Antecubital Fossa Research Articles

A New Protocol for Controlling and Targeting Reactive Hyperemia Shear Stress to Assess Endothelial Function

Conduit artery endothelial function is most commonly assessed via measurement of flow mediated dilation (FMD) evoked by a transient post-limb occlusion increase in shear stress [reactive hyperemia (RH)]. A limitation of RH-FMD is the uncontrolled nature of the RH shear stress stimulus which produces RH-FMD response variability that is independent of conduit artery endothelial function. The purpose of this study was to develop a protocol to create a uniform, targeted, and transient (40 second) shear stress stimulus and compare it to the standard RH-FMD approach. We hypothesize that incorporating arterial compression in the controlled targeted RH (CTRH) protocol will allow us to achieve a uniform target shear rate (estimate of shear stress) within and between participants. Young, healthy men and women (females n = 4, age = 22 ± 1 years; males n = 2, age = 25 ± 3 years) underwent one trial of RH-FMD and two trials of CTRH-FMD with duplex ultrasound assessment. The CTRH protocol incorporated three-minutes of ischemic handgrip exercise at 30% of participants’ maximum voluntary contraction during a five-minute occlusion to create a large forearm vasodilation and hyperemic reserve. Upon cuff release, the ensuing hyperemia was controlled with manual brachial artery compression at the antecubital fossa. A live velocity readout permitted compression adjustments to achieve the velocity required to maintain a target shear rate of 120 s-1. The cuff was re-inflated after 40s of cuff release. The RH-FMD trial followed the standard five-minute forearm occlusion protocol. The 40s average shear rate was 116.0 ± 8.8s-1 in the CTRH test and 102.1 ± 15.4 s-1 in the RH test. The CTRH test shear rate was significantly closer to the 120s-1 target; calculated as the absolute distance from target in 3s time bins over the 40s period: CTRH = 19.0 ± 3.9s-1; RH = 36.5 ± 6.7 s-1 p = 0.002. The between participant coefficient of variation (CV) for the RH 40s average shear rate was lower in the CTRH test (CTRH CV = 8.1%; RH CV = 15.1%). The within subject trial to trial CV for the CTRH 40s average shear rate was 3.0 ± 4.6%. FMD responses were similar between tests (CTRH-FMD% = 8.3 ± 1.6%; RH-FMD% = 7.6 ± 4.8%, p=0.717). These preliminary findings demonstrate the capacity for RH stimulus control. CTRH-FMD is minimally impacted by stimulus variability and may provide a clearer reflection of brachial artery endothelial function.

Influence of Acute, Sympathetic Nervous Activity‐Independent Changes in Blood Pressure on Forearm Arterial Stiffness

Several studies have demonstrated the relationship between acute changes in blood pressure and arterial stiffness utilizing perturbations that alter sympathetic nervous activity (SNA), which influences vascular tone. The purpose of the current study was to elicit changes in blood pressure without altering SNA to thus observe the isolated influence of local changes in blood pressure on arterial stiffness. In this scenario, myogenic responses and changes in elastic reserve may contribute to changes in stiffness. Eleven young and healthy adults (age 20± 2 years) participated in this study. Left forearm blood pressure was acutely manipulated by elevating the forearm above heart level (AHL; reduced blood pressure) or lowering the forearm below heart level (BHL; increased blood pressure). Using applanation tonometry at the wrist and antecubital fossa, arterial stiffness was assessed via pulse wave velocity (PWV) after 5 min of rest in three positions: heart level (HL), AHL and BHL. To determine myogenic response involvement, forearm vascular conductance (VC; forearm blood flow/forearm mean blood pressure) was also assessed with duplex ultrasound. Results are mean ± SD. Forearm mean blood pressure was significantly different between arm positions (p<0.001): BHL 99 ± 6 mmHg; HL 80 ± 5 mmHg; AHL 60 ± 4 mmHg. PWV was higher in the BHL (13.4 ± 7.6 m/s) and HL (10.8 ± 4.5 m/s) positions compared to the AHL position (7.4 ± 3.6 m/s) (p<0.001 and 0.01 respectively). Including all positions, blood pressure and PWV were positively correlated (r2=0.4, p=0.002). Forearm VC was significantly lower in the BHL position compared to the HL and AHL positions (p=0.002 and 0.001 respectively). AHL and HL VC were not significantly different (p=1.0). There was no correlation between PWV and VC (r2=0.04, p=0.78). In conclusion, these results indicate that increasing blood pressure results in increases in local arterial stiffness, independent of changes in SNA. The absence of correlation between VC and PWV suggests that changes in elastic reserve played a larger role than myogenic tone in determining changes in stiffness with acutely altered forearm blood pressure.

228 Shifts in the skin bacteria and fungi in healthy children transitioning through puberty

While skin microbial shifts among different age groups are known from several culture- and sequencing-based studies, the influence of sexual maturation on the skin microbiome in individuals followed longitudinally has not been studied as systematically. In this prospective and longitudinal study, twelve healthy children were evaluated up to 6 years to investigate puberty-associated skin microbial shifts. Using 16S rRNA (V1-V3) and ITS1 amplicon sequencing with DADA2 analysis, bacterial and fungal communities of five different skin sites were analyzed and compared with serum hormone levels. The composition and the diversity of skin microbial communities transitioned toward a more ‘adultlike’ microbiome. The microbial shifts were associated with Tanner stages and showed sex-specific differences. Female children demonstrated increasingly predominant lipophilic Cutibacterium and Malassezia in early Tanner (2-3) versus late Tanner (4-5) stages (mean relative abundances of Cutibacterium, P < 0.001 [15.9% to 32.2%] for antecubital fossa; Malassezia, P = 0.03 [28.6% to 53.3%] for antecubital fossa and P < 0.001 [24.5% to 58.5%] for volar forearm). Furthermore, the microbial communities in female children converged to be more similar to one another with increasing Tanner stages, but not in male children. The higher relative abundances of lipophilic species, C. acnes and M. restricta, were strongly associated with levels of serum androgens which are known to influence sebaceous gland activity (testosterone, P < 0.001 for C. acnes and M. restricta; androstenedione, P = 0.11 for C. acnes and P = 0.16 for M. restricta), suggesting hormonal effects on the skin microbial communities. In summary, these results signify complex interrelationships of sexual maturation, skin microbiome, and skin physiology.

Vitamin Cobalamin deficiency in macrocytic anemia reporting at a Tertiary Care Hospital.

Objective: Determine the frequency of vitamin cobalamin deficiency in macrocytic anemia cases reporting at tertiary care hospital. Study Design: Cross Sectional study. Setting: Faculty of Medicine and Allied Medical Sciences, Isra University, Hyderabad, Sindh Pakistan. Period: January 2017 to October 2018. Material &amp; Methods: 450 cases of both genders, diagnosed as macrocytic- megaloblastic anemia were studied for the vitamin Cobalamin levels. Cases were collected through non- probability convenient sampling by inclusion and exclusion criteria. Consenting volunteers were asked for blood sampling. 5 mL blood was taken from ante – cubital fossa. Samples were centrifuged and sera were collected for the estimation of vitamin cobalamin by ELISA – assay kit. Continuous and categorical variables were entered in SPSS (version 21.0) and analyzed by Student t-test and Chi-square test respectively at 95% CI (P ≤ 0.05). Results: Male and female comprised 225 (43.3%) and 294 (56.6%) of 519 subjects. Male to female ratio was noted 1.30:1. MCV, MCH and MCHC show statistically significant difference between male and female (P&lt;0.05). MCV in male was 96.8±9.92 fl vs. 105.5±12.04 fl in female (P=0.0001). Normal cobalamin was noted in 15.2% (n= 79) and any type of cobalamin deficiency was noted in 84.7% (n= 440) (P=0.0001). Conclusion: The present study reports frequency of 84.7% Cobalamin deficiency in macrocytic anemia reporting at Indus Medical College Hospital. Further studies are recommended by the treating physicians.

