Lower Limb Research Articles

Lower limb acute onset muscle pain: what do we have to look for? A case of isolated rupture of the rectus femoris.

Acute muscle pain is muscle soreness that occurs during or within 24 hours of strenuous activity. Possible causes of acute muscle pain include localized muscle trauma, muscle tear, contusion with acute hemorrhage, or acute compartment syndrome. Isolated ruptures of the rectus femoris muscle are rare clinical conditions that result from excessive muscle strain following an abrupt contraction, incorrect movement, or sudden snap that exceeds the physiological limit of strain that the muscle can withstand. To date, there are few published reports evaluating the results of non-invasive treatment of such injuries. Herein, we report an unusual case of isolated distal rectus femoris tear in a 46-year-old female patient with no risk factors, who initially presented with extensor muscle weakness and pain and was treated conservatively with functional rest, physiotherapy, and cryotherapy.

The Comorbidity-Polypharmacy Score as a Predictive Tool of Survival and Limb Salvage in Patients Undergoing Lower Limb Revascularization Procedures for Chronic Limb-Threatening Ischemia

ObjectiveThe comorbidity-polypharmacy score (CPPS) was created to evaluate the clinical burden of comorbidities in geriatric patients. It represents an objective tool to stratify patients’ risk in different settings. The study aimed to evaluate CPPS in predicting mortality and amputation in patients undergoing elective revascularization procedures in CLTI patients. MethodsThis is 2 years retrospective single-centre study. We included all patients undergoing elective lower-limb revascularization procedures admitted with CLTI diagnosis. Four CPPS groups were defined: mild, moderate, severe and morbid. The primary early and long-term outcomes were 30-day overall mortality, 30-day amputation rate and overall survival and limb salvage respectively. ResultsA total of 442 patients were enrolled in the study. Mean age was 76.5±9.9 years and 61.5% (272/442) were male. CPPS was calculated: 22.6% (100/442) have mild CPPS, 54.3% (240/442) moderate, 21.9% (97/442) severe and 1.2% (5/442) morbid.Kaplan-Meier curves for overall survival stratified for CPPS grade highlighted a strong statistically significant difference (p<0.0001) among the four CPPS classes.Mild CPPS has significantly higher limb salvage rate among moderate, severe and morbid CPPS groups (p<0.0001). Limb salvage for mild and severe CPPS, at 36 months was 95% vs. 85.1% respectively.Stepwise multivariable Cox-analysis revealed that mortality was independently associated with dialysis, Rutherford Classification V, age and CPPS. Male sex, multilevel arterial disease, and hybrid surgical repair were independently associated with amputations. ConclusionCPPS is a straightforward tool to evaluate the patient’s complexity and could be used as an adjuvant tool to stratify early- and long-term outcomes in CLTI patients undergoing elective revascularization procedures.

Intravascular Lithotripsy for Peripheral Artery Calcification: 30-Day Outcomes From the Disrupt PAD III Observational Study.

Intravascular lithotripsy (IVL) has shown promising safety and effectiveness in calcified peripheral artery disease (PAD) in large trials and small real-world experiences. Real-world evidence from a larger cohort is lacking, so we aimed to evaluate the real-world acute performance of IVL in the treatment of calcified PAD. The Disrupt PAD III Observational Study (OS) is a prospective, multicenter, single-arm study. Patients with claudication or critical limb-threatening ischemia (CLTI) and at least moderate calcification were eligible. Independent predictors of procedural outcomes were assessed by multivariable analysis. Between November 2017 and June 2021 across 30 global sites, 1373 patients with 1677 lesions (1531, 91.3% core lab evaluable) were enrolled. Diameter stenosis and lesion length was 80.6±17.6% and 93.5±74.3 mm, respectively. Target vessels included femoropopliteal (61%), iliac (15.8%), common femoral (10.7%), and infrapopliteal arteries (12.8%). Lesion characteristics included 31.1% chronic total occlusions (CTOs) and 19.3% long lesions (≥15 cm). At final assessment, residual stenosis was 23.8±11.3%, with 0.9% serious angiographic complications, no abrupt closures, distal embolization, no flow, or thrombotic events. Independent predictors of ≤30% residual stenosis were lesion length ≥15 cm (odds ratio [OR]=0.384), female sex (OR=1.850), age ≤75 years (OR=1.625), IVL balloon to artery ratio ≥1.0 (OR=1.538), and CTO lesions (OR=0.638). Lesion length ≥15 cm (OR=16.076) was an independent predictor of procedural complications. The Disrupt PAD III OS represents the largest assessment of IVL periprocedural outcomes in calcified PAD. It confirmed excellent procedural safety and effectiveness in complex lesions across multiple peripheral vascular beds. This final analysis of the PAD III OS represents the largest report of peripheral IVL utilization in daily clinical practice. The outcomes of this study indicate that previously reported procedural results in clinical trial settings can be translated to a broader patient population. Treatment with peripheral IVL in severely calcified stenotic lower limb lesions demonstrated consistent acute safety and stenosis reduction, even in complex patients across multiple vessel beds. In addition, the importance of proper IVL balloon sizing to achieve excellent acute stenosis reduction was confirmed by multivariate analysis.

