Left Forearm Research Articles

Kinetic methods used in the postoperative recovery of a patient diagnosed with a puncture wound and foreign body retention in the middle third of the posterior face of the left forearm

Due to its superficial positioning, the muscle is more frequently exposed to trauma than bone or joint elements. Muscle injuries can occur either as a result of external forces, such as a traumatic agent, or internal forces that affect muscle function. This paper presents a patient diagnosed with a puncture wound and retention of a for-eign body in the middle third of the posterior aspect of the left forearm, with its extraction following three surgical interventions. This type of injury presents an increased risk of af-fecting daily life activities. The patient was functionally assessed post-operatively upon inclusion in the rehabili-tation program, during the program to observe progress, and at the end of kinetic treat-ment. The rehabilitation plan must be preceded by an adequate assessment, followed by setting goals according to the patient's needs and test results. Consequently, the patient rigorously followed the initial kinetic exercise plan established by the physiotherapist, leading to an improvement in muscle strength, joint mobility, and motor control. This re-sulted in an increase in the quality of life and social-professional reintegration. Keywords: Osteoarthritis, knee, ultrasonography, cartilage, pain.

The curious case of subcutaneous dirofilariasis mimicking a fibroma - Report of a rare disease from North India.

Human dirofilariasis is a rare arthropod-borne zoonotic infection caused by a filarial nematode of the genus Dirofilaria. It typically manifests in humans as pulmonary, ocular, or subcutaneous lesions. In India, the disease is predominantly seen in the southern states, especially Kerala. Cases documented from India are mostly of ocular infection, and very few cases of subcutaneous dirofilariasis (SD) are reported. We hereby present a case of SD in a 25-year-old male, clinically diagnosed to have fibroma of the left forearm. Histopathology confirmed the diagnosis of SD. We present this case to reiterate that SD, though very rare in North India, should always be considered as a differential for subcutaneous swellings.

Clinicopathological analysis of EWSR1/FUS::NFATC2 rearranged sarcoma in the left forearm: A case report

BACKGROUND We present a case of an EWSR1/FUS::NFATC2 rearranged sarcoma in the left forearm and analyze its clinicopathological and molecular features. CASE SUMMARY The patient is a 23-year-old woman. Microscopically, the tumor cells were medium-sized round cells arranged in small nests. The cytoplasm was clear, nuclei were relatively uniform, chromatin was dense, nucleoli were visible, and mitotic figures were rare. Immunohistochemically, the tumor cells were positive for Vimentin, INI-1, CD99, NKX2.2, CyclinD1, friend leukaemia virus integration 1, and NKX3.1. Next-generation sequencing revealed the presence of the EWSR1-NFATC2 fusion gene. EWSR1/FUS::NFATC2 rearranged sarcomas are rare and can easily be misdiagnosed. CONCLUSION Clinical imaging, immunohistochemistry, and molecular pathology should be considered to confirm the diagnosis.

The impact of an immersive digital therapeutic tool on experimental pain: a pilot randomized within-subject experiment with an active control condition.

Pain is a complex and multifaced sensory and emotional experience. Virtual reality (VR) has shown promise in reducing experimental pain and chronic pain. This study examines an immersive VR environment initially designed for endometriosis patients, which demonstrated short-term analgesic effects. The research aims to determine the impact of the VR environment on experimental pain intensity and unpleasantness both during and after VR exposure (3D with binaural beats), while using an active control condition (2D with no binaural beats). Additionally, a secondary objective of the study was to identify the psychological and psychophysical factors that predict the analgesic effects of the immersive digital therapeutic tool. The study involved twenty-one healthy individuals and used a within-subject design, comparing a VR treatment with an active control condition. Continuous heat stimulation was applied to the left forearm with a Peltier thermode. Pain ratings were collected for immediate and short-term effects. In both the VR and Control conditions, there were no significant differences in pain intensity before, during, and after exposure. However, during VR exposure, there was a significant decrease in pain unpleasantness as compared to before exposure (p < 0.001), with a 27.2% pain reduction. In the Control condition, there were no significant differences in pain unpleasantness during and after exposure. Furthermore, no psychological and psychophysical factors predicted the analgesic effects. The study investigated how a VR environment affected experimentally induced pain in healthy volunteers. It showed that VR reduced pain unpleasantness during exposure but had no lasting impact. The VR environment mainly influenced the emotional aspect of pain, possibly due to its inclusion of binaural beats and natural stimuli. The study suggests that the VR environment should be tested in chronic pain population with high distress levels. NCT06130267.