Reconstruction of the elbow using pedicle joint freezing after wide excision for soft tissue sarcoma: A case report.

A 35-year-old man presented with a four-year history of a growing mass on the anterior aspect of his left elbow. Magnetic resonance imaging revealed a soft tissue tumor in the brachialis muscle extending to the cubital fossa. Following an open biopsy, the tumor was diagnosed as a monophasic fibrous synovial sarcoma. After neoadjuvant chemotherapy, the patient underwent wide excision and reconstruction of the elbow joint with a pedicle frozen autograft. At the final follow-up four years after surgery, the elbow range of motion was 0-120˚. Although there were signs of osteoarthritis, there was no narrowing of the joint -, and the patient experienced only mild pain. To the best of our knowledge, the present case report is the first to describe wide tumor excision and reconstruction using a pedicle frozen autograft of the elbow. This method should be considered after excision of malignant bone and soft tissue tumors, especially in non-weight-bearing joints. Further cases have to be evaluated to understand the complications and long-term prognosis of this procedure.

Influence of Cement Dust Exposure on Indicators of Hepatic Function in Male Cement Handlers in Ekpoma, Nigeria

Background: The rising cases of cancer and associated mobidity and mortality are indirectly linked to occupational health hazards especially in developing cases. This is further comounded by low level of compliance to safety health measures among factory workers. Ignorance and low-level of awareness on the associated health-implication of occupational risk exposure have been implicated in this regard. Methods: The present study was carried out to evaluate the effect of cement dust exposure on selected liver function parameters in cement handlers at Ekpoma, Nigeria. A total of 114 subjects comprising 57 with history of exposure to cement dust by means of their occupation or by means of livelihood for at least one (1) year, designated as cement handlers (CH) and another 57 non-cement handlers designated as control (CT). Blood sample was collected from the anti-cubital fossa vein of each participant by venipuncture first thing in the morning before the commencement of daily activity into lithium heparin anticoagulant bottles. Plasma bilirubin (conjugated, unconjugated and total) as well as AST, ALT, ALP activities were determined using standard colorimetric methods. Results: Bilirubin levels were altered significantly (p < 0.05), while ALT activity was significantly decreased (p < 0.05) in CH compared CT. AST and ALP activities were not significantly altered. Conclusion: The results presented in this study showed that exposure to cement dust led to markedly increased level of some liver function parameters in cement handlers. This is indicative of a compromised liver function due to hepatotoxicity.

Prevalence of systemic lupus erythematosus amongst child-bearing female patients attending University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Systemic lupus erythematosus (SLE), a chronic and progressive multisystem autoimmune disorder is chiefly mediated by immune complexes in which the body’s immune system produce antibody (mostly antinuclear antibody) against normal cells and organs leading to inflammatory injuries. Several studies on this disease have been done in different parts of the world but very little exist in Nigeria, particularly in Port Harcourt. The study aim to determine the prevalence of systemic lupus erythematosus in Child-bearing female patients between the age ranges of 15 – 45 years, attending University of Port Harcourt Teaching Hospital, Rivers State, Nigeria. Ethical approval was sought for and obtained from the Ethical committee of the University of Port Harcourt Teaching Hospital. A total sample size of 207 was used. 5ml of blood samples were collected with 5ml syringe and needle into non-heparinized bottle from the antecubital fossa of recruited study group between 8am and 11am each day and was taken to the laboratory for analysis. De-fibrination method was used with the aid of centrifuge and microscope for detection of LE cell. Using an SLE latex reagent, the serum was analyzed for the presence of antinuclear antibody after centrifuging for 10mins. The SLE test kit used contained positive and negative controls to which the results were compared. Results gotten were all negative for the test group. This indicates a zero (0) prevalence level of systemic lupus erythematosus amongst child-bearing female patients attending the University of Port Harcourt Teaching Hospital.

Clinician guide to COVID-19 diagnostics

The pterygium syndrome consists of the neck, the antecubital fossae and the popliteal regions together with flexion deformities of the limb joints and anomalies of the vertebrae. A family, three...