Impact of computed tomography/magnetic resonance imaging registration on rehabilitation after percutaneous endoscopic decompression for lumbar stenosis: Retrospective study.

Percutaneous endoscopic lumbar decompression (PELD) shows promise for lumbar spinal stenosis (LSS) treatment, but its use is limited by the disease's complexity and procedural challenges. In this study, the effects of preoperative planning and intraoperative guidance with computed tomography (CT)/magnetic resonance imaging (MRI) registration techniques on PELD for LSS and postoperative rehabilitation outcomes were evaluated. This retrospective study was conducted with data from patients who underwent PELD for LSS between January 2021 and December 2023. Patients were assigned to preoperative CT/MRI registration and control groups. Data collected included the operative time, length of hospital stay, visual analog scale (VAS) scores for low back and leg pain, and the Japanese Orthopaedic Association (JOA) lumbar spine score. Differences between groups were assessed using Student's t test. Data from 135 patients (71 in the CT/MRI registration group, 64 in the control group) were analyzed. The operative time was significantly shorter in the CT/MRI registration group (P = 0.007). At 2 months postoperatively, both groups showed significant reductions in VAS leg and low back pain scores (all P < 0.001) and improvements in the JOA score (both P < 0.001). No complication or death occurred. Preoperatively, pain and JOA scores were similar between groups (P = 0.830, P = 0.470, and P = 0.287, respectively). At 2 months postoperatively, patients in the CT/MRI registration group reported lower leg and low back pain levels (P < 0.001 and P = 0.001, respectively) and had higher JOA scores (P = 0.004) than did patients in the control group. Preoperative CT/MRI registration for PELD for LSS reduced the operative time and VAS pain scores at 2 months and improved JOA scores, demonstrating enhanced effectiveness and safety.

Dimensional assessment on baseline MRI of soft-tissue sarcomas: longest diameter, sum and product of diameters, and volume-which is the best measurement method to predict patients' outcomes?

The longest diameter (LD) is a strong prognostic factor for patients with soft-tissue sarcoma (STS). Other dimensional assessments, such as the sum of diameters (SoD), product of diameters (PoD), and volume (3D-COG - proposed by the Children Oncology Group), can be rapidly performed; however, their prognostic values have never been compared to LD. Our goal was to investigate their performance in improving patients' prognostication for STS of the lower limbs. All consecutive adults managed with curative intent at our sarcoma reference center for a newly diagnosed STS of the lower limbs between 2000 and 2017, with pre-treatment MRI, were included in this retrospective study. Multivariable Cox regression models were trained to predict metastasis-free survival (MFS) in a Training cohort of 66.7% patients based on LD, PoD, SoD, or 3D-COG (and systematically including age, histologic grade, histotype, radiotherapy, chemotherapy, and surgical margins as covariables). The models were then compared on a validation cohort of 33.3% patients using concordance indices (c-index). The same approach was applied for overall survival (OS) and local relapse-free survival (LFS). Measurement reproducibility among three readers was evaluated with an intraclass correlation coefficient (ICC). 382 patients were included in the survival modeling (72/253 [28.5%] metastatic relapses in Training and 36/129 [27.9%] metastatic relapses in Validation). Higher dimensions were associated with lower MFS (multivariable hazard ratio [HR] = 2.44 and P = 0.0018 for LD; HR = 1.88 and P = 0.0009 for PoD, HR = 1.52 and P = 0.0041 for SoD; and HR = 1.08 and P = 0.0195 for 3D-COG). Higher c-indices were obtained with PoD model in Training (c-index = 0.772) and Validation (c-index = 0.688), but they were not significantly higher thanthose obtained with LD model. None of the measurements was associated with LFS or OS. All measurements demonstrated excellent ICC (> 0.95). Regarding its simplicity and good performance, LD appeared as the best metric to incorporate in prognostic models and nomograms for MFS.