Merkel cell carcinoma - particularities and morphological aspect of a unique and rare entity

Abstract Introduction: Merkel cell carcinoma is a very rare malignant neoplasm which presents high aggressivity, high recurrence rate and has meta-static potential. Our purpose is to present the histological and immunohistochemical particularities of Merkel Cell Carcinoma while reviewing potential differential diagnoses and challenges that we can encounter in daily practice. Case presentation: We present the case of an 86-year-old female patient who presented with a nodular tumour located in the left forearm, raising suspicion of a soft tissue tumour. The histological appearance of this unique type of cancer is highlighted on the Haematoxylin-eosin stain as a solid tumour composed of nests and chords of monomorphic cells. The nuclei of these tumoral cells appear characteristically as enlarged with dispersed chromatin. The immunohistochemical reactions have been performed and it was observed that the tumoral cells exhibited positivity for synaptophysin, CD56, NSE, EMA, as well as a “dot-like” expression for CK20. These histopathological and immunohistochemical features were consistent with a diagnosis of MCC, stage pT3, based on the assessment of tumour size. Conclusions: Sometimes, differentiating this tumour from other primary malignant neoplasms of the skin or even cutaneous metastases can be difficult. Immunohistochemistry remains the most important tool of diagnosis, especially for differentiating this neoplasm from metastatic neuroendocrine tumours that can affect the skin.

A case series of forearm compartment syndrome complicating transradial cardiac catheterization

BackgroundAcute compartment syndrome following a transradial coronary approach is rare. However, as the incidence of coronary arterial disease increases due to lifestyle factors and multiple comorbidities, transradial coronary angiography has become more common for diagnostic and therapeutic purposes in cardiovascular centers. Despite its rarity, we encountered two cases of acute compartment syndrome within a 1-week interval in the cardiology unit of a tertiary hospital.Case presentationThe first case involved a 75-year-old woman diagnosed with non-ST elevation myocardial infarction (NSTEMI). A coronary angiogram was performed via an uncomplicated right radial artery puncture. Following the procedure, the patient experienced significant swelling in the right forearm. An emergency fasciotomy release of the right forearm was conducted, revealing a gushing hematoma upon entering the flexor compartment. Fortunately, the wound healed well two months postoperatively with no functional deficits. In the second case, an 80-year-old man presented with severe angina pectoris upon exertion and was diagnosed with NSTEMI. The following day, he developed compartment syndrome in the left forearm, necessitating an emergency fasciotomy. Intraoperative examination revealed muscle bulging within the forearm compartments accompanied by extensive hematoma. Postoperatively, a deranged coagulation profile caused oozing from the wound. However, since there was no arterial bleeding, a compression dressing was applied. This led to a gradual drop in hemoglobin levels and worsened his heart condition. Despite resuscitative efforts and attempts to correct the coagulopathy, the patient experienced cardiorespiratory arrest and succumbed to ischemic heart disease in failure.ConclusionClinicians must remain vigilant in identifying this potentially limb-threatening condition. Patients with pre-existing anticoagulant therapy and underlying atherosclerotic disease are at a higher risk of bleeding complications. Implementing effective hemostasis techniques and promptly managing swelling can help prevent the occurrence of compartment syndrome. Timely assessment and maintaining a high level of clinical suspicion are paramount. If necessary, early consideration of decompressive fasciotomy is essential to avert catastrophic outcomes.