To differentiate between different types of anaemia morphologically and its distribution in different age groups and sex

Background & Methods : Males who attended various departmental OPDs at tertiary care centre, and inpatients participated in this study as per the inclusion and exclusion criteria. Blood was withdrawn from an cubital vein by mean of dry sterile 5mldisposable plastic syringe with a needle of 20 guage after preparing the cubital fossa with a sterile swab, 3ml of blood was withdraw slowly, immediately blood is transferred to sterile tube with di-potassium EDTA as anticoagulant. Results: Out of 500 cases, 320 cases were male cases and 180 were female cases. Of these 320 male cases, 98 (30.63%) cases had mild anaemia, 189 cases (59.6%) had moderate anaemia and 33 cases (10.31%) had severe anaemia. Similarly, of 180 female cases, 55 (30.56%) cases had mild anaemia, 101 cases (56.11%) had moderate anaemia and 24 cases (13.33%) had severe anaemia. Male to female ratio is 1.8:1 i.e male outnumbered female in the study. However, the distribution of severity of anaemia did not differ significantly between males and females (P-value>0.05). Out of the 500 cases studied, 50 cases (10%) had >80fl MCV, 319 cases (63.80%) had MCV between 59-80 fl and 131 cases (26.20%) had Conclusions: Anemia is the most common problem occurring in males in our country, due to various reasons. Prevalence is being higher in Indian scenario, as compared to developed countries. Hence, it is recommended that, this age group is compulsorily screened for anaemia. Study of morphological pattern of anaemia directs us to the further management of underlying etiology. Keywords: Anaemia, Morphologically, Age & Sex.

Asymptomatic brown patches on the trunk

A 6-year-old otherwise healthy boy presented with a one year history of asymptomatic brown patches on the trunk. The lesions were progressively spreading despite daily cleaning of the skin with soap and hot water. The eruption had been treated with antifungal cream for one month, with no improvement. Physical examination revealed brown-reticulated scaly macular plaques on the abdomen (Fig. 1). There were no other skin lesions. What is the most likely diagnosis? (Answer on page ••) Given the appearance of the lesions, terra firma-forme dermatosis (TFFD) was suspected. This diagnosis was confirmed by using the alcohol wipe test. The lesions completely disappeared after being rubbed with a 70% isopropyl alcohol-soaked gauze. TFFD, also known as Duncan's dirty dermatosis, is an underdiagnosed benign skin disorder of unknown aetiology that affects predominantly children and young adults. The condition is characterised by asymptomatic brown to black, hyperkeratotic plaques and patches with a dirt-like appearance, typically located on the trunk and skin folds (flexures of the anterior neck, axilla, cubital fossae, inguinal region and umbilical fold). Commonly, multiple sites are involved.1 The lesions are resistant to regular washing with soap and water, but can be easily removed by rubbing with 70% isopropyl alcohol or ethyl alcohol.2 The main differential diagnosis is dermatosis neglecta, a skin condition caused by poor hygiene and characterised by brown scales that can be removed with washing with soap and water. Others differential diagnoses include dirty neck syndrome, confluent and reticulated papillomatosis of Gougerot and Carteaud, acanthosis nigricans and hyperpigmented pityriasis versicolor.3 The application of 70% isopropyl alcohol is the gold standard treatment. However, in extensive cases, mild topical keratolytics may be associated in order to avoid aggressive rubbing.2

HEMATOLOGICAL REFERENCE RANGES FOR HEALTHY ADULTS IN THE NORTHWEST REGION OF CAMEROON / GAMMES DE RÉFÉRENCE HÉMATOLOGIQUE POUR LA SANTÉ ADULTES DANS LA RÉGION NORD-OUEST DU CAMEROUN