Effect of Low Molecular Weight Heparin Calcium on Prevention of Lower Limb Deep Venous Thrombosis in Oral Cancer Patients With Anterolateral Thigh Flap Reconstruction.

This study aimed to evaluate the effect of low molecular weight heparin calcium (LMWH-Ca) on the prevention of deep venous thrombosis (DVT) in patients with anterolateral thigh (ALT) flap reconstruction. In total, 1001 patients with oral cancer who underwent ALT flap reconstruction were recruited. Based on the postoperative use of LMWH-Ca, the patients were divided into case (n = 633) and control groups (n = 368). The incidence of postoperative DVT was compared between groups. There was no significant difference in DVT incidence between the two groups. Among patients older than 60 years, the incidence of lower limb DVT in the case group (0.813%) was significantly lower than that in the control group (8.108%, p = 0.012). The postoperative use of LMWH in oral cancer patients with ALT flap transfer does not prevent the development of lower limb DVT. However, patients older than 60 years old benefited from the postoperative use of LMWH-Ca.

Enhancing gait recognition in lower limb exoskeletons: adaptive feature selection and random forest with Bayesian optimization

Abstract To improve human-machine cooperation and enhance the accuracy of gait recognition in wearable lower limb exoskeletons, an enhancement method of gait recognition based on adaptive feature selection and an optimized machine learning algorithm was proposed. In this study, surface electromyography (sEMG) signals of rectus femoris, medialis femoris, lateralis femoris, semitendinosus and biceps femoris were recorded during level-ground walking. Then, time domain, frequency domain, time-frequency domain and nonlinear features were extracted. The integrated value of electromyography, variance, root mean square and wavelength were selected as the time domain features, and the mean power frequency and median frequency were selected as the frequency domain features. Wavelet packet energy was selected as the time-frequency domain feature. Nonlinear features including approximate entropy, sample entropy and fuzzy entropy of sEMG were extracted. To reduce feature dimension and improve the calculation efficiency, adaptive feature selection was performed by particle swarm optimization combined with sigmoid function. Then, the feature matrix was determined as the input for a random forest classifier to recognize different gait phases. An adaptive optimization mechanism based on Bayesian optimization was applied to random forest. Compared with random forest, the overall performance of the optimized model was improved. Its accuracy was increased by 3.57%. The feature selection and adaptive optimization mechanisms in gait recognition not only enhance the accuracy of random forest algorithms applied to sEMG for gait prediction, but also facilitate the flexibility and consistency required for lower limb exoskeleton gait control.

Peripheral Ischemia and Necrosis Revealing Buerger&amp;apos;s Disease in an Internal Medicine Department

Buerger&amp;apos;s disease is a systemic vasculitis strongly correlated with tobacco use. It entails a heavy socio-occupational impact. We report the case of a 26-year-old patient with ischemia of the lower limbs revealing Buerger’s disease. He is known smoker with passive exposure to Indian hemp. He was seen for ischemic foot pain that had been progressing for a year. Involvement began in the left big toe. Subsequently, hyperalgesic necrotic lesions were observed on the 3rd, 4th and 5th toes of the foot. Biological investigations revealed an inflammatory syndrome with normocytic anemia and increased C-reactive protein. Retroviral, syphilitic, Hepatitis B and C viruses and SARS-CoV-2 serologies were negative. Antinuclear antibodies were initially borderline at 100 IU with speckled fluorescence, then negative on control. Neutrophil cytoplasmic antibodies and antiphospholipid antibodies were negative. Investigation of thrombophilia was non-contributory, notably factor V mutation testing, antithrombin III assay, proteins C and S and fibrinogen. An arterial ultrasound revealed extensive arterial thrombosis with thickening of the femoral arterial vessel walls. Thromboangiitis obliterans was confirmed and the patient was put on corticosteroids and adjuvant therapy. Surgical treatment was performed 4 months later. Buerger&amp;apos;s disease is a serious vascular disorder which must be diagnosed very early in order to prevent complications. Early smoking cessation leads to remission in the early phase.