Utilizing Low-cost Vacuum-assisted Closure as Adjuvant Therapy in Soft Tissue Reconstruction for a Mangled Upper Extremity

Summary: Soft tissue reconstruction using flaps in managing mangled injuries is occasionally insufficient due to large defects and low flap viability. Conversely, delaying the closure of the defect can elevate the risk of infection. Adjuvant therapy becomes essential in the management of mangled injuries. We aim to present the use of low-cost vacuum-assisted closure (VAC) as an adjuvant therapy for mangled injuries. We reported the case of a 20-year-old man who sustained a mangled injury to his left forearm in a traffic accident 4 hours before admission. The mangled extremity severity score was 9; however, the patient declined amputation. Although the initial reconstruction was done, the flap could only cover vital structures. VAC was utilized to address the uncovered portion of the defect, to promote optimal granulation and prevent infection. The reconstruction proceeded with a skin graft and wrist arthrodesis. At 1-year follow-up, viable tissue was obtained but contracture occurred at the metacarpophalangeal and proximal interphalangeal joints. We intend to perform functional reconstruction at a later stage. Although the benefits of VAC in wound management are well established, reports regarding its advantages in mangled injury management remain relatively scarce. The high cost of VAC is a limiting factor, particularly in developing countries. This prompts the need for an affordable VAC innovation with comparable efficiency to the commercial model. Reverse Aqua Pump VAC, our innovative low-cost VAC, shows satisfactory outcomes in managing patients with mangled injuries with mangled extremity severity score indicating amputation.

Left-Sided Pneumothorax in a Potential Kidney Transplant Recipient—A Surprise in the Surgical Ward: Case Report

The risk of morbidity and mortality in the group of people qualified for kidney transplantation is high. Although currently, the qualification for kidney transplantation is very extensive and detailed, the final examination and assessment at the transplant center is crucial for the success of the transplantation. A 50-year-old woman with end-stage kidney disease was admitted to the Department of General, Vascular, and Transplant Surgery on July 21, 2023, for kidney transplantation. A month earlier, she had undergone surgery to create an arteriovenous fistula on the left forearm. The regional anesthesia was performed. Apart from temporary pain and cough, the postoperative course was uncomplicated. Upon admission to the Department, the patient was in good general condition, and only a dry cough was noted during the physical examination. Chest X-ray revealed pneumothorax on the left side with partial lung atelectasis. The patient was temporarily disqualified from kidney transplantation and the pneumothorax was cured. She is currently on the active list waiting for a kidney transplant. The analysis of the above case emphasizes the importance of a physical examination and final qualification at the transplant center. Detailed examination and evaluation at the above center can improve patients' quality of life and survival.

Cartilage within lipomyelomeningocele and ulnar longitudinal deficiency syndrome as VACTERL association, alliance in SHH/GLI3, and Wnt pathway: illustrative case.

Lipomyelomeningocele associated with an ulnar club hand in the spectrum of VACTERL association ([costo-]vertebral abnormalities; anal atresia; cardiac defects; tracheal-esophageal abnomalities, including atresia, stenosis, and fistula; renal and radial abnormalities; limb abnormalities; single umbilical artery) is a very rare and infrequently reported phenomenon. Within the fat mass of the lipoma, it is not common to find a well-defined cartilaginous mass with no attachments to the surrounding tissue. The authors present the case of a 3-month-old male with low-back swelling that was off-center to the left, accompanied by a left short forearm displaying outward bowing. Echocardiography showed an atrial septal defect. This rare VACTERL association comprises lipomyelomeningocele, atrial septal defect, and ulnar longitudinal deficiency syndrome. During surgical intervention for the lipoma, a well-defined cartilaginous mass was discovered within the adipose tissue. The manifestation of VACTERL association can be partially explained by the Shh/Gli and Wnt pathway defects. It is prudent to screen children with neural tube defects to be aware of any associated syndromes. This case is very rare, and the literature has contained no prior report on the VACTERL association of lipomyelomeningocele, atrial septal defect, and ulnar longitudinal deficiency.

Ergonomic Interventions in Knowledge-based Companies

Objectives: In the last decade in Iran, the highest prevalence of musculoskeletal pain and discomfort among office workers has been reported in the neck, back, and shoulder areas. The present study aimed to assess the impact of ergonomic interventions in knowledge-based companies on musculoskeletal disorders, work-related stress, and quality of work life. Methods: In this quasi-randomized controlled trial study, the participants, including 311 office workers, received ergonomic interventions at both individual and managerial levels. Results: The implementation of individual ergonomic training interventions significantly reduced disorders in the neck, right and left shoulders, right forearm, and right wrist. Social support also demonstrated a significant increase in all three intervention groups. The interventions had a significant impact on the quality of working life. The changes in the mean quality of working life for the second and third groups in the first month of growth were significant and then continued similar to the trend of the control group. Conclusion: The implementation of individual ergonomic training interventions significantly reduced musculoskeletal disorders in the neck, shoulders, and upper limbs. Nonetheless, management training interventions did not affect the musculoskeletal disorders of employees. Furthermore, concurrent implementation of individual ergonomics and management interventions exerted a more pronounced effect on the reduction of disorders. The implementation of management educational interventions and combined interventions led to a marked increase in the level of control experienced by participants, while both types of social support interventions also increased. The implementation of a multi-component ergonomics intervention program was demonstrated to enhance the impact of interventions on employees' health and productivity.

Radiation exposure in therapeutic endoscopic retrograde cholangiopancreatography with two types of fluoroscopy systems

AbstractFluoroscopy is necessary for endoscopic retrograde cholangiopancreatography (ERCP). Occupational radiation exposure of staff (endoscopists, nurses, or assistants) is inevitable. Fluoroscopes with a tube over‐couch (OC) rather than under‐couch (UC) may have more radiation reflection dosage on the staff's upper body theoretically, where the most vital organs are. In the study, we assessed the radiation exposure on staff by two different types of fluoroscopes in real‐world practice. Using a radiation dosimeter to measure the radiation dosage on endoscopists and assistants in each ERCP procedure under two different fluoroscopic systems (UC vs. OC). Forty‐one ERCP procedures were enrolled. Dosimeters were used NanoDots for the measurement of personal radiation exposure. Those dosimeters were attached to the left forearm and chest of the endoscopist and only the chest of two assistants, the wall of the ERCP room, and the controlling room in every procedure. Nine‐teen ERCPs were performed under the OC unit, and the other 22 ERCPs were UC method. Fluoroscopic time and output of radiation dose showed no significant difference between the two groups. Radiation exposure in endoscopist were 0.0911[0.1041–0.3974] mGy (OC) versus 0.0276 [0.0080–0.2924] mGy (UC), p &lt; .01 for the forearm; and 0.0318 [0.0070–0.2628] mGy (OC) versus 0.0182 [0.0088–0.1628] mGy (UC), p = .04 for the endoscopist's body. There was no difference in radiation exposure from assistants in both groups. For all the ERCP procedures, the measurement of radiation exposure from high to low is endoscopist's hand, endoscopist's body, assistant 1, assistant 2, and ERCP room (p &lt; .01). Radiation detection from ERCP room is slightly higher but close to controlling room (p = .06). For the safety of occupational radiation protection, tube of fluoroscope UC is better than OC for the endoscopists more than assistants. Besides, the assistant 1 took higher radiation exposure than assistant 2 for each ERCP procedure.

Prevention of Musculoskeletal Injuries in Gastrointestinal Endoscopists

Gastroenterologists are exposed daily to musculoskeletal (MSK) stress during upper and lower gastrointestinal endoscopy, both during routine endoscopies and during long, demanding therapeutic procedures. There is evidence that endoscopy-related MSK injuries are becoming more common, particularly in the back, neck, shoulders, elbows, and hands. The aims of this study were to identify the most stressed muscle groups during endoscopy; to measure their activity using surface electromyographical (EMG) sensors; to detect areas of muscle overload; and to identify the number of microbreaks taken in specific muscles. Furthermore, we measured differences in the loading of these muscle groups with and without the use of special support systems such as a belt-like holder. Measurements were performed on 15 subjects (7 experienced endoscopists and 8 non-endoscopists). Due to this small sample size, inside each group, we achieved inconclusive results regarding statistically significant differences in different muscle groups. We increased the sample size by comparing all participants with and without the belt support system, disregarding their endoscopic background. There was a statistically significant difference (p &lt; 0.05) in muscle tension and in levels of microbreaks in the muscles of the left forearm, biceps, and trapezius muscles. No statistically significant difference was observed in the muscle tension and level of microbreaks in the left deltoid muscle (p &gt; 0.05). We hypothesize that the increased level of muscle loading and decreased level of microbreaks in the deltoid muscle are due to different muscle activity and different shoulder movements. Additionally, the deltoid muscle is not connected to the kinetic chain of body posture and stabilization. It is our belief that MSK injuries in gastrointestinal (GI) endoscopy can be prevented with the use of a belt-like support system.