The interpretation of laboratory test results requires reference or cutoff values. An improved diagnosis with accurate, reliable laboratory reference ranges saves valuable healthcare resources essential for effective clinical evaluation and monitoring. This benefit provides improved cost containment by eliminating unnecessary testing, treatment changes, and use of other healthcare resources during the episode of care. Based on the above fact, this study was designed to establish reference ranges for hematological parameters in apparently healthy voluntary non-remunerated blood donors. The study was a hospital based cross-sectional experimental study conducted between February and October 2020. Blood samples were taken from 356 healthy adults (18 to 60 years) 211 (59.3%) males and 145 (40.7%) females and routine hematology analysis performed. Patients were assessed as healthy on the basis of a medical history and medical examinations. Venous blood from the antecubital fossa was collected in 2-3mL of K- ethylenediamine tetra acetic acid (EDTA) for complete blood counts. A total of nineteen hematological parameters were tested in this study and showed significant differences (p&lt;0.001) among males and females with the former showing higher CBC values, except WBC, GRAN# and platelet. More than 10% of the female population presented results that were out of that of the accompanying manual of the hematology analyzer used in the study. The reference range for LYM % for the female was above the upper limit of the manufacturers’ manual reference and for GRAN% in the males was below the lower limit of the accompanying manual of the hematology analyzer. Several differences were also observed when compared to previously established values from Yaounde (Cameroon), most notably in platelets. Our findings for CBC parameters, are in general agreement with previously published data from more limited trials undertaken in other African countries. In spite of the uncontrolled factors influencing hematological values, this study permitted to establish new hematological reference values for use in the North West region of Cameroon. In the absence of previously detailed and more comprehensive investigated hematological reference values for the region we offered to use these results for clinical management of patients from this region and interpretations of laboratory data.&#x0D; &#x0D; L'interprétation des résultats des tests de laboratoire nécessite des valeurs de référence ou de coupure. Un diagnostic amélioré avec des plages de référence de laboratoire précises et fiables permet d'économiser de précieuses ressources de santé essentielles pour une évaluation et un suivi cliniques efficaces. Cet avantage permet une meilleure maîtrise des coûts en éliminant les tests inutiles, les changements de traitement et l'utilisation d'autres ressources de soins de santé pendant l'épisode de soins. Sur la base de ce qui précède, cette étude a été conçue pour établir des plages de référence pour les paramètres hématologiques chez des donneurs de sang volontaires non rémunérés apparemment en bonne santé. L'étude était une étude expérimentale transversale en milieu hospitalier menée entre février et octobre 2020. Des échantillons de sang ont été prélevés sur 356 adultes en bonne santé (18 à 60 ans) 211 (59,3%) hommes et 145 (40,7%) femmes et une analyse hématologique de routine a été réalisée. Les patients ont été jugés sains sur la base des antécédents médicaux et des examens médicaux. Le sang veineux de la fosse antécubitale a été collecté dans 2-3 ml d'acide K-éthylènediamine tétra acétique (EDTA) pour une numération globulaire complète. Un total de dix-neuf paramètres hématologiques ont été testés dans cette étude et ont montré des différences significatives (p &lt;0,001) entre les hommes et les femmes, le premier montrant des valeurs de FSC plus élevées, sauf globules blancs, GRAN # et plaquettes. Plus de 10% de la population féminine a présenté des résultats différents de ceux du manuel d'accompagnement de l'analyseur d'hématologie utilisé dans l'étude. La plage de référence pour LYM% pour la femelle était au-dessus de la limite supérieure de la référence manuelle du fabricant et pour GRAN% chez les mâles était inférieure à la limite inférieure du manuel d'accompagnement de l'analyseur d'hématologie. Plusieurs différences ont également été observées par rapport aux valeurs précédemment établies à Yaoundé (Cameroun), notamment dans les plaquettes. Nos résultats pour les paramètres du FSC, sont en accord général avec les données publiées antérieurement à partir d'essais plus limités entrepris dans d'autres pays africains. Malgré les facteurs incontrôlés influençant les valeurs hématologiques, cette étude a permis d'établir de nouvelles valeurs hématologiques de référence à utiliser dans la région du Nord-Ouest du Cameroun. En l'absence de valeurs de référence hématologiques étudiées précédemment détaillées et plus complètes pour la région, nous avons proposé d'utiliser ces résultats pour la prise en charge clinique des patients de cette région et l'interprétation des données de laboratoire.&#x0D; &#x0D; &lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt; Article visualizations:&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;img src="/-counters-/edu_01/0775/a.php" alt="Hit counter" /&gt;&lt;/p&gt;

