Small Soft Tissue Research Articles

Magnetic Resonance Elastography Methodology for the Evaluation of Tissue Engineered Construct Growth

Traditional mechanical testing often results in the destruction of the sample, and in the case of long term tissue engineered construct studies, the use of destructive assessment is not acceptable. A proposed alternative is the use of an imaging process called magnetic resonance elastography. Elastography is a nondestructive method for determining the engineered outcome by measuring local mechanical property values (i.e., complex shear modulus), which are essential markers for identifying the structure and functionality of a tissue. As a noninvasive means for evaluation, the monitoring of engineered constructs with imaging modalities such as magnetic resonance imaging (MRI) has seen increasing interest in the past decade. For example, the magnetic resonance (MR) techniques of diffusion and relaxometry have been able to characterize the changes in chemical and physical properties during engineered tissue development. The method proposed in the following protocol uses microscopic magnetic resonance elastography (μMRE) as a noninvasive MR based technique for measuring the mechanical properties of small soft tissues. MRE is achieved by coupling a sonic mechanical actuator with the tissue of interest and recording the shear wave propagation with an MR scanner. Recently, μMRE has been applied in tissue engineering to acquire essential growth information that is traditionally measured using destructive mechanical macroscopic techniques. In the following procedure, elastography is achieved through the imaging of engineered constructs with a modified Hahn spin-echo sequence coupled with a mechanical actuator. As shown in Figure 1, the modified sequence synchronizes image acquisition with the transmission of external shear waves; subsequently, the motion is sensitized through the use of oscillating bipolar pairs. Following collection of images with positive and negative motion sensitization, complex division of the data produce a shear wave image. Then, the image is assessed using an inversion algorithm to generate a shear stiffness map. The resulting measurements at each voxel have been shown to strongly correlate (R(2)>0.9914) with data collected using dynamic mechanical analysis. In this study, elastography is integrated into the tissue development process for monitoring human mesenchymal stem cell (hMSC) differentiation into adipogenic and osteogenic constructs as shown in Figure 2.

Small metal soft tissue foreign body extraction by using 3D CT guidance: A reliable method

ObjectiveTo introduce a useful and accurate technique for the locating and removal of small metal foreign bodies in the soft tissues. MethodsEight patients presented with suspected small metal foreign bodies retained in the soft tissues of various body districts. Under local anesthesia, 3–6 pieces of 5ml syringe needles or 1ml syringe needles were induced through three different planes around the entry point of the foreign bodies. Using these finders, the small metal FBs were confirmed under 3D CT guidance. Based on the CT findings, the soft tissues were dissected along the path of the closest needle and the FBs were easily found and removed according to the relation with the closest needle finder. ResultsEight metal foreign bodies (3 slices, 3 nails, 1 fish hook, 1 needlepoint) were successfully removed under 3D CT guidance in all patients. The procedures took between 35min and 50min and the operation times took between 15min and 25min. No complications arose after the treatment. Conclusion3D CT-guided technique is a good alternative for the removal of small metal foreign body retained in the soft tissues as it is relatively accurate, reliable, quick, carries a low risk of complications and can be a first-choice procedure for the extraction of small metal foreign body.

Isolated Muscular Cysticercosis: A Rare Pseudotumor and Diagnostic Challenge, can It be treated Nonoperatively? A Report of Two Cases and Review of Literature

ABSTRACT Cysticercosis, an infection with the larval form of pork tape worm, Taenia solium, commonly presents with multiple muscular cysts or CNS involvement. Due to vague clinical presentation and unfamiliarity of clinicians with this entity, it is difficult to diagnosis when seen as an isolated cyst. Traditional treatment is surgical excision and a course of deworming agents. We present two cases of isolated muscular cysticercosis diagnosed by USG, MRI and blood tests, who responded successfully to oral medication without need of operative intervention. Case reports A 45-year-old male patient had a tender 2 week swelling of 4 × 5 cm on medial right proximal calf. A 26-year male presented with discomfort and diffuse 6 cm swelling at inner left forearm. In both ultrasound showed characteristic hypoechoic cyst with hyperechoic scolex, and MRI revealed isolated cyst surrounded by inflamed muscles. FNAC confirmed cysticercosis, and the patient responded to oral albendazole (3 weeks) with oral steroids (2 weeks). Conclusion Although rare, possibility of isolated muscular cysticercosis should always be considered in any small musculoskeletal soft tissue swelling presenting with nonspecific clinical findings. Both our patients responded to medical therapy and were disease free, as confirmed at 3 months by follow-up MRI. These cysts can be confidently diagnosed on the basis of ultrasound and MRI, and can be very well-treated nonsurgically with an oral drug regimen consisting of albendazole and steroid. How to cite this article Rangdal SS, Prabhakar S, Dhatt S S, Prakash M, Dhillon MS. Isolated Muscular Cysticercosis: A Rare Pseudotumor and Diagnostic Challenge, can It be treated Nonoperatively? A Report of Two Cases and Review of Literature. J Postgrad Med Edu Res 2012;46(1):43-48.