Pediatric extremity rhabdomyosarcoma–A diagnostic dilemma

Rhabdomyosarcoma (RMS) is a common soft-tissue malignancy of childhood, accounting for approximately 7% of cancers in children. They arise from primitive mesenchymal cells of skeletal muscle differentiation and occur most commonly in the head-and-neck region. Despite aggressive approaches, the overall outcome remains poor. Here, we present the case of a 9-year-old girl who presented with complaints of swelling over the left forearm for 2 months. Magnetic resonance imaging revealed a well-defined lobulated mass in the flexor compartment of the left forearm, suggestive of soft-tissue neoplasm. A biopsy done of the mass showed a malignant round blue cell tumor. Immunohistochemistry led to the diagnosis of RMS. The patient was started on multimodal therapy and is doing well on follow-up. Extremity swelling in the pediatric age group with malignant round cell morphology can pose diagnostic difficulty. A detailed work-up is essential for an accurate diagnosis. This case report emphasizes the role of a multimodality approach to the diagnosis and treatment of pediatric RMS.

Human Protothecosis: Case Report of a Rare Algal Infection

Protothecosis: is a rare disease caused by opportunistic algae infection of the genus Prototheca. An 84-year-old female patient has presented with an erythematous, infiltrated, papulopustular plaque with areas of central atrophy on the left forearm for the past 10 months. Histopathology revealed structures similar to morulae, corresponding to algae, and culture was positive for Prototheca spp. Itraconazole 200 mg/day was prescribed, resulting in improvement of cutaneous lesions. Protothecosis has a high potential for underreporting and misdiagnosis due to its rarity and linical similarities with other dermatoses. The patient in this study presented a lesion in a typical area due to the ease of trauma and entry point, with a good therapeutic response to oral antifungal monotherapy.

Can single-use versus standard duodenoscope improve ergonomics in ERCP? A comparative, simulation-based pilot study.

Background and study aims Musculoskeletal disorders (MSDs) and injuries (MSIs) are frequent in gastrointestinal endoscopy. The aim of this study was to assess potential ergonomic advantages of a lighter single-use duodenoscope compared with a standard reusable one for endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP). Methods Three experienced endoscopists performed an ergonomic, preclinical, comparative protocol-guided simulation study of a single-use and a standard reusable duodenoscope using an anatomic bench model. Surface EMG signals from left forearm and arm muscles were recorded. A commercial inertial sensor-based motion capture system was applied to record body posture as well. Results A significant lowering of root mean square amplitude and amplitude distribution of biceps brachii signal (ranging from 13% to 42%) was recorded in all the participants when using a single-use duodenoscope compared with a reusable one. An overall reduction of muscle activation amplitude and duration was also associated with the single-use duodenoscope for forearm muscles, with different behaviors among subjects. Participants spent most of the time in wrist extension (> 80%) and ulnar deviation (> 65%). A consistent pattern of functional range of motion employed for completing all procedures was observed. Conclusions Our study showed that a lighter scope has a promising effect in reducing upper arm muscle activity during ERCP with potential benefit on musculoskeletal health in the ERCP setting.

Painful eccrine spiradenoma containing nerve fibers in the forearm: a case report

Eccrine spiradenomas are rare benign adnexal tumors that originate from the eccrine glands. They mainly arise in the head, neck, and upper trunk of young adults and are sometimes accompanied by pain and tenderness. Although spontaneous pain is a typical symptom of eccrine spiradenoma, the underlying mechanism remains unclear. We report the case of a patient who had a spiradenoma in the subcutaneous tissue of the left forearm that was accompanied by agonizing pain triggered by pressure. A 42-year-old man who had undergone surgical excision of a left forearm mass 5 years ago presented for relapsed pain and a palpable mass at the previous excision site. The agonizing pain had been triggered a few days ago, in response to even a slight touch. The mass measured approximately 0.8×0.8 mm, and ther e were no changes visible around the scar. Irregularly shaped masses, each measuring approximately 5 mm, were removed with a 2-mm safety margin from the subcutaneous fat. A histopathologic examination revealed the resected nodules were surrounded by delicate fibrous capsules, some parts of which contained blood vessels and prominent thickened nerve fibers. By the time of the 6-month follow-up, the masses had not recurred, and the biopsy site was well maintained without pain. We describe the surgical and histopathologic findings of an isolated eccrine spiradenoma accompanied by recurrent agonizing pain. The peculiar microscopic arrangement of the thickened nerve fibers encasing the nodule of eccrine spiradenoma may correlate with its pain mechanism.