Localized Scarlatiniform Rash of the Ears and Antecubital Fossa in COVID-19

The worldwide spread of the novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to a global pandemic since its identification in Wuhan, China in December 2019.1 Few cases of COVID-19-associated dermatologic manifestations have been reported in the literature to date. This report describes the clinical features of a localized pruritic scarlatiniform rash of the ears and antecubital fossa on defervescence in a 29-year-old patient with COVID-19. Our case stands to further illuminate the dermatologic manifestations of this novel disease.

A cadaveric study of brachial artery and its variations with its ontogenic basis: An Anatomical Perspective

Introduction: Conventional knowledge of the brachial artery, the principal artery of the upper limb &amp; its branches has played a major role in vascular surgeries. Literature along with various cadaveric &amp; clinical studies suggest that brachial artery vary widely in origin, course and branching pattern. The great variability of this arterial pattern may be attributed to the failure of regression of some paths of embryonic arterial trunks. Anatomical knowledge of this principal artery and its variations has many clinical implications especially in surgeries related to orthopedic and vascular re-constructive procedures. MATERIALS AND METHODS: The present study was conducted on 56 upper limbs of different age group and sex (19 Male and 9 Female) The brachial arteries were identified and branching pattern and relations of the brachial artery with brachial plexus in arm was observed and presence or absence of variations were documented. Results: Out of 56 upper limbs studies, 53 (94.64%) limbs showed normal morphological pattern of brachial artery, 3 (5.35%) limbs showed superficial brachial artery, 1 limb (1.78%) showed tortuous and SBA with trifurcation into radial artery, ulnar artery and common interosseous artery in the cubital fossa. Conclusion: The study of Brachial artery and variation in its course and branching pattern is clinically important for surgeons, ortho-paedicians operating on the supracondylar fracture of humerus and radiologists performing angiographic studies on the upper limb. KEY WORDS: Common Interosseous Artery, Median Nerve, Superficial Brachial Artery, Trifurcation, Ulnar Artery.

Prospective cohort study on the management and complications of peripheral venous catheter in patients hospitalised in internal medicine

ObjectiveTo analyse compliance with the recommendations on the insertion-maintenance of peripheral venous catheter (PVC) and the incidence of complications according to the healthcare department that inserted the PVCs. Patients and methodsWe conducted a prospective cohort follow-up study of PVCs, from their insertion in the emergency or internal medicine (IM) department until their withdrawal. ResultsWe monitored 590 PVCs, 274 from the emergency department and 316 from IM. In terms of compliance with the process indicators, there was a cannulation rate in the antecubital fossa of 3.5 and 1.6 per 100 catheters-day (p < .001) in the emergency and IM departments, respectively. The sterile placement rates were 1.6 and 12.4 (p < .001), and the rate for transparent dressing was 2.1 and 11.5 (p < .001) per 100 catheters-day in the emergency and IM departments, respectively. The complications rates showed no differences between the departments. The most common complication was phlebitis (95 cases, 16.1%). ConclusionsCompliance with the insertion-maintenance recommendations for PVC showed differences between the departments; however, the incidence of complications was similar.

Lateral epicondylitis: Are we missing out on radial nerve involvement? A cross-sectional study