Intraoperative Ultrasound Assistance for Excision of Impalpable Musculoskeletal Soft Tissue Tumors

Intraoperative ultrasonography is a useful tool for the detection and extirpation of liver metastases, breast masses, and melanoma. However, the efficacy of this technology in intraoperative localization and resection of small soft tissue tumors has not been addressed. The purpose of this study is to report on the efficacy of intraoperative ultrasound assistance in excising impalpable musculoskeletal soft tissue tumors. Twenty-two soft tissue tumors <3 cm (range, 0.7-3 cm) were resected with intraoperative ultrasound assistance. All tumors were localized in the deep panniculus, fascia, or muscle. Surgical time and length of incisions was recorded in all the cases. Intra- and postoperative reregistration was made to confirm the tumor resection. Ultrasound assistance was successful in obtaining an accurate localization in all treated cases. Mean surgical time was 30 minutes (range, 13-87 minutes). Average incision length was 5.7 cm (range, 2.5-10.6 cm). Reregistration allowed intraoperative confirmation of the adequacy of the excision. The procedure allowed recognized and excised additional nodules not previously diagnosed in 3 cases. Postoperative echography done in all patients confirmed complete extirpation of the tumors, and histopathology confirmed adequate margins obtained. Intraoperative ultrasound can be used as an efficient tool to localize and treat impalpable small soft tissue tumors.

Poster 03: Foreign Body Reaction to Injectable Fillers: A Case Report

Injectable fillers are a common modality to correct small volume soft tissue deficiencies of the face. There are very few recommendations present regarding patients in which other than normal caution should be exercised in filler selection. One such subset of individuals are those with autoimmune conditions undergoing modulatory therapy. A 64-yr-old female presented for evaluation of multiple perioral nodular submucosal lesions that were exquisitely painful. The lesions were present for a maximum of 4 weeks. Upon interview, the patient reported the following significant medical history: psoriatic arthritis, non insulin dependent diabetes mellitus (exacerbated by long term steroid therapy), hypertension, hyperlipidemia, ulcerative colitis, and a history of hospitalizations in the last year for fevers of unknown origin. The patient had been receiving various autoimmune therapies since 2006 with her most recent regimen consisting of Arava, Sulfasalazine, Remicaide infusions, and Prednisone therapy. Recently her rheumatologist had initiated a steroid taper and a Remicaide holiday due to concerns of drug-induced systemic lupus erythematosus. No history of previous cosmetic procedures was elicited during the initial interview. After discussion with the patient regarding conservative monitoring versus surgical therapy, a decision was made to have the largest and most painful lesion removed and submitted for pathologic evaluation. This procedure was completed under local anesthesia via an intraoral approach. The lesion was removed without complication and submitted in formalin for review. Of clinical significance, when removing the lesion, superficial dimpling was noted below the lip indicating extension into the dermis. The problem in question had a single however unique presentation in the aforementioned patient. Gross and histologic examinations were performed by in-house oral pathology. This case report occurred over a period of 8 months from initial evaluation to the most recent follow up. The histologic findings were as follows: the surgical specimen demonstrated variably dense fibrous connective tissue containing multifocal non-caseating granulomatous inflammation as characterized by aggregates of epitheliod histiocytes and surrounding foreign-body-type giant cells. The giant cell population was intimately associated or closely juxtaposed to abundant collections of amorphous, basophilic, and somewhat vacuolated-appearing foreign material. During the follow up appointment, the pathologic findings were discussed with the patient. The patient volunteered a history of perioral Restylane injections approximately 14 months prior. These findings were then discussed with the patient's rheumatologist. The rheumatologist decided to restart her Remicaide infusions and increase her prednisone dosage. This therapy resulted in a complete resolution of the remaining lesions in approximately 4 weeks. The patient has been followed for 8 months without recurrence. While average individuals do not typically mount severe inflammatory reactions to injectable filler material, the hyperinflammatory state that exists in patients with autoimmune disorders may predispose these individuals to a pronounced granulomatous reaction. This may be especially true when the patient is not medically optimized.

Mesenteric panniculitis part 2: prevalence and natural course: mdct prospective study

Mesenteric panniculitis (MP) is an uncommon benign inflammatory condition of unknown etiology that involves the adipose tissue of the mesentery. I can be evaluated as a single disease with two pathological subgroups: MP, representing the very large majoritary subgroup where inflammation and fat necrosis predominate and Retractile Mesenteritis, rarely found, where fibrosis and retraction predominate. To re-estimate the prevalence of MP in general population through a large prospective study, to compare the results with those of the literature and to evaluate the natural course of the condition. A continuous series of 613 consecutive unselected patients (280 females and 333 males) imaged with abdominal MDCT for various neoplastic (27%) or non neoplastic conditions (73%) constitutes the prospective material. A positive CT diagnosis of MP was based on the observation of at least three of five typical CT signs comprising: the presence of a well-defined "mass effect" on neighbouring structures (sign 1) constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent retroperitoneal or mesocolonic fat (sign 2), containing small soft tissue nodes (sign 3) typically surrounded by a hypoattenuated fatty "halo sign" (sign 4). Finally a hyperattenuating pseudocapsule may surround the all entity (sign 5). A positive diagnosis of MP was made in 48 patients (prevalence of 7,83%) on the basis of the presence of at least 3 CT signs. After reconsidering the presence of the "halo sign" (sign 4) and of the "pseudocapsule" (sign 5) as "sine qua non" conditions for a positive diagnosis, a more restricted positive group of 21 cases was constituted (prevalence of 3,42%) comprising 10 males (3%) and 11 females (3,93%). There were 14 "non-neoplastic" patients - 6 males (2,27 %) and 8 females (3,6%) - and 7 "neoplastic" patients - 4 males (3,73%) and 3 females (5,17%) -. The prevalence of MP appears much higher than previously reported and the reason probably resides in the major technological evolution experienced in CT imaging during the last decade. This high prevalence probably explains the spontaneous association with the numerous and probably unrelated clinical situations found in the literature. Finally the vast majority of cases are considered as idiopathic, benign an asymptomatic. Except a discrete higher prevalence found in patients presenting with bladder and/or prostatic neoplasms and with lymphoma in group 1 the general prevalence of MP in our study doesn't significantly differs in the "neoplastic" and "non neoplasic" groups of patients. We conclude that the value of MP in term of predictivity of an associated neoplasm is probably non relevant. Finally PET/CT is proved useful to correctly exclude mesenteric tumoral involvement in patients presenting with typical MP and follow-up studies show a great stability of the CT findings of MP in about 85% of cases.

Combined inhibition of the BMP pathway and the RANK-RANKL axis in a mixed lytic/blastic prostate cancer lesion

The purpose of this study was to investigate the influence of combined inhibition of receptor activator of nuclear factor kappa-B ligand (RANKL) and bone morphogenetic protein (BMP) activity in a mixed lytic/blastic prostate cancer lesion in bone. Human prostate cancer cells (C4 2b) were injected into immunocompromised mice using an intratibial injection model to create mixed lytic/blastic lesions. RANK-Fc, a recombinant RANKL antagonist, was injected subcutaneously three times a week (10 mg/kg) to inhibit RANKL and subsequent formation, function and survival of osteoclasts. Inhibition of BMP activity was achieved by transducing prostate cancer cells ex vivo with a retroviral vector expressing noggin (retronoggin; RN). There were three treatment groups (RANK-Fc treatment, RN treatment and combined RN and RANK-Fc treatment) and two control groups (untreated control and empty vector control for the RN treatment group). The progression of bone lesion and tumor growth was evaluated using plain radiographs, hindlimb tumor size, 18F-Fluorodeoxyglucose and 18F-fluoride micro PET-CT, histology and histomorphometry. Treatment with RANK-Fc alone inhibited osteolysis and transformed a mixed lytic/blastic lesion into an osteoblastic phenotype. Treatment with RN alone inhibited the osteoblastic component in a mixed lytic/blastic lesion and resulted in formation of smaller osteolytic bone lesion with smaller soft tissue size. The animals treated with both RN and RANK-Fc demonstrated delayed development of bone lesions, inhibition of osteolysis, small soft tissue tumors and preservation of bone architecture with less tumor induced new bone formation. This study suggests that combined inhibition of the RANKL and the BMP pathway may be an effective biologic therapy to inhibit the progression of established mixed lytic/blastic prostate cancer lesions in bone.

Hand and Foot Abnormalities Associated with Genetic Diseases

The small bones and soft tissues of the hands and feet can be affected by systemic disorders, and frequently, the findings are quite unique and virtually diagnostic for some genetic or metabolic disorders. Photographs and imaging studies for the hands and feet are available in a digitized system, which has been approved by our hospital institutional review board. Examination of these and their description can establish a relationship with some degree of certainty to a series of highly variable and uncommon clinical disorders. Description of the clinical, physiologic and genetic characteristics, and illustrations of hand and foot abnormalities are provided for an array of diseases, including Ellis-van Creveld syndrome, fibrodysplasia ossificans progressiva, achondroplasia, Kniest dysplasia, pseudo- and pseudo-pseudohypoparathyroidism, acromegaly, nail-patella syndrome, Marfan's disease, cartilage-hair hypoplasia, and several forms of mucopolysaccharidosis. The findings support the concept that many genetic disorders can often be diagnosed by clinical and imaging examination of the patient's hands and feet.

Ultrasound Dynamic Micro-Elastography Applied to the Viscoelastic Characterization of Soft Tissues and Arterial Walls

Quantitative noninvasive methods that provide in vivo assessment of mechanical characterization of living tissues, organs and artery walls are of interest because information on their viscoelastic properties in the presence of disease can affect diagnosis and treatment options. This article proposes the dynamic micro-elastography (DME) method to characterize viscoelasticity of small homogeneous soft tissues, as well as the adaptation of the method for vascular applications [vascular dynamic micro-elastography (VDME)]. The technique is based on the generation of relatively high-frequency (240–1100 Hz) monochromatic or transient plane shear waves within the medium and the tracking of these waves from radio-frequency (RF) echoes acquired at 25 MHz with an ultrasound biomicroscope (Vevo 770, Visualsonics). By employing a dedicated shear wave gated strategy during signal acquisition, postprocessed RF sequences could achieve a very high frame rate (16,000 images per s). The proposed technique successfully reconstructed shear wave displacement maps at very high axial (60 μm) and lateral (250 μm) spatial resolutions for motions as low as a few μm. An inverse problem formulated as a least-square minimization, involving analytical simulations (for homogenous and vascular geometries) and experimental measurements were performed to retrieve storage ( G′) and loss ( G″) moduli as a function of the shearing frequency. Viscoelasticity measurements of agar-gelatin materials and of a small rat liver were proven feasible. Results on a very thin wall (3 mm thickness) mimicking artery enabled to validate the feasibility and the reliability of the vascular inverse problem formulation. Subsequently, the G′ and G″ of a porcine aorta showed that both parameters are strongly dependent on frequency, suggesting that the vascular wall is mechanically governed by complex viscoelastic laws. (E-mail: guy.cloutier@umontreal.ca)