Skin lightening properties of zerumbone cream: A placebo-controlled study.

Despite the demonstrated anti-melanogenic and UV protective effects of Zerumbone (ZER) invitro, there is a lack of clinical trials that have been done to assess these properties. The primary objective of this study was to assess the effectiveness of ZER in lightening the skin tone of human participants with a single-blind approach. Twenty-six participants were randomly assigned to two groups to investigate the application location (left or right volar forearm) for the placebo and ZER creams. Both creams were topically administered to the volar forearms twice daily over a duration of 4 weeks. Initial skin irritation was assessed before and 30 min after applying creams. The melanin and erythema levels were quantified with Mexameter MX 18. Twenty participants were included in the analysis. The cream formulation had excellent physical properties and was well-received by the participants. The initial skin irritation study results indicated that neither of the creams elicited an allergic reaction. The administration of ZER cream resulted in a statistically significant reduction in melanin levels (p < 0.05) after 1 week compared to the initial baseline. Furthermore, after 2 weeks of application, ZER cream demonstrated significant differences in melanin levels compared to placebo (p < 0.05). No adverse effects were observed in the group using ZER cream. ZER demonstrated significant potential as a skin-lightening agent.

The second cutaneous anthrax infection diagnosed by metagenomic next-generation sequencing: A case report.

Anthrax is a severe zoonotic infectious disease caused by Bacillus anthracis. Most reported cases were traditionally diagnosed through culture and microscopy. We reported here the second case of cutaneous anthrax diagnosed by metagenomic next-generation sequencing (mNGS). A 63-year-old man had a history of contact with an unwell sheep, developing local redness and swelling on wrist. The dorsal side of the left hand and forearm, with tension blisters on the back of the left. B anthracis was detected from culturing and mNGS of tension blisters. On the second day of admission, the patient was administered 3.2 million units of penicillin every 6 hours, and isolated and closely observed. The patient improves and is discharged. Traditional bacterial cultures are time-consuming, while mNGS offers the advantage of accurate, quick, high-throughput, unbiased sequencing of all genetic material in a sample, which is a good technical tool for assisting in the diagnosis of rare pathogen infections.

A case of a large and kidney-shaped thoracic mass

A 60-year-old woman with a high-grade myxofibrosarcoma of her left forearm, submitted to surgical excision and postoperative radiotherapy, presented to the emergency department, after 3 years, with a 2-months history of progressive asthenia and shortness of breath.

Temporal evolution of postsurgical bone repair in a rabbit model: A [99mTc]Tc-MDP scintigraphic study.

Bone regeneration is crucial for repairing bone tissue following various injuries. Research techniques that enable the study of metabolic changes in bone tissue under different conditions are important for understanding bone repair and remodeling. This study used bone scintigraphy to evaluate osteogenesis secondary to osteotomy in a preclinical model of New Zealand rabbits. For this purpose, we conducted a longitudinal, prospective, case-control study in which scintigraphic variables were measured in both the right forearm (case-operated) and the left forearm (control - non-operated). The study sample consisted of 10 rabbits subjected to osteotomy, followed by a 12-week postoperative evaluation period, divided into six imaging stages at 1, 2, 3, 4, 8, and 12 weeks. We observed that the operated forearm showed significantly higher external radiation than the control side, using the pinhole collimator, denoting an increase in the biodistribution and tropism of the radiopharmaceutical to the operated forearm. Among the three evaluated time points, osteoblastic activity was highest in the second week and presented a significant decline in the 8th and 12th weeks, denoting regeneration and resolution of the surgical injury; the control forearm was also influenced by the inactivity imposed by the operated forearm. This fact was notably evidenced by the reduction in the metabolic activity of osteoblasts in the left forearm. Our study suggested that bone scintigraphy was sensitive enough to semi-quantitatively differentiate the metabolic activity of osteoblasts in the operated forearm in the three temporal landmarks evaluated in the study.