IntroductionLateral epicondylitis (LE) is a common ailment causing pain and functional limitations. There is an inadequate understanding of its etiopathogenesis. Involvement of the radial nerve (RN) as the primary causative factor for this condition remains debatable. The aim of the present study was to assess the RN thickness in patients with LE and compare it with the unaffected side. MethodsThe study included seventy eligible patients (M:F, 22:48) in the age group of 30–60 years with a clinical diagnosis of LE. The cross-sectional area of RN was measured at the spiral groove (SG) and around the antecubital fossa (AF) using ultrasound and compared with the unaffected side. Numeric Pain Rating Scale (NPRS) and the QuickDASH scale were used to assess pain and functional impairment. ResultsThickness of RN at the AF (p = 0.026) and the SG (p = 0.0117) on the affected were statistically significant compared to the unaffected side in the cohort comprising of all the 70 patients. Out of 70 patients, increased thickness was seen in 23 at the SG and 19 at the AF. QuickDASH was statistically significant in patients who had thickened nerves compared to the unaffected side at the SG (p = 0.04) but not at the AF (p = 0.16). NPRS was not statistically significant at either the AF (p = 0.34) or the SG (p = 0.71) in patients with thickened nerves. ConclusionTennis elbow needs to be no longer acknowledged only as tendinopathy. It also requires consideration of the involvement of the RN.

Skin barrier status during dupilumab treatment in patients with severe atopic dermatitis.

Background:Atopic dermatitis (AD) is a common chronic-relapsing inflammatory skin disease hallmarked by epidermal barrier dysfunction, increased transepidermal water loss (TEWL) and decreased skin hydration. Recent findings on the T helper 2 (Th2)-driven pathogenesis of AD have led to the development of dupilumab, a monoclonal antibody directed against interleukin-4 and interleukin-13 that has been demonstrated to be effective in the treatment of moderate-to-severe AD. The effect of dupilumab on skin barrier dysfunction, however, has not yet been adequately investigated.Objectives:The primary endpoint of this study was to assess the status of the skin barrier in nonlesional skin of patients with severe AD treated with dupilumab, by evaluating the association between the relative variation of TEWL and the achievement of a 75% reduction of EASI (EASI75) over time.Methods:TEWL was measured below the antecubital fossae by means of the Vapometer® at baseline, at week 4 (T4), at week 16 (T16) and at week 32 after dupilumab starting. EASI and NRS-itch were measured at the same time points.Results:Seventy-eight patients with severe AD treated with dupilumab were enrolled. Median TEWL relative variation respect to baseline was significantly higher in patients who achieved EASI75 as compared with those who did not achieve EASI75 at T16 and at T32, but not at T4.Conclusion:During dupilumab treatment, TEWL on nonlesional skin tends to significantly improve 4 months after treatment initiation and could be a good tool for monitoring response to therapy.

Ulcerated Arm Lesion in a 10-day-old Girl

1. Brittany Lehrer, MD* 2. Kyle Pronko, MD*,† 3. Alina G. Burek, MD*,† 1. *Medical College of Wisconsin, Milwaukee, WI 2. †Children’s Wisconsin, Milwaukee, WI 1. Address correspondence to Brittany Lehrer, MD, Children’s Corporate Center, Suite 730, 999 N 92nd St, Milwaukee, WI 53226. E-mail: blehrer{at}mcw.edu A 10-day-old girl presents with a progressive right upper extremity skin lesion. She was born large for gestational age at term via cesarean delivery for fetal distress. Pregnancy was complicated by diet-controlled gestational diabetes and a maternal history of genital herpes. The mother received prophylactic valacyclovir and no active herpes lesions developed during pregnancy. Immediately after birth, the infant was noted to have a 2-cm, tender, well-circumscribed area of erythema and induration over the right antecubital fossa. The extremity also had decreased movement, diminished radial pulse, and weak grasp reflex. Otherwise, she was well-appearing and her examination was normal. Radiographs of the forearm and clavicle were negative for fracture. She was diagnosed with hematoma and possible brachial plexus injury and discharged from the nursery on postnatal day 3 with the arm immobilized in a sling and acetaminophen as needed for pain. Since discharge from the nursery, the lesion has spread, ulcerated, and started draining malodorous white discharge, so the patient returns for evaluation on postnatal day 10. On physical examination, she has a poorly demarcated, erythematous, tender, indurated, circumferential plaque that extends from the mid-upper arm through the antecubital fossa to the mid-forearm. The center of the lesion is violaceous and ulcerated with white discharge (Fig 1). The affected extremity has decreased spontaneous movement, weak radial pulse, nearly absent grasp reflex, and she has pain with passive manipulation of the affected elbow. Her vital signs and the remainder of her physical examination are normal. Complete blood cell count with differential, procalcitonin, and c-reactive protein are within normal limits for age. Blood culture and herpes simplex virus polymerase chain reaction …

Efficacy of a local corticosteroid injection on pain, disability and radial nerve thickness in patients with lateral epicondylitis.