Predictive Ability of the Pedal Medial Arterial Calcification Score for Major Adverse Limb Events Among Patients with Chronic Limb-Threatening Ischemia

ObjectivePedal medial arterial calcification (pMAC) is a potential predictor of major adverse limb events (MALE) among patients with critical limb-threatening ischemia (CLTI). This study aims to validate the prognostic value of the pMAC score in predicting major lower limb amputation (MLLA) and need for re-do revascularisation. MethodsA single centre study involving 196 patients diagnosed with CLTI, reviewed between 2012 and 2022. Patients’ pMAC scores were obtained through X-ray assessments. Correlations between pMAC scores and the incidence of MALE and re-do revascularisation, were analysed. A power analysis using G* Power 3 software determined a needed sample size of 157 participants. Statistical analysis employed SPSS 26, utilising descriptive statistics, Chi Square, Mann-Whitney, Kaplan-Meier with log-rank test, and Cox regression for predictor identification. ResultsThe cohort was predominantly male (79.1%) and diabetic (59.2%). Re-do revascularisation need was 15.3%, increasing with pMAC scores: 3.3% (low), 24.5% (medium), and 50% (high) (p<0.001). MLLA frequency also rose with pMAC scores: 6.7%, 27.5%, and 50% respectively (p<0.001). Higher pMAC scores correlated with a higher incidence of MALE (p=0.029). Multivariate analysis showed medium pMAC (HR 4.159, p=0.002), high pMAC (HR 7.366, p=0.015), and GLASS stage 3 (HR 3.529, p=0.011) as independent MLLA predictors. Re-do revascularisation predictors included female sex (HR 2.106, p=0.063), Black race (HR 64.498, p=0.001), medium pMAC (HR 6.812, p=0.002), high pMAC (HR 11.455, p=0.008), and GLASS stage 3 (HR 2.899, p=0.037). ConclusionThe pMAC score effectively predicts MALE in CLTI patients and enhances risk stratification. Using both, pMAC scores and GLASS stages enhances predictive accuracy, identifying patients at higher risk for MLLA, Informing clinical decision-making and therapeutic strategies.

Clinical manifestations, diagnosis and treatment of hereditary fibrinogen Aα-chain renal amyloidosis: one case report and systematic review.

We reported a confirmed case of Fibrinogen Aa-chain (AFib) amyloidosis and conducted systematic review of the genetic and protein mutation types, clinical manifestations, diagnostic methods and treatment for patients with this disease worldwide. We reported a case of AFib amyloidosis. Meanwhile, a systematic search was performed using defined terms and updated up to November 2023 in the Wanfang, China National Knowledge Infrastructure, VIP, PubMed, and Web of Science databases to identify reported cases of AFib renal amyloidosis worldwide, according to PRISMA guidelines. A 46-year-old male patient was admitted for more than half a month because of oedematous lower limbs. Renal tissue mass spectrometry suggested an AFib type. Gene detection demonstrated that the patient carried the c.1673del (p.Lys558Argfs*10) locus heterozygous mutation of Fibrinogen Aα-chain gene (FGA). The patient was treated with haemodialysis because of uncontrollable hypertension. This systematic review comprised 46 cases. We found the onset age to be lower in women than in men (P < 0.05). All patients showed incipient symptoms including proteinuria; 10 (21.7%) patients progressed to end-stage renal disease (ESRD) or received renal replacement therapy (including dialysis and kidney transplantation) within 1year; 18 (39.1%) patients progressed to ESRD or received renal replacement therapy within 1-5years, and 4 (8.7%) patients did not progress to ESRD or received renal replacement therapy within 5years. AFib amyloidosis progresses rapidly. The diagnosis of this disease is primarily based on renal biopsy, mass spectrometry, and molecular gene detection. Reducing proteinuria is the main method of treating this disease. CRD42024516146.

Effectiveness of lower limb robotic rehabilitation on peak of oxygen uptake among patients with stroke: a systematic review and meta-analysis

ObjectivesTo evaluate the effectiveness of lower limb robotic rehabilitation (LLRR) on cardiovascular health among individuals with stroke undergoing rehabilitation.DesignSystematic reviews and meta-analysis.Data sourcesPubMed, Web of Science, Science Direct, Embase, China...

A rare anomalous muscle in the popliteal region - a case report.

