Extremity Swelling Research Articles

DANTE-SPACE: a new technical tool for DVT on 1.5T MRI

The aim of the study was to compare CE-MRV with DANTE-SPACE on a 1.5T MRI system for the diagnosis of DVT. The patients were diagnosed with deep venous thrombosis of the lower extremities based on swelling, pain, and superficial varicose veins of the lower extremities. MRI examination confirmed the diagnosis. DANTE-SPACE images were obtained before the conventional contrast-enhanced MRV, which uses gadolinium. The scanning field started from the end of the inferior vena cava to the end of the ankle, divided into five observation segments, namely, the common iliac vein, external iliac vein, femoral vein, popliteal vein, and calf vein. The DANTE-SPACE and CE-MRV results were used for a consistency analysis. For the DANTE-SPACE and CE-MRV images, the signal intensity ratios of the thrombus/cavity and thrombus/muscle were calculated, and the ratio difference was compared using the paired t test. Twenty-six patients completed the examination; one of the patients underwent a right lower limb amputation, yielding a total of 255 lower limb vascular segments. The analysis of the DANTE-SPACE images showed that there were 14 iliac vein thromboses, 18 external iliac vein thromboses, 23 femoral vein thrombi, 21 popliteal vein thromboses, and 18 calf vein thromboses; these findings were consistent with the diagnostic results of CE-MRV. The ratio of the thrombus/cavity signal intensity measured in the DANTE-SPACE and CE-MRV images were as follows: 20.51 ± 12.96 vs. 0.51 ± 0.46; P < 0.05, n = 51; the difference was statistically significant. The ratio of the thrombus/muscle signal intensity measured on the DANTE-SPACE and CE-MRV images were as follows: 1.74 ± 0.57 vs. 0.99 ± 0.53; P < 0.05, n = 51; the difference was statistically significant. Compared with CE-MRV, DANTE-SPACE showed no significant difference in the ability to detect deep venous thrombosis of the lower extremities. DANTE-SPACE did not use contrast-enhancing agents and showed no evidence of inflammatory enhancement, and the display effect of small diameter veins was slightly poor. However, deep venous thrombosis of the lower extremities presents different levels of high signal in the DANTE-SPACE images, making it easy to identify and diagnose. It can also indicate the different components and age of the thrombus and help with the selection of a more accurate clinical treatment plan. MRI DANTE-SPACE is the preferred imaging modality for patients with deep venous thrombosis who are unable or unwilling to use gadolinium contrast agents.

Case Study: Dilated Cardiomyopathy Evolves into Apical-Variant Hypertrophic Cardiomyopathy

Introduction Apical-variant hypertrophic cardiomyopathy (HCM) is a form of HCM in which hypertrophy is limited to the left-ventricular apex. Apical-variant HCM is rarely obstructive, though there is still an increased risk of atrial fibrillation, myocardial infarction, and sudden cardiac death (SCD). Apical-variant HCM has not previously been described in a patient with a prior diagnosis of dilated cardiomyopathy (DCM). Case A 53-year-old female with a history of hypertension and type-II diabetes mellitus presented with progressive dyspnea on exertion, fatigue and lower extremity swelling. Family history was significant for SCD of her mother at age 45. An initial transthoracic echocardiogram (TTE) showed DCM with an ejection fraction (EF) 15% and left ventricular end diastolic dimension (LVEDD) of 6.8 cm. The patient was placed on guideline-directed medical therapy (GDMT) and ultimately received cardiac resynchronization therapy with a defibrillator (CRT-D). One year later, EF was 25% with LVEDD 7.1 cm (Figure 1). A subsequent TTE two years later showed resolution of DCM with EF 55% and LVEDD of 5.1 cm. However, a new finding on this TTE was apparent: the apex demonstrated a spade-like shape on contraction consistent with apical-variant HCM (Figure 2). The patient underwent genetic testing but no genetic cause of either DCM or HCM was identified. Discussion HCM is caused by autosomal-dominant inheritance of a defective gene in sarcomere proteins. DCM and HCM are linked in that some etiologies of DCM are driven by sarcomeric protein abnormalities. DCM is also a rare phenotypical variant of HCM generally occurring very late in the disease and evolving from an initially hypertrophic myocardium. The opposite, in which DCM evolves into apical-variant HCM, to the best of our knowledge, has not been described in the literature. This relationship, as well as a family history of early SCD, suggest an inherited sarcomeric disorder manifesting as two discrete phenotypes within the same individual. This evolution may be due to treatment with GDMT, or it may be a rare expression of the disease's natural history. Only a fraction of cases of idiopathic DCM and HCM have an identifiable genetic cause and, thus, lacking an identified mutation does not preclude an inherited cardiomyopathy.