Introduction:The aim of this study was to compare the effect of a steroid injection with conservative therapy (CT) versus CT alone on pain, functional limitations and the cross-sectional area (CSA) of the radial nerve (RN) in patients with lateral epicondylitis (LE).Methods:In this clinical trial, seventy subjects in the age group of 30–60 years with a clinical diagnosis of LE were recruited. Patients received an ultrasound-guided steroid injection and CT (Group A, n = 35) or CT alone (Group B, n = 35). Pain intensity (numeric pain rating scale), functional limitations (Quick Disabilities of the Arm, Shoulder, and Hand questionnaire) and the CSA of RN (mm2) using ultrasound were assessed at baseline, 4 and 12 weeks.Results:There was a significant difference in pain intensity (P < 0.05) at 4 weeks in favour of Group A but not at 12 weeks. A statistically significant difference was not present favouring either group concerning disability at both the follow-ups. The difference in CSA of the RN at the affected side in both groups A and B was not statistically significant at either the spiral groove or the antecubital fossa at baseline or the subsequent follow-ups.Conclusions:The CT with a steroid injection proved to be more efficacious in the short term concerning pain intensity and functional limitations. The RN thickness is not increased in patients with LE, thereby refuting its role to some extent in the pathogenesis of LE.

Median Basilic Vein and Median Cephalic Vein: a Rare Variant

Median cubital vein is a large communicating superficial vein of the upper limb. It shunts blood from the cephalic vein to basilic vein in the cubital fossa. As median cubital vein is widely opted for blood withdrawal or transfusion anatomical variations of this vein create lot of confusion. During routine dissection one of the variations was identified i.e. absence of a median cubital vein and presence of median cephalic vein and median basilic vein arising from the median vein of forearm. Anatomical variations of the median cubital vein have great importance in surgical and clinical interventions.

An Anatomical Insight into the Morphology of the Brachialis Muscle and its Clinical Implications

Introduction: Being the chief flexor of the elbow joint, brachialis muscle, also known as ‘work horse’ of the elbow or Portal’s muscle is one of the three muscles of the front of arm. Ascertaining the morphology of the muscle is of considerable clinical significance because infrequent mention of the pathologies like tear, rupture, tendinopathies, etc., coupled with the conflicting reports of its morphology may often leads to inaccurate diagnosis of clinical conditions pertaining to it. Aim: To study the origin of the muscle in the form of number of heads and type of fibres at origin, site and manner of insertion, mode of nerve supply and presence of accessory slips. Materials and Methods: The study was carried out in the Department of Anatomy, Parul Institute of Medical Sciences and Research, Parul University, Vadodara on the 82 upper limbs used for routine dissection of first MBBS students. After incising the skin, superficial and deep fascia of the arm and cubital fossa, the biceps was retracted to visualise the origin, insertion and nerve supply of the brachialis muscle. Results: In all 82 (100%) arms, the muscle arose by lateral superficial and medial deep heads. Deep head inserted into the coronoid process and upper part of the ulnar tuberosity by an aponeurosis. In 81 (98.8%) specimens, superficial head was inserted by round tendon on to the ulnar tuberosity distal to the deep head. In one (1.2%) specimen, fibres of the superficial head were merging with biceps tendon and inserted on to the radial tuberosity. In 75 (91.5%) arms, muscle was supplied by musculocutaneous nerve and radial nerves and in four (5%) cases by the musculocutaneous, median and Radial Nerve (RN) whereas in 3 (3.5%) case by median and radial nerves. Accessory slips were present in four (5%) specimens. Conclusion: Considerable difference in the morphology of the brachialis was found with regards to the classical picture and should be kept in mind before undertaking any surgical procedure in the arm and elbow region.