Anomalous muscles are rarely seen in the popliteal region of the lower limb. Some of them are harmless and go unnoticed and some create problems such as neuropathies. We report a novel case of an unusual additional muscle in this region. The additional muscle was closely associated with the short head of the biceps femoris muscle. It took its origin from the lower part of the lateral supracondylar line and the adjoining popliteal surface of the femur. The muscle was 10cm in length, 1cm in breadth and was fleshy throughout. It was oriented parallel to the medial side of the tendon of biceps femoris. It was inserted to the posterior aspect of the head of the fibula, medial to the insertion of the biceps femoris. The additional muscle derived its nerve supply from the sciatic nerve. The common peroneal nerve was closely related to the medial border of the additional muscle.

Unusual late presentation of cryptococcal meningitis with simultaneous CMV antigenemia in a kidney transplant recipient.

Cryptococcosis is the third most common invasive fungal infection in solid-organ transplant (SOT) recipients after candidiasis and aspergillosis. These patients are at risk of disseminated cryptococcosis because of immuosuppressive therapy. The median time to disease onset after kidney transplantation is approximately 35months and it rarely occurs more than 10years after transplantation. Herein, we report a case of 64-year-old kidney transplant recipient suffering from coexisting disseminated cryptococcosis with brain and skin involvement, together with cytomegalovirus (CMV) antigenemia more than 20years after transplant. She presented with frontal headache and bilateral hand tremor, in addition to multiple nodular lesions over bilateral lower limbs. The diagnosis was made after lumbar puncture and skin biopsy. She was successfully treated with a course of anti-fungal and anti-CMV regimen without any relapse of central nervous system infection. Our case illustrates that disseminated cryptococcosis can occur very late after organ transplant. It is thus important to watch out for late-onset opportunistic infections and strike the balance between risks of infections and rejections in SOT patients.

A Recurrent Deep Network for Gait Phase Identification from EMG Signals During Exoskeleton-Assisted Walking

Lower limb exoskeletons represent a relevant tool for rehabilitating gait in patients with lower limb movement disorders. Partial assistance exoskeletons adaptively provide the joint torque needed, on top of that produced by the patient, for a correct and stable gait, helping the patient to recover an autonomous gait. Thus, the device needs to identify the different phases of the gait cycle to produce precisely timed commands that drive its joint motors appropriately. In this study, EMG signals have been used for gait phase detection considering that EMG activations lead limb kinematics by at least 120 ms. We propose a deep learning model based on bidirectional LSTM to identify stance and swing gait phases from EMG data. We built a dataset of EMG signals recorded at 1500 Hz from four muscles from the dominant leg in a population of 26 healthy subjects walking overground (WO) and walking on a treadmill (WT) using a lower limb exoskeleton. The data were labeled with the corresponding stance or swing gait phase based on limb kinematics provided by inertial motion sensors. The model was studied in three different scenarios, and we explored its generalization abilities and evaluated its applicability to the online processing of EMG data. The training was always conducted on 500-sample sequences from WO recordings of 23 subjects. Testing always involved WO and WT sequences from the remaining three subjects. First, the model was trained and tested on 500 Hz EMG data, obtaining an overall accuracy on the WO and WT test datasets of 92.43% and 91.16%, respectively. The simulation of online operation required 127 ms to preprocess and classify one sequence. Second, the trained model was evaluated against a test set built on 1500 Hz EMG data. The accuracies were lower, yet the processing times were 11 ms faster. Third, we partially retrained the model on a subset of the 1500 Hz training dataset, achieving 87.17% and 89.64% accuracy on the 1500 Hz WO and WT test sets, respectively. Overall, the proposed deep learning model appears to be a valuable candidate for entering the control pipeline of a lower limb rehabilitation exoskeleton in terms of both the achieved accuracy and processing times.

A proportional fusion adaptation algorithm to reduce noise in sEMG signals of the lower limb

Abstract To address issues related to unknown noise pollution and the inadequate performance of single adaptive noise reduction algorithms in measuring lower limb surface electromyography (sEMG) signals, this paper proposes an algorithm that combines the fast convergence speed and strong noise reduction capability of recursive least-squares (RLS) with the low computational complexity of the normalized least-mean-square (NLMS) and improved proportionate NLMS (IPNLMS). Through the proportional fusion of RLS with NLMS and RLS with IPNLMS, the proposed algorithm greatly improves convergence speed, stability, and noise reduction performance while effectively reducing computational complexity. Moreover, considering the influence of the initial value of weights on the noise reduction performance during the updating process of the adaptive noise reduction algorithm, a weight initial value setting (WIS) module is proposed to optimize the initial value of the weights by the known amount of data. Based on 50 independent experiments, an adaptive noise reduction algorithm and WIS module were used to reduce the unknown noise in the lower limb sEMG signals, which was generated by white Gaussian noise, power line interference, or hybrid noise interfered by an unknown environment. The noise reduction performance was evaluated by using the average value of the signal-to-noise ratio (SNR), the root-mean-square error, and R-square. Compared with the RLS, NLMS, and IPNLMS algorithms for noise reduction of vastus lateralis, rectus femoris, and biceps femoris signals containing unknown noise, the SNR of RLS-NLMS, RLS-IPNLMS, WIS-RLS-NLMS, and WIS-RLS-IPNLMS is improved by an average of [7.92%, 55.54%, 55.63%], [7.45%, 54.90%, 54.99%], [19.70%, 72.38%, 72.71%], [19.32%, 71.84%, 72.19%]. The simulation results verify that the proportional fusion adaptive noise reduction algorithm and the WIS module effectively accelerate the convergence speed, enhance the noise reduction capability, and reduce the computational complexity.

Free fillet flap: Outcomes in emergency microsurgical reconstruction of upper and lower limb

INTRODUCTIONDespite its infrequency, “spare-part surgery” represents a reconstructive strategy that uses segments of amputated limbs as donor tissue to preserve function in other injured anatomical regions. The purpose was to review our 14-year experience in emergency microsurgical reconstruction of traumatised limbs using free fillet flaps obtained from non-salvageable amputated parts. MATERIALS AND METHODSA retrospective observational study was conducted on patients who underwent urgent free fillet flap transfer for upper or lower limb reconstruction between 2007 and 2021. The characteristics and levels of injury, as well as the flap designs, functional outcomes and complications were documented. RESULTSA series of eight clinical cases is presented. One osteo-tendino-cutaneous and seven fasciocutaneous flaps were filleted from non-replantable amputated limbs for free transfer. Stable coverage of the dorsal aspect of the hand and fingers was achieved in three patients, and limb shortening was avoided in five patients. An open fracture of the thumb with bone defect, three below-knee stumps and one trans-metatarsal level were preserved. The mean Q-DASH score for upper limb reconstructions was 16.75 points. In all cases of lower limb reconstruction, the nerves were repaired, resulting in a protective sensitivity (S3 level) with no pressure ulcer development during the follow-up period. All patients were able to return to normal prosthetic ambulation with a mean Amputee Mobility Predictor Pro score of 45 points. Two haematomas, one surgical wound dehiscence, and two immediate revisions of venous anastomoses were registered. CONCLUSIONSThe microvascular filleted flap demonstrated versatility in the emergency reconstruction of complex limb injuries, providing stable coverage and optimised limb length preservation within a single major surgical procedure while eliminating morbidity from any other uninjured donor site.

Neurosarcoidosis Masquerading as Spinal Stenosis.

A 65-year-old woman was admitted to the neurology department with a suspected demyelinating disease due to complaints of progressive pain and weakness in both upper and lower limbs, as well as urinary incontinence. MRI of the spine revealed complex disc osteophyte with compression of the spinal cord in the cervical and lumbar spine at several vertebral levels, and localized enhancement in the cervical spine at the site of maximal spinal canal stenosis. During her hospitalization, the patient underwent extensive evaluation to rule out any systematic inflammatory diseases, infections, and malignancy. Chest CT revealed bilateral mediastinal lymphadenopathy. Transbronchial mediastinal lymph node biopsy showed numerous non-necrotizing granulomas without evidence of malignancy. After a thorough and careful exclusion of a demyelinating, infectious, and paraneoplastic myelopathies, and based on clinical, radiographic, and pathological findings, the patient was diagnosed with both neurosarcoidosis and spondylotic myelopathy. She was then treated for neurosarcoidosis, including glucocorticosteroids, azathioprine, and a biosimilar of the anti-TNF alpha agent infliximab, resulting in both clinical and radiographic improvement. Intramedullary spinal neurosarcoidosis is very rare and may present with clinical features of spondylotic myelopathy, with typical imaging findings occurring only in areas of spinal canal stenosis.

Central retinal artery occlusion as the initial manifestation of mixed connective tissue disease in a young woman: a case report

BackgroundRetinal artery occlusions are rare amongst young adults, and relevant risk factors and etiology remain unclear. In this report, we present a case of central retinal artery occlusion (CRAO) as the initial manifestation of mixed connective tissue disease (MCTD) in a young woman.Case presentationA 22-year-old female presented to the emergency department with a sudden decrease in visual acuity in her right eye for 1 hour. She reported a similar episode in her left eye five years prior, which resolved spontaneously after 2 hours. Initially misdiagnosed with optic neuritis in the right eye at another hospital, she was referred to our institution the following day. Clinical examination revealed a CRAO in her right eye. A detailed medical history revealed that she had developed livedo reticularis (LR) on both lower limbs five years ago, which had been overlooked and untreated. Further rheumatologic history, hematologic tests, and an autoimmune work-up confirmed a diagnosis of mixed connective tissue disease (MCTD).ConclusionIn young patients presenting with CRAO, further examinations should be conducted to investigate systemic disease or an embolic source to prevent future sequelae.

Hemorrhagic hepatic infarction in a pregnant woman with severe preeclampsia: A case report

Introduction and importance: Severe preeclampsia is a medical condition that affects women during the last two trimesters of pregnancy. Hemorrhagic hepatic infarction is a hepatic complication and is rarely encountered in women with severe preeclampsia. This case report aims to present the characteristics of hemorrhagic hepatic infarction in a pregnant woman with severe preeclampsia. Case presentation: A 27-year-old pregnant woman with a 30-week gestation of amenorrhea was admitted with a blood pressure of 160/100 millimeters of Mercury (mm Hg), headaches, dizziness and oedema in the lower limbs. Clinical discussion: These complaints with clinical and paraclinical examinations led to the diagnosis of severe preeclampsia and she underwent an emergency cesarean section but 6 hours later, she presented with hypovolemic shock and this led to a new surgery. A surgery which made it possible to develop or discover a diffuse hepatic infarction with hemorrhagic infiltration of the gallbladder and the falciform ligament without active bleeding in the liver. Emergency management of preeclampsia was adopted and the postoperative course was simple with a good clinical outcome when the patient was discharged. Conclusion: Severe preeclampsia and hemorrhagic hepatic infarction are complications of pregnancy which require emergency treatment and above all these medical conditions require the termination of the pregnancy.

Leukotrienes E4 and B4 and vascular endothelium – New insight into the link between vascular inflammation and peripheral arterial

Leukotrienes are proinflammatory mediators that participate in the process of atherogenesis and contribute to the development of symptomatic peripheral arterial disease. The aim was to evaluate the relationship between leukotriene E4 (LTE4) and B4 (LTB4) with parameters reflecting endothelial vascular function in patients with chronic lower limb ischemia. This prospective observational study enrolled 50 consecutive patients undergoing endovascular treatment due to chronic lower limb ischemia (Rutherford 3). All participants were followed-up for one year (after 1, 3, 6 and 12 months), with a sequential assessment of urinary LTE4 and LTB4, as well as measures of endothelial and vascular function: Flow-Mediated Dilatation (FMD), Intima-Media Thickness (IMT), corrected Augmentation Index (AI75), Shear Rate (SR), Ankle-Brachial Index (ABI), Toe-Brachial Index (TBI). There was a significant relationship between LTE4 and measures of vascular function: FMD (R2 = 0.69, P < 0.001), IMT (R2 = 0.12, P < 0.01), AI75 (R2 = 0.43, P < 0.001), SR (R2 = 0.48, P < 0.001). Similar findings were noted for LTB4: FMD (R2 = 0.47, p < 0.001), IMT (R2 = 0.23, P < 0.001), AI75 (R2 = 0.61, P < 0.001) and SR (R2 = 0.33, P < 0.001). Alterations in parameters were significantly related: ΔLTE4 vs ΔFMD(R2 = 0.63, P < 0.001), ΔSR (R2 = 0.42, P < 0.001) and ΔLTB4 vs AI75(R2 = 0.40, P < 0.001), SR(R2 = 0. 29, P < 0.001). We conclude, that increasing concentrations of LTE4 and LTB4 are associated with impairment of vascular and endothelial function, which may lead to worse endovascular treatment clinical outcomes.