A case of unilateral extremity swelling

A case of unilateral extremity swelling

May-Thurner Syndrome: An often-missed cause of chronic pelvic pain.

May-Thurner syndrome (MTS), or iliac vein compression syndrome, is a pelvic condition that involves compression of the iliac veins resulting in endothelial damage. This condition is typically asymptomatic and often missed in primary care. As progression occurs over time, symptoms related to venous hypertension may be present including acute extremity pain and swelling, pelvic pain, venous claudication, deep venous thrombosis, or chronic development of venous insufficiency. A case report is provided to enhance primary health care providers' knowledge of MTS and promote early detection and recognition to enhance positive and expedited outcomes.

P094 Henoch–Schonlein purpura and inflammatory bowel disease

BACKGROUND: Approximately 7.5% of children with inflammatory bowel disease (IBD) develop cutaneous extra-intestinal manifestations, with erythema nodosum, pyoderma gangrenosum, and psoriasis being the most common. Although rare, cases of cutaneous small-vessel vasculitis in children with IBD have been reported. CASE: An 8 Y/M with ileo-colonic Crohn disease presented with 3 days of bilateral lower extremity swelling and 1 day of tender palpable rash on the right arm, chest and dorsal surface of the right foot. Crohn disease was diagnosed at age 5 years and was on mesalamine for treatment at the time of presentation. A year ago he had been on infliximab infusions, but had to stop the treatment after a severe infusion reaction. On exam, patient was uncomfortable, unable to bear weight, afebrile, and without abdominal pain or tenderness to palpation. He had limited range of motion of right foot secondary to pain. No joint swelling was noted. He had a palpable purpuric rash on his right arm, chest and dorsal surface of the right foot. Urinalysis was positive for trace protein and ketones. His ANA titers were positive and rheumatoid factor was negative. A clinical diagnosis of Henoch-Schonlein purpura (HSP) was made based on the typical rash and urinalysis. He was treated symptomatically with acetaminophen and did well subsequently DISCUSSION: HSP occurs in approximately 10–22 persons/100,000 each year. More than 90% of patients are children younger than 10 years, with a peak incidence at 6 years of age. HSP is the most common vasculitis in children and has a slight predominance in males. The clinical features of HSP are a consequence of widespread leukocytoclastic vasculitis owing to immunoglobulin A deposition in vessel walls. In 15% to 20% of patients, the gastrointestinal symptoms precede the diagnostic rash by a number of days. In such patients, IBD is a diagnostic consideration, even though the coexistence of HSP and IBD is quite uncommon. In this report, we describe a child with Crohn disease who developed HSP 3 years after diagnosis. HSP can be seen as a complication of infliximab or adalimumab therapy, but our patient was not on biologic therapy at the time HSP diagnosis.

The association of Klippel-Trenaunay syndrome and abdominal aortic aneurysms

A 71-year-old woman described a gradual progression of right lower extremity swelling, which had been a lifelong problem. Physical examination revealed a right lower extremity femoral port wine stain (A), superficial venous varicosities (A), right gluteal and posterior thigh soft tissue swelling, and violaceous skin coloration, consistent with venous malformation (B). The right leg was longer than the left and the right thigh and calf were significantly larger than the left. There was 2+ right ankle edema and right thigh lymphedema, with only trace edema on the left.