Hip, Groin &amp; Thigh Pain In A Semi-professional Football Player

HISTORY: A 24-year-old football player presented to clinic on crutches with 6 weeks of left hip pain starting 2 days post-game. Pain was dull, constant, intensity 6-10/10, radiating to knee, worse with walking, better supine. Refractory to Naproxen. Denied trauma, bowel/bladder change. Had 20 lb. weight loss, night sweats, fever, "knot" in left low back. Daily cigarettes, occasional alcohol, no injection drugs. Epidural injection worsened pain; leg "locked up," could not walk. Spine surgeon found spondylosis, referred for pelvis evaluation. PHYSICAL EXAMINATION: Unable to bear weight, FABER positive, hip rotation painful. Tender spinous processes, paraspinal muscles, femur, but no mass or skin change. Healed abscess at knee joint line. Abscess right arm. Wasting thigh muscle. Tender groin node. DIFFERENTIAL DIAGNOSIS: 1. sacroiliitis, bursitis, tendonitis, synovitis, capsulitis, iliotibial band syndrome, lumbar plexitis, Reiter's syndrome, ankylosing spondylitis, Lyme disease, food poisoning, inflammatory bowel disease, rheumatoid arthritis, eosinophilic granuloma, osteomyelitis. 2. radiculopathy, piriformis syndrome, hernia, meralgia paresthetica, facet syndrome, vertebral diskitis, nephrolithiasis, epididymitis. 3. fracture, contusion, sprain, strain, labral tear, femoroacetabular impingement, osteoarthritis. 4. Ewing's sarcoma, osteosarcoma, lymphoma, costochondroma, metastasis. 5. osteonecrosis, sickle cell disease. 6. chondrocalcinosis, pseudogout. 7. athletic pubalgia. TEST AND RESULTS: MRI: L5-S1 spondylosis, left proximal femur marrow edema in muscles, superficial femoral vessels, sciatic nerve, T2 hyperintense femoral diaphyseal lesion with small soft tissue mass. Xray: 14 cm destructive lesion posteromedial proximal femur with periosteal reaction, malignancy v. infection v. tumor. CT: no metastases. WBC 4.3, Hgb 10.1, Plt 200, ESR 42, CRP 6.1. Blood cultures: negative. Echocardiogram: No vegetations. CT-guided bone biopsy: acute osteomyelitis. FNA soft tissue: MRSA. FINAL/WORKING DIAGNOSIS: MRSA osteomyelitis. TREATMENT AND OUTCOMES: Irrigation and debridement. Infectious disease consult: antibiotics 3 months. Physical Therapy. Return to activity by week: 6: toe touch. 13: weight bear as tolerated & return to work. 25: run. 36: football.

'How to' guide to surgery

Veterinary RecordVolume 166, Issue 6 p. 180-180 Book Review ‘How to’ guide to surgery Manual of Small Animal Soft Tissue Surgery, Karen M. Tobias Richard J. Coe, Richard J. CoeSearch...

Treatment and outcome of giant cell tumors of the pelvis

Background and purpose Giant cell tumors (GCTs) of bone rarely affect the pelvis. We report on 20 cases that have been treated at our institution during the last 20 years.Methods 20 patients with histologically benign GCT of the pelvis were included in this study. 9 tumors were primarily located in the iliosacral area, 6 in the acetabular area, and 5 in the ischiopubic area. 8 patients were treated by intralesional curettage and 6 by intralesional resection with additional curettage of the margins. 3 patients with iliacal tumors were treated by wide resection. 2 patients were treated by a combination of external beam irradiation and surgery, and 1 patient solely by irradiation. In addition, 9 patients received selective arterial embolization one day before surgery. Of the 6 patients with acetabular tumors, 1 secondarily received an endoprosthesis and 1 was primarily treated by hip transposition. The patients were followed for a median time of 3 (1–11) years.Results 1 patient with a pubic tumor developed a local recurrence 1 year after intralesional resection and additional curettage of the margins. The recurrence presented as a small soft tissue mass within the scar tissue of the gluteal muscles and was treated by resection. No secondary sarcoma was detected and none of the patients developed pulmonary metastases or multicentricity. No major complication occurred during surgery.Interpretation We conclude that most GCTs of the pelvis can be treated by intralesional procedures. For tumors of the iliac wing, wide resection can be an alternative. Surgical treatment of tumors affecting the acetabular region often results in functional impairment. Pre-surgical selective arterial embolization appears to be a safe procedure that may reduce the risk of local recurrence.

