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Background Dynamic contrast-enhanced magnetic resonance imaging has the potential to show disease activity of rheumatoid arthritis even in complex anatomic areas as the atlantodental region. Purpose To demonstrate the technical feasibility of measuring synovial volume and perfusion characteristics with dynamic contrast-enhanced magnetic resonance imaging of the atlantodental region in patients with rheumatoid arthritis. Material and Methods Ten patients with rheumatoid arthritis and cervical spine involvement underwent dynamic contrast-enhanced magnetic resonance imaging of the cervical spine at 1.5 T. For each patient, 80 3D datasets were acquired using the commercialized Time Resolved Imaging of Contrast KineticS (TRICKS) sequence. Volumes of synovia with active synovitis on anatomical and parametric images were segmented. Synovial tissue perfusion parameters, namely plasma flow (Fp), relative plasma volume (vp), and the permeability-surface area product (PS), were calculated using a two-compartment uptake model. Statistical analysis included calculation of intra- and inter-reader agreement and a correlation of perfusion parameters with Outcome Measures in Rheumatology Clinical Trials (OMERACT) criteria. Results Dynamic contrast-enhanced magnetic resonance imaging as well as quantification of volume and perfusion characteristics of synovia was successful in most patients (80%). Intra- and inter-reader agreement was excellent (0.89–0.99). There was a positive correlation between OMERACT score and the permeability-surface product. Conclusion Dynamic contrast-enhanced magnetic resonance imaging using a 4D angiography sequence for the atlantodental region in patients with rheumatoid arthritis for quantitative and qualitative assessment of synovial volume and perfusion characteristics is technically feasible.

Prosthetic valve thrombosis is a rare and severe complication of the mechanical prosthetic valve. Management can be challenging due to varying clinical presentation, overlapping features of differential diagnosis, and lack of randomized controlled trials on the therapeutic options. In this article, we report the case of a patient with a mechanical prosthetic mitral valve presented with symptoms of heart failure, and an echocardiography showing increased mean pressure gradient across the prosthesis along with a fixed posterior leaflet and a partially restricted anterior leaflet with no visible mass. That raised the concern for an obstructed prosthesis. After multimodality imaging and multidisciplinary team discussions, prosthetic valve thrombosis diagnosis was favored over other different diagnoses that included but not limited to pannus ingrowth. Fibrinolytic therapy was administrated, and the patient was discharged on optimal anticoagulation. