role in injury prevention. Passive stability of the ankle is predominantly the responsibility of ligaments supporting the bony structure of the talocrural joint because there are no musculotendinous insertions on the talus. Ligaments supporting the lateral complex of the ankle include the anterior talofibular ligament (ATFL), calcaneofibular ligament, and posterior talofibular ligament. The ATFL is a flat ligament that attaches from the anterior border of the lateral malleolus to the talus, just anterior to the lateral malleolus articular surface.⁸ The ATFL limits plantar flexion and inversion, motions that coincide with the most common mechanism of injury.⁸ As a result, the ATFL becomes vulnerable in a plantar-flexed and inverted position and is most susceptible to damage during an LAS.^5,6,9 An isolated tear of the ATFL occurs in about 80% of LASs.^10,11After an LAS, the fibrous structure of an ankle ligament is often disrupted by severe damage. Using MRI, Takao et al¹² reported visible scarring of the ATFL after injury. Using MSUS, McCarthy et al¹³ described a thickened ATFL, osseous spurs, and synovitic lesions after injury. Thickness values for the ATFL have been derived primarily from cadaveric studies^14,15; however, MRI-based in vivo studies demonstrated thickness of the ATFL to be in the range of 2 to 3 mm.^16,17 An abnormal ligament could affect the stabilizing properties of the ligament. In animal studies, although scar tissue formed within a ligament after injury, the newly scarred ligament allowed normal movement; however, the load capacity of that ligament was decreased by 60%.^18–20 Therefore, the strength of a ligament can be sufficient for active movement and injury rehabilitation soon after injury, but the decrease in load capacity of the scarred ligament may affect its stabilizing properties.Despite medical treatment and postinjury rehabilitation, more than 50% of individuals who sustain a moderate or severe ankle sprain experience some degree of residual disability and impairment due to symptoms such as pain, instability, loss of range of motion, and edema.^6,21 Those who do not fully recover from their ankle sprain often develop chronic ankle instability (CAI), which limits function not only in sport but also in activities of daily living. Patients with CAI typically complain of the ankle “giving way” or of repeated ankle sprains under seemingly low-risk conditions.²²Typically, CAI researchers have categorized participants into 2 groups: those with ankle instability (unstable) and those without ankle instability (healthy). The unstable group consists of individuals who experience recurrent sprains, sensations of instability, or both. Unfortunately, this method of grouping ignores those who sustained an ankle sprain but did not experience recurrent sprains or sensations of instability. In general, an ankle “coper” refers to an individual who has experienced an initial ankle sprain but not a subsequent sprain.²³ Only recently have copers been addressed in ankle-instability research.^24–29 Because copers are still a new cohort in this research, the classification of ankle copers differs somewhat among researchers.^25,28Although we understand that the fibrous nature of a ligament is disrupted after an LAS, little is known about the actual morphologic changes in a ligament. Therefore, the purpose of our study, using a mixed-model analysis, was to determine whether MSUS can be used to see differences in ligament thickness between the uninjured limb and the injured limb among the healthy, coper, and unstable groups. We hypothesized that the ligaments of the previously injured ankles would be thicker than the uninjured ankles.     

Immediate Effects of Thoracic Spine Thrust Manipulation on Neurodynamic Mobility

Objective

The purpose of this study was to investigate the immediate effects of thoracic spine thrust manipulation (TSM) on the upper limb provocation test (ULPT) and seated slump test (SST) in individuals with identified neurodynamic mobility impairments. A secondary aim was to determine if correlation existed between the perception of effect and improvements in neurodynamic mobility following a thrust manipulation compared with mobilization.

Functional tricuspid regurgitation secondary to aortic annular abscess: An unusual presentation of infective endocarditis

An unusual case of aortic annular abscess is presented, in which the patient presented with features of gross tricuspid regurgitation. There was no direct involvement of the tricuspid valve. Tricuspid regurgitation disappeared following surgical repair of the annular abscess. The present case also illustrates the utility of trans-oesophageal echocardiography in establishing the diagnosis and planning surgical intervention.