Tendon involvement in pedal infection: MR analysis of frequency,distribution, and spread of infection

OBJECTIVE: The objective of our study was to evaluate the frequency, distribution, and extent of tendon involvement in patients with pedal infections. MATERIALS AND METHODS: Contrast-enhanced MR imaging examinations of 159 infected feet performed at 1.5 T were reviewed by two musculoskeletal radiologists for the presence and location of tendon infection (peritendinous enhancement contiguous to an adjacent ulcer or cellulitis) and for the spread of infection along tendons, which was defined as peritendinous contrast enhancement extending more than 2 cm beyond surrounding cellulitis. The study group was composed of 156 consecutive patients, 82.7% of whom had diabetes; all patients underwent subsequent surgical treatment. Results of MR evaluations were compared with the patients' charts and surgical reports. RESULTS: Of the 129 MR examinations showing an infection in the forefoot, MR evidence of tendon involvement in the infection was observed in 56 MR examinations (43%). The sum of involved tendons per ray was as follows: first ray (flexor tendon, n = 19; extensor tendon, n = 13), second (flexor tendon, n = 12; extensor tendon, n = 7), third (flexor tendon, n = 5; extensor tendon, n = 4), fourth (flexor tendon, n = 5; extensor tendon, n = 1), and fifth (flexor tendon, n = 11; extensor tendon, n = 6). Of the 32 MR examinations showing infection in the hindfoot, 14 examinations (44%) showed evidence of tendon involvement, most frequently of the distal Achilles tendon (n = 7). MR evidence of the spread of infection along a tendon was seen in 12 examinations, always with proximal spread of infection; and infection led to the development of an abscess in the central plantar compartment in three patients. Intraoperative evidence of a tendon infection was documented in 11 patients. The surgical procedure was altered because of the tendon infection in six patients. CONCLUSION: MR evidence of tendon infection is present in approximately half the patients who require surgery for pedal infection. Evidence of spread of the infection along tendons is seen infrequently on MR imaging. Detection of a tendon infection could influence surgical therapy.     

Pimecrolimus: absorption, distribution, metabolism, and excretion in healthy volunteers after a single oral dose and supplementary investigations in vitro.

The absorption and disposition of pimecrolimus, a calcineurin inhibitor developed for the treatment of inflammatory skin diseases, was investigated in four healthy volunteers after a single oral dose of 15 mg of [(3)H]pimecrolimus. Supplementary information was obtained from in vitro experiments. Pimecrolimus was rapidly absorbed. After t(max) (1-3 h), its blood concentrations fell quickly to 3% of C(max) at 24 h, followed by a slow terminal elimination phase (average t(1/2) 62 h). Radioactivity in blood decreased more slowly (8% of C(max) at 24 h). The tissue and blood cell distribution of pimecrolimus was high. The metabolism of pimecrolimus in vivo, which could be well reproduced in vitro (human liver microsomes), was highly complex and involved multiple oxidative O-demethylations and hydroxylations. In blood, pimecrolimus was the major radiolabeled component up to 24 h (49% of radioactivity area under the concentration-time curve(0-24) h), accompanied by a large number of minor metabolites. The average fecal excretion of radioactivity between 0 and 240 h amounted to 78% of dose and represented predominantly a complex mixture of metabolites. In urine, 0 to 240 h, only about 2.5% of the dose and no parent drug was excreted. Hence, pimecrolimus was eliminated almost exclusively by oxidative metabolism. The biotransformation of pimecrolimus was largely catalyzed by CYP3A4/5. Metabolite pools generated in vitro showed low activity in a calcineurin-dependent T-cell activation assay. Hence, metabolites do not seem to contribute significantly to the pharmacological activity of pimecrolimus.     

Complications of total hip arthroplasty: MR imaging-initial experience

PURPOSE: To investigate the use of standard magnetic resonance (MR) imaging sequences with simple parameter modifications for the detection and characterization of total hip arthroplasty (THA) complications. MATERIALS AND METHODS: An initial phantom study was performed with cobalt-chrome and titanium prostheses to establish the imaging parameters for a subsequent clinical study. In the clinical study, coronal and transverse MR imaging of 14 THA prostheses was performed before and after intravenous contrast material administration in 12 patients who were being considered for revision arthroplasty. The images were reviewed for evidence of juxtaarticular or periprosthetic abnormalities, patterns of contrast enhancement, and quality of periprosthetic tissue depiction. RESULTS: Phantom study results showed improved periprosthetic tissue depiction with use of thin sections, increased frequency-encoding gradient strength, and fast spin-echo sequences. The clinical study results demonstrated periprosthetic abnormalities in 11 cases: mechanical loosening in two cases (including one case with an associated periprosthetic fracture); granulomatosis, eight; and infection, one. In 100% of cases, tissue depiction around the femoral component was judged to be of "diagnostic quality." Tissue depiction around the acetabular component was of diagnostic quality in five (36%) cases. In all seven surgically confirmed cases, a correct diagnosis was made preoperatively with MR imaging. CONCLUSION: By using simple modifications to standard MR imaging sequences, diagnostic-quality MR imaging of THA complications can be performed, particularly around the femoral prosthetic stem.     

Antiglaucoma medication and clinical depression

OBJECTIVE: The aim of this paper is to alert the medical community to the potential risk of clinical depression following the use of antiglaucoma medication. METHOD: The available literature concerning systemic side-effects of topical antiglaucoma medication and the association of these agents with clinical depression were reviewed. In addition, two cases are reported of the occurrence of clinical depression following use of topical betaxolol which only resolved completely after switching glaucoma medication. RESULTS/CONCLUSIONS: The case reports presented here add to the increasing body of literature linking topical ophthalmic beta-adrenoceptor antagonists with depression. While these cases are uncommon, this phenomenon continues to be poorly recognized by the medical profession, psychiatrists, ophthalmologists and general practitioners alike.     

Partial interosseous ligament tears of the wrist: difficulty in utilizing either primary or secondary MRI signs

PURPOSE: Prior reports on scapholunate ligament (SLL) and lunotriquetral ligament (LTL) tears have evaluated complete tears. As these complete tears have markedly different biomechanical manifestations and surgical considerations than do partial tears, we evaluated the accuracy of MR and the usefulness of secondary MR signs to diagnose partial interosseous ligament tears. METHOD: Fifty wrists in 50 patients underwent arthroscopy following 1.5 T MR. Images were evaluated by two independent blinded observers for normal or partially torn SLL and LTL and for three secondary signs potentially seen as mechanical sequelae of tears: osseous offset, arc disruption, or focal osteoarthritis. RESULTS: Arthroscopically, there were 16 SLL and 14 LTL partial tears. Accuracy of primary MR signs of partial tears was lower than that described in the literature for complete tears [sensitivity/specificity (kappa) = 0.56/0.56 (0.12)-SLL, 0.31/0.76 (0.13)-LTL]. Secondary signs showed low sensitivity but high specificity, particularly for LTL tears: arc disruption [0.17/0.83 (0.43)-SLL, 0.0/1.00 (1.0)- LTL], focal osteoarthritis [0.32/0.78 (0.18)-SLL, 0.11/0.91 (0.12)-LTL], and focal osseous offset [0.39/0.75 (0.10)-SLL, 0.26/0.93 (0.39)-LTL]. Additionally, there was poor interobserver consistency for both primary and secondary signs. CONCLUSION: The sensitivity of morphologic evaluation for diagnosing partial intercarpal ligament tears, particularly those of the LTL, is limited. Secondary signs increase specificity but have low sensitivity, and with the exception of arc disruption, all signs had poor interobserver agreement.     

Partial tears of the distal biceps tendon: MR appearance and associated clinical findings

PURPOSE: To describe the magnetic resonance (MR) appearance and associated clinical findings of partial distal biceps tendon tears. DESIGN: Twenty elbow MR images at 1.5 T, performed over a 7 year period, were reviewed for an appearance of partial tears in the distal biceps. These images were assessed by two musculoskeletal radiologists for the extent of: (a) abnormal signal intensity within the tendon, and the presence of (b) bicipitoradial bursitis, and (c) bony microavulsive injury of the radial tuberosity. Medical records for nine of the 20 cases were reviewed for the clinical findings of ecchymosis, trauma, sensation of a "pop", loss of function, and acuity of onset. RESULTS: Twenty partial distal biceps tendon tears were seen. All displayed an abnormally increased signal in the distal biceps tendon. Three of 20 (15%) showed a 25% to 50% tear, ten of 20 (50%) showed a 50% tear, and seven of 20 (35%) showed a 75% to 90% tear. Bicipitoradial bursitis was seen in 11 of 20 (55%) cases. Bony microavulsive injury of the radial tuberosity was observed in 10 of 20 (50%). Of the nine cases reviewed for associated clinical findings, surprisingly, only three (33%) experienced an acute traumatic episode with an abrupt onset of pain. An insidious onset was reported in four of nine (44%). Sensation of a "pop" was recorded in only two of nine (22%) cases. Ecchymosis and loss of function were not seen in any of the cases. Finally, surgical conformation was obtained for three cases. CONCLUSION: Partial distal biceps tendon tears have a characteristic MR appearance, demonstrate little functional deficit, and may be attritional in their etiology due to the observation of a low number of patients reporting trauma or an acute onset.     

Oral contraceptives in acute viral hepatitis.

Thirty-four women took oral contraceptives during a major part, or throughout the course, of acute viral hepatitis. The acute illness and sequelae during the following year were compared to those of 34 matched control women with acute viral hepatitis who never took oral contraceptives. Statistical and clinical analysis showed no difference in severity of acute illness or frequency of sequelae. These findings suggest that oral contraceptives are not detrimental when taken during a course of acute viral hepatitis.     

Multiple mucosal neuroma (MMN) or multiple endocrine neoplasia (MEN) type 3 syndrome

Case report of a young man showing neuromas of the palpebral and bulbar conjunctiva and markedly thickened nerve fibers in both cornea. Multiple neuromas were seen on the lips and in the oral cavity. A medullary carcinoma of the thyroid was found. These symptoms pointed to the diagnosis of a MMN or MEN type 3 syndrome. There were no signs of a phaeochromocytoma, however, which also belongs to this syndrome.The ophthalmologist, who may be the first to see such a patient as a child, should be aware of the malignancies which develop around puberty and of the strong and dominant heredity of this disease.