Chest Pain in a Football Strength Coach

HISTORY: A 29-year-old adopted, African American male football coach traveled with the football team to Colorado to hike Pikes Peak. At 14,000 feet, he developed mid-sternal chest pain that radiated to his left upper abdomen and left shoulder. The pain worsened with deep breathing and exertion. He presented to a local ED, where a CT abdomen/pelvis revealed splenomegaly. Routine labs revealed a mild anemia and thrombocytopenia. Upon returning home, the pain continued for 2 days so he presented to clinic. There, he denied calf pain, extremity swelling, fever, nausea, palpitations, vomiting, hematuria, and syncope. He denied taking medications, supplements, and alcohol/drugs. He reported developing similar symptoms in 2015, also when hiking. At that time, he was diagnosed with pericarditis with symptom resolution in a few days. PHYSICAL EXAMINATION: Temp 36.9F, BP 132/61, HR 67, RR 16, O2 sat 97% At rest, he was alert and comfortable. Breathing comfortably with symmetric aeration; no wheezing or crackles. Heart had regular rate and rhythm, without murmur. Abdomen was soft and non-distended, though he was tender to palpation in the left upper quadrant. No lower extremity edema; calves were symmetric and non-tender to palpation. DIFFERENTIAL DIAGNOSIS: Pulmonary Embolus Pericarditis Mononucleosis Sickle cell crisis in a patient with sickle cell trait TEST AND RESULTS: A CT angiography chest, chest radiograph, and abdominal ultrasound were obtained and were notable for splenomegaly (14.3cm); otherwise unremarkable. An EKG revealed sinus bradycardia with sinus arrhythmia. Labs were obtained including CBCPD, CMP, CK, haptoglobin, LDH, and hemoglobin electrophoresis, and notable for a mild anemia (hemoglobin 12.2), thrombocytopenia (platelets 52), mild transaminitis (AST 42, ALT 37), and evidence of hemolysis (haptoglobin < 10, LDH 486, CK 348). Hemoglobin electrophoresis was consistent with sickle cell trait. FINAL WORKING DIAGNOSIS: Sickle cell crisis in a patient with sickle cell trait TREATMENT AND OUTCOMES: 1. Trended labs for 2 weeks. 2. Avoid strenuous activity until pain resolved. 3. Provide counseling regarding hydration, heat illness, and training especially at altitude. 4. Follow up with hematology. 5. Consider screening NCAA coaches/athletic trainers given NCAA athletes are screened for sickle cell.

IPC01. The Utilization of Bilateral Lower Extremity Venous Duplex in Patients With Bilateral Lower Extremity Swelling in an Acute Setting: Emergency Department

IPC01. The Utilization of Bilateral Lower Extremity Venous Duplex in Patients With Bilateral Lower Extremity Swelling in an Acute Setting: Emergency Department

Clinical Significance of Late Onset Arthritis in Kawasaki Disease

Objectives: The aim of this study was to report the prevalence, clinical course, and sequela of arthritis in Kawasaki disease (KD), and to establish its relationship to coronary outcomes. Methods: We retrospectively reviewed the records of 524 patients between March 2006 and February 2016. Results: The overall prevalence of arthritis was 17.6 % (n = 92/524) and among them, 21 cases (22.8%) had late-onset arthritis and they were older (32.7 ± 12.1 vs. 62.5 ± 23.8 months), had longer fever duration (5.8 ± 1.94 vs. 7.11 ± 2.51 days), more frequent swelling or redness of extremities (35.2 vs. 71.5%), higher neutrophil counts (58.69 ± 13.84 vs. 72.16 ± 16.43%), and higher prohormone brain-type natriuretic peptide levels (ProBNP, 1343.80 ± 1080.44 vs. 3754.42 ± 4272.71 pg/mL) than patients with early onset arthritis. Coronary artery changes were not different and no patients complained of chronic arthritic changes, regardless of arthritis type. Conclusions: Although late-onset arthritis was found in KD patients who were older with longer fever duration, more frequent swelling or redness of extremities, higher neutrophil counts, and higher ProBNP levels than early-onset arthritis patients, there was no statistical significance between arthritis onset type and coronary artery changes, and outcomes were excellent with no chronic arthritis change.