Painful metacarpal bone lesion in a healthy young man: looks can be deceiving

A 33-year-old man was seen for severe pain and swelling on the dorsal side of his right hand (between the 2nd and 3rd metacarpal heads) for the last 9 months. He denied any trauma but admitted that his complaints were worse when he used his hand. The medical history was otherwise unremarkable for any systemic illness. He declared that his complaints had initially started with only pain and he had been diagnosed to have an overuse injury in another center. The hand X-rays had been inconclusive then. As he could have not improved completely with anti-inXammatory treatment, he was substantially evaluated also with regard to rheumatic disorders. Laboratory tests (including complete blood count, liver/renal function tests and acute phase reactants) were unremarkable. Due to lack of any overt diagnosis despite his persistent pain, he was seen even by a psychiatrist in the interim. He was also found to be psychosocially normal. After swelling (without erythema or warmth) had started to accompany his painful complaints, he was referred to infectious diseases department. Repeat laboratory analysis was again noncontributory. As two lymph nodes were detected in the ipsilateral axilla (0.5–1 cm), he was given cephalosporin (Wrst generation) therapy for 2 weeks (2 g/day). Since the patient did not beneWt from the treatment, the patient was consulted to us. Current physical examination revealed swelling (1.5 £ 2 cm) between the 2nd and 3rd metacarpal heads on the dorsal side of his right hand (Fig. 1a). The lesion was very painful on palpation. Lateral X-ray was suspective for a focal sclerotic thickening of the distal 2nd metacarpal bone (Fig. 1b). Sonographic evaluation disclosed an additional soft tissue reaction in the 2nd dorsal interosseous muscle. Magnetic resonance imaging was also performed but it could not demonstrate any other pathology. Eventually, the patient was decided to be operated. During surgery, a focal cortical thickening and a small reactive soft tissue lesion (3–4 mm) were detected and resected (Fig. 1c). Pathological examination was consistent with normal bone tissue and vascularized Wbroconnective tissue, respectively. On the postoperative 16th day, he was completely free of his aforementioned complaints. Although very few, there are similar cases of metacarpal bone involvement—either in the form of periostitis or in the form of osteotitis—in the literature. The spectrum encompasses stress-induced trauma [1], Paget disease [2], foreign body [3] and thyroid disease [4]. Further, the condition can easily mimic several forms of rheumatic diseases with metacarpophalangeal involvement. In this case, we could not illuminate an underlying reason for such an involvement. Accordingly, our message is simple and clear; despite every eVort including radiological, surgical and pathological procedures, it may sometimes be quite diYcult to ascertain the exact scenario. In this regard, although surgery always remains as the last resort in the management, the diagnostic/therapeutic algorithm may inevitably need to have such an end in certain patients. Clinicians should always be vigilant. M. Kurklu · O. Tatar Department of Orthopedics, Gulhane Military Medical Academy, Ankara, Turkey

TU-D-BRC-04: Evaluation of Positioning and Margin Selection in Image-Guided Whole-Pelvis Prostate IMRT

Purpose: To evaluate the interplay of margin selection and alignment strategies on image‐guided whole pelvis prostate IMRT using serial CTimage studies and deformable image registration.Method and Materials: Forty‐two CT scans of 7 patients are studied — each patient has one initial and 5 serial CT scans. Three PTVs are created on the initial CT scan using three different margins ranging from 3 to 13mm. Each PTV is used to create a unique IMRT plan, which is registered to the serial CT scans, by bony alignment or by prostate‐based alignment. The dose computed on the 5 serial CTimage sets is accumulated onto the initial CT using deformable image registration with mesh method (Pinnacle 8.1x). Results: Prostate‐based alignment introduces statistically significant increase of dose to rectum, prostate and seminal vesicles (SV), and reduction of dose to bladder, for all the three planning margins. There is no statistically significant difference in doses to vascular spaces expanded by 7mm or 10mm under either alignment. IMRT plans with small margins and soft tissue alignment compared to large margins with bony alignment show marginal statistically significant difference in rectal DVHs, prostate or SV coverage, and statistically significant increases in doses to bladder and vascular spaces. The reduction of margins around prostate and SV with soft tissue alignment will results in statistically significant reduction of dose to rectum, bladder, prostate and SV, but no statistically significant difference of dose to LN. Conclusion: Comparing the recommended planning strategies —(a) tight margins with prostate‐based alignment and, (b) large margins with bony anatomy alignment— we find that similar doses to rectum and targets are achieved, and a slight reduction in bladder doses occurs under strategy a. From these we recommend small margins with prostate‐based alignment to maximize sparing and target coverage.

Three-dimensional Morphological Analyses of Positional Dependence in Patients with Obstructive Sleep Apnea Syndrome

It is generally considered that patients with obstructive sleep apnea syndrome (OSAS) at increased perioperative risk should be placed in nonsupine positions throughout the recovery process; however, not all patients with OSAS show positional dependence. The authors hypothesized that morphological differences exist in three-dimensional (3D) soft tissue and craniofacial structures of the pharyngeal airway between positional and nonpositional OSAS. The subjects of the study were body mass index-matched, age-matched, and apnea hypopnea index-matched positional (n = 10) and nonpositional (n = 10) Japanese OSAS patients and body mass index-matched Japanese control subjects (n = 10). Pharyngeal magnetic resonance imaging and cephalometric radiography were performed during wakefulness. The patients with positional OSAS had a smaller volume of the pharyngeal lateral wall soft tissues, larger maxilla-nasion-mandible angle, and smaller lower facial height than the nonpositional OSAS and the control subjects. The patients with positional OSAS showed a significantly steeper sella-nasion-mandible angle and smaller craniofacial volume than the control subjects. There were no significant differences in tongue volume and 3D pharyngeal anatomical balance between positional and nonpositional OSAS. Multivariate stepwise regression for positional dependence showed that the dominant determinant was the volume of the lateral pharyngeal wall, followed by lower facial height and maxilla-nasion-mandible angle. Patients with positional OSAS have wider airways in the lateral parts, lower facial height, and more backward position of the lower jaw, which may explain differences in the maintenance of pharyngeal airway patency in the lateral sleep position.

Bedside Ultrasound for the Detection of Soft Tissue Foreign Bodies: A Cadaveric Study

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm 3 in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN ® (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%–56.2%), and overall specificity was 47.2% (95% CI 39.9%–54.5%). Positive predictive value was 79.9% (95% CI 76.3%–83.5%), and negative predictive value was 20.0% (95% CI 16.2%–23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% ± 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% ± 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.

Esthetic Grafting for Small Volume Hard and Soft Tissue Contour Defects for Implant Site Development

Ridge contour defects around dental implants are caused by underlying bony defects. Although adequate bone may exist to obtain stability of the implant, irregular bony anatomy can result in an unnatural appearance of the final crown. Particulate onlay grafting to support the peri-implant soft tissue along with tension-free closure while using pedicle papilla regeneration techniques can convert unaesthetic gingival contours into favorable sites.

Methicillin-resistant Staphylococcus aureus: From the hospital to the community

Infections due to community-associated methicillin---resistant Staphylococcus aureus (CA-MRSA) are becoming more prevalent. CA-MRSA infections have unique epidemiologic features and virulence factors. Compared with health care-associated MRSA (HA-MRSA), most CA-MRSA is clonal type USA300 or 400 and has the Staphylococcal cassette chromosome mec type IV, which carries the mecA gene that encodes for resistance to methicillin and other beta-lactam antibiotics but generally not for other antibiotics. CA-MRSA often contains various virulence factors that may result in tissue necrosis. CA-MRSA clinical presentation includes mostly skin and soft tissue infections and less frequently pneumonia. In many of the small soft tissue abscesses due to CA-MRSA, primary treatment with surgical drainage may result in improvement without antibiotic therapy. Optimal treatment and prevention of CA-MRSA infections are unclear. However, distinction between CA-MRSA and HA-MRSA may be less relevant in the future, as CA-MRSA strains are now diagnosed in the hospital setting.

Ewing tumors in infants

Malignancies in infancy are extremely rare. Ewing tumors are hardly ever noted in these children. Since it is generally assumed that malignancies in infancy have an extremely poor outcome, we wanted to investigate whether this was also the case in Ewing tumors. We identified in the Munster data bases of CESS81, CESS86, EICESS92 and EuroEwing99 14 children <12 months of age with a tumor of the Ewing family. Numbers of girls and boys were equal. All infants had axial tumors, including pelvic primaries; 80% of the tumors were <200 ml. An uncommon pathology distribution was noted; the majority were peripheral neuroectodermal tumors, only two atypical Ewing, one classical Ewing, and one unspecified PAS positive small round blue cell soft tissue sarcoma was found. Three patients had metastatic disease at initial diagnosis. Treatment modalities were comparable with patients of older age. The number of cytostatic courses ranged from 6 to 15. Dose reductions were limited, ranged from 73% to 90%. Outcome results were similar to those in patients of older ages (5-year EFS 65%, OS 72%). Infants with Ewing family tumors are in the majority of cases PNETs and are predominantly axial tumors. Outcome is similar to patients with Ewing tumors at older ages. Generally accepted adverse prognostic factors did not influence outcome.

Updates in small animal soft tissue surgery

Updates in small animal soft tissue surgery