191P - Imaging-proven venous thromboembolism among breast cancer patients in a tertiary hospital in the Philippines from 2010-2015

Background: Venous thromboembolism (VTE) is a common cause of mortality in cancer patients. This paper looks into prevalent characteristic of breast cancer in association with VTE, if any. Methods: Hospital patient database were gathered from 2010-2015 with Venous Dupplex Scan or Computed Tomographic Pulmonary Angiography. Each result were reviewed for final conclusion bearing acute pulmonary embolism or acute thrombosis. Only the first VTE event after the diagnosis of cancer was considered. Results: There were 10,380 CTPA/Venous duplex scan performed for the year 2010-2015, where 916 (8.8%) had positive venous thromboembolism. Of the patients who had positive for venous thromboembolism, 208 (2%) had malignancy. Among all the malignancy-associated venous, majority 17.9% (n = 37) had breast cancer. Mean age for Breast cancer patients who had positive VTE was 60.9(46-84) with majority 64.8% having normal BMI. Most had VTE of lower extremities 75.67%, presented with swelling of extremities 48.6%. Twenty-one patients (57.7%) had VTE within one year of cancer diagnosis, 8(21.6%) had VTE more than two years from cancer diagnosis. Sixteen (43.2%) were alive for more than two years from VTE diagnosis, 14 (37.8%) died within 3 months to one years from VTE diagnosis. During the time of VTE diagnosis, active cancer management were chemotherapy 17 (45.9%), hormonal therapy 12 (32.4%), surgery 4(10.8%), while 4(10.8%) had VTE as the presenting symptom of cancer diagnosis. Among those receiving chemotherapy, 11(64.7%) had VTE during chemotherapy days while 35% had VTE with one month after completion of chemotherapy. Those with hormonal therapy 83.3% had aromatase inhibitor, while only 5.4% received tamoxifen. Conclusions: Breast cancer patients with VTE have normal BMI, presenting as swelling of the lower extremity. VTE presented within one year of cancer diagnosis and were mostly alive for more than two years. Active cancer management during VTE diagnosis was mostly during chemotherapy and hormonal with aromatase inhibitor. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Penoscrotal edema: a case report and literature review

BackgroundPenoscrotal edema is typically caused by lymphatic obstruction, which can have both primary and secondary causes. Studies describing congenital penoscrotal edema are rare. Surgery can be divided into two types: The first approach involves extensive removal of diseased tissue and tissue reconstruction. The second approach is removal of the lesions and creating additional lymphatic vascular anastomoses.Case presentationWe present a case report of a 15-year-old patient with recurrent penoscrotal edema and swelling of both lower extremities. The literature were also reviewed to provide additional information. Physical examination revealed slow lymphatic reflux of the lower extremities and no obvious abnormalities in testicular morphology, bilaterally, or blood supply. Surgery was performed by excising the affected skin and subcutaneous tissue and the flaps was cut in the middle in Y shape to cover the penis and scrotum. Postoperative follow-up revealed wound integrity and patient satisfaction with the outcome.ConclusionExcision and reconstructive surgery are the primary treatments for penoscrotal edema. The majority of reported patients undergoing excision and reconstruction achieved satisfactory reshaping and improved their life quality.

SUN-581 An Unusual Presentation of Hypothyroidism

Introduction: Hashimoto’s thyroiditis (HT) rarely presents with clinical myopathy, with elevated muscle enzymes and acute kidney injury (AKI) due to rhabdomyolysis. A pilot study has suggested an increased prevalence of subclinical hypothyroidism in patients with unprovoked deep venous thrombosis (DVT). We report a case of HT presenting with asymmetric myopathy, AKI, and bilateral lower extremity DVTs, who responded well to thyroid hormone replacement. Case Description: A 58-year-old man with history of psoriasis presented with new erythematous plaques over the trunk and extremities for one month. He had episodic numbness and heaviness in the arms, thighs, and hands, especially when he held objects for sometime (e.g. steering wheel or holding a cell phone). He had difficulty in getting up from a sitting position. He also felt that his calves were swollen. He experienced stiffness in the hands. On examination, he had an asymmetric decrease in muscle power (4/5) in the proximal muscles of the upper and lower extremities. He had small circumscribed psoriatic plaques on the elbows, knees, and trunks. In addition, bilateral pitting edema was noted. Laboratory evaluation was remarkable for elevated creatinine phosphokinase 2310 IU/L, aldolase 15.6 U/L, elevated serum creatinine at 1.34 mg/dl, and elevated CRP at 9.5 mg/dl. Serological tests for connective tissue disease were all negative. Myositis associated and specific antibodies were negative. Electromyography was consistent with myopathic process with changes in numerous muscle groups bilaterally, most prominent in gluteus medius, lumbar, thoracic and cervical paraspinals. Nerve conduction study showed bilateral carpal tunnel syndrome. Three weeks later, his lower extremity swelling worsened. Ultrasound venous dopplers revealed bilateral DVT in the posterior tibial and peroneal veins. Thyroid function tests revealed elevated TSH (103.26 micro-IU/mL) and low free T4 (0.22 ng/dl). He has elevated thyroid peroxidase and thyroglobulin antibodies. He was hospitalized for management of unprovoked DVT and severe hypothyroidism secondary to HT. He was started on levothyroxine. Four weeks later, the myopathy resolved and muscle enzymes normalized. TSH improved to 35 micro-IU/ML. Discussion: HT presenting with clinical myopathy and DVT is extremely rare. Few features in this case raised the question of an alternative etiology for the myopathy – asymmetric proximal muscle involvement, acute to subacute course, and absence of myositis specific antibodies. In a pilot cross sectional study, increased prevalence of subclinical hypothyroidism was found in patients with unprovoked DVT, as noted in our case. This case highlights the atypical presentation of hypothyroidism due to HT. The identification of the hypothyroidism and initiation of thyroid hormone replacement improved the quality of life and physical function in our patient.

Consistently fitting orthopedic casts

Personalized orthopedic casts largely improve the comfortability and functionality for patients compared to classical plaster casts. Current attempts on the geometric modeling of customized casts have not taken the swelling of the patients' broken extremities into account that causes a gradual deformation during the healing process. Thus, the shape of the injured body parts is not constant during wearing a cast, but may change along with a decreasing swelling. In this paper, we propose a framework for generating 3D printed personal casts that consistently fit and adapt to such deformations and allow to use a single cast throughout the whole healing process. The cast consists of two layers, an outer rigid layer, which provides enough strength and protection of the body parts and an underlying flexible layer that offers adaptability to the deformations. Both layers can be fabricated with standard 3D printers and easily be assembled around the injured body parts. We show a number of 3D printed results and demonstrate the effectiveness of our approach.

SIGNET-RING CELL CARCINOMA OF UNKNOWN PRIMARY: A CASE REPORT AND REVIEW OF RELATED LITERATURE OF A RARE TYPE OF CANCER WITH A RARE PRESENTATION

PURPOSE: We report a case of metastatic signet-ring cell carcinoma (SRRC) of unknown primary presenting with superior vena cava syndrome and discuss our approach to diagnosis and management. METHODS: Case report and review of literature. RESULTS: A 53-year-old man, non-smoker, presented with a three-month history of worsening non-productive cough, upper back pain and facial and bilateral upper extremity swelling. On admission, he had a blood pressure of 180/100 mmHg, facial puffiness, neck vein engorgement, absent breath sounds with decreased vocal fremitus over the right lower lung and swelling of bilateral upper extremities. Work-up done revealed the following: (a) chest CT scan:right para-tracheal and hilar mass compressing the superior vena cava and bilateral pleural effusion; (b) fiberoptic bronchoscopy:extrinsic compression of the right lower lobe - superior lung segment; (c) pleural fluid and bronchoalveolar lavage histopathology:consistent with metastatic adenocarcinoma (SRCC subtype – positive for CK7, negative for CK 20, TTF-1, and calretinin), favoring a gastric or pancreaticobiliary primary; (d) abdominopelvic CT scan:slight fundic wall thickening and normal pancreas and bile duct; multiple scattered metastatic foci were noted. CONCLUSIONS: He gradually improved with radiotherapy and intravenous steroids. Out-patient chemotherapy was then planned. CLINICAL IMPLICATIONS: SRCC is an aggressive type of poorly differentiated adenocarcinoma with superior vena cava syndrome as a rare initial manifestation. Determining the primary site remains priority and is paramount in guiding further management. However, current evidences have mainly focused on palliative chemotherapy as treatment of choice in most cases.

MARKED FIRST-DEGREE ATRIOVENTRICULAR BLOCK ASSOCIATED WITH PSEUDO-PACEMAKER SYNDROME: A CASE REPORT

Distinctive atrioventricular type I heart block is diagnosed when the PQ interval is 0.30 s. or more. Prolongation of the PQ interval more than 0.50 s. is a very rare condition. Usually it is associated with a pseudo-pacemaker syndrome. The last one manifests itself with dizziness, syncope, general weakness, shortness of breath upon physical exertion, cough, seizures, cold sweat, a feeling of pulsation in the head, neck and abdomen, a headache, paroxysmal nocturnal dyspnea, swelling of the lower extremities, tachypnea and jugular venous pulsation. The P wave appears immediately after the previous QRS complex. Atrial contraction occurs at the moment when the ventricles don’t relax after the previous contraction; due to the fact that pressure in the ventricles at this moment is higher than in the atria, the tricuspid and mitral valves remains closed. During the atrial contraction, most of the blood is ejected not into the ventricles, but backward into the pulmonary veins from the left atrium and into the venae cavae from the right atrium. Also, an atrial kick is absent which results in a less ventricular filling. There is increased pressure in the atria leading to their distension and excessive secretion of the atrial natriuretic peptide.&#x0D; A case report of the distinctive atrioventricular type I heart block associated with the pseudo-pacemaker syndrome is described. The patient suffered from a pre-syncope, short-term dizziness during the previous two days, tinnitus, general weakness, feeling of pulsation in the abdomen, neck, head, which interfered with his sleep. He developed these complaints after an infectious disease, which manifested as a runny nose and sore throat. In this patient, an extremely prolonged PQ interval up to 0.70 s. was observed. Also, episodes of Mobitz I and Mobitz type II atrioventricular block were detected. During the monitoring of patient state, the interval PQ was gradually shortening, and in 1 month it reached the normаl duration.&#x0D; It can be assumed that in the case of distinctive atrioventricular type I heart block, a significant prolongation of the refractory period in the rapid pathways of the AV-node plays a key role in the pathogenesis of this condition.&#x0D; According to the recommendations of the ACC/AHA (1998), for patients with distinctive atrioventricular type I heart block accompanied by the pseudo-pacemaker syndrome and documented alleviation of symptoms with temporary AV pacing, the pacemaker implantation should be considered (IIaB). The implantation of dual chamber pacemaker may reduce symptoms and lead to an improvement in the functional state of patients, in whom shortening of the interval between atrial and ventricular contractions improves hemodynamics. For asymptomatic patients with the PQ interval of ≥ 0.30 s, pacemaker is not recommended. The distinctive atrioventricular type I heart block in patients with pseudo-pacemaker syndrome is a rare condition and often remains undiagnosed. But it may have a benign course with a gradual normalization of the PQ interval. Indications for permanent pacemaker implantation should be reviewed as this block may be completely reversible. A permanent pacemaker may be used in the case of absence of positive dynamics in a shortening of the PQ interval.&#x0D; &#x0D;

Granulomatous lobular mastitis: a clinicopathological analysis of 300 cases

Objective: To investigate the clinicopathologic features and possible causes of granulomatous lobular mastitis(GLM). Methods: Three hundred cases of GLM were collected from surgical specimens diagnosed at Longhua Hospital, Shanghai University of Traditional Chinese Medicine from January 2015 to November 2017. Morphologic features were reviewed using HE staining. A total of 116 cases were investigated by Gram staining. The expression of CD3, CD20, CD68, IgG, IgG4, CD38 and CD138 was detected by immunohistochemical staining. Results: The age of the patients was 23 to 47 years and the median age was 32 years. All patients were female, 96.7% (290/300) had a history of lactation.There were 143 cases of left breasts, 138 cases of right breast and 19 cases of bilateral breasts. Serum prolactin increased in 39.7%(119/300) patients. Within 15.7%(47/300) of patients were associated with nodular erythema or joint swelling and pain of the lower extremities. Pathological observation showed that lobular-centric suppurative granulomatous inflammation, accompanied by dilatation of intralobular and interlobular ducts. There were 16 cases accompanied with duct ectasia. Immunohistochemistry showed CD3-positive lymphocytes were more than CD20-positive lymphocytes in the peripheral aggregation zone of neutrophils within granulomatous lesions. Gram positive bacteria were found in the lipid vacuoles of the 51.7%(60/116) patients. Conclusions: GLM has distinctive histologic features. It may be related to corynebacterium infection, or accompanied by the increase of serum prolactin and erythrocyte sedimentation rate. The age, location and history of the disease are importance in the diagnosis and differential diagnosis.

Dominant Factors That Effecting The Working Position Change On Beverage Packing Enployment

Work done by standing requires a lot of energy compared to sitting. Because the standing position is an alert attitude peformed by the body both physically and mentally, so that the work activities carried out are faster, stronger and more thorough. Prolonged health problems related to standing position are discomfort of lower extremities and fatigue, swelling of lower extremity, back pain and fatigue throughout the body. The purpose of this study is to determine the dominant factors and the influence of the variables tested on changes in working position and the fatigue level that occurs. The analysis results with the assist of the SmartPLS program show that the dominant factor of each influential variable was work shift variable, the dominant indicator was the time of morning shift packing speed, the workload variable was the heart rate, and the physical work environment variable was air condition. While the variables that most influence the level of fatigue was changes in working positions that have a positive and significant effect.

Acute Megakaryoblastic Leukemia With Diffuse Periosteal Reaction of Bilateral Lower Extremities

We report the case of a 3-year-old girl diagnosed with acute megakaryoblastic leukemia, who presented after >1 year of bilateral leg pain. At times the pain was severe enough to prevent ambulation, prompting visits to her primary care provider. However, it was not until acute respiratory failure occurred with subsequent hospitalization in the pediatric intensive care unit that severe anemia and thrombocytopenia were discovered and the diagnosis of acute myeloid leukemia was made. Bilateral lower extremity swelling was noted on admission and radiographs showed diffusely abnormal appearance of the long bones of her lower extremities with periosteal reaction and echogenic debris in the subperiosteal space, thought to represent leukemic cells. This case highlights the importance of recognizing atypical signs and symptoms of myelodysplastic syndrome progressing to acute leukemia in the context of abnormal bone pain and radiographic changes.

Perioperative management of a patient with hereditary angioedema(HAE) undergoing endometrial ablation: A case report and review of literature

Introduction: HAE is a rare autosomal dominant disorder caused by deficiency of C1 esterase inhibitor. It is clinically characterised by recurrent face, skin or extremity swelling and gastrointestinal concerns and respiratory system failure. HAE manifestations in the upper respiratory system may lead to asphyxiation which is the primary cause of death. There are many known HAE episode inciting factors as medical or dental operations, stress, menstruation, infections or certain medications as estrogen containing pills. Perioperative prophylaxis with Danazol and C1 inhibitor concentrate (C1-INH) are commonly used to prevent angioedema episodes. Airway oedema and hypovolaemic shock due to the tissue leak of fluids are specially significant in the perioperative period, challenging even the most experienced anaesthesiologist.

The relationship between lower extremity swelling, quadriceps strength, and functional performance following total knee arthroplasty

BackgroundThe relationships between swelling after total knee arthroplasty (TKA) and quadriceps strength and functional performance are poorly understood.Therefore, the aim of this study was to examine the relationships between lower extremity swelling, measured using bioelectrical impedance assessment (SF-BIA), and quadriceps strength and timed up and go (TUG) times following TKA. Methods53 participants (64 ± 9.5 y/o, 43% male) undergoing primary unilateral TKA were recruited for the longitudinal observational study with repeated measures.Quantities of swelling were examined for contribution to two and six-week outcomes of strength and TUG time using hierarchical regression controlling for age, sex, and the baseline value of the dependent variable. Swelling was assessed using bioelectrical impedance assessment and quantified as the peak level of swelling and cumulative swelling (integral) over the post-TKA time window. Maximum isometric quadriceps strength (MVIC) was measured using a electromechanical dynamometer and participant functional performance measured using the TUG. ResultsNeither peak swelling nor cumulative swelling significantly contributed to the variance of two-week quadriceps strength. At six weeks, peak swelling significantly improved the variance in maximal quadriceps strength by an additional four percent (p = 0.05), while cumulative swelling did not significantly contribute. Peak swelling significantly contributed to the variance in two-week (16%) and six-week (five percent) TUG times (p < 0.05), but the cumulative swelling did not. ConclusionsPeak swelling represents a value of post-TKA swelling that is associated with strength and function. Reducing the peak level of swelling, occurring early after surgery, may improve patient functional recovery. Level of evidenceLevel II — Prospective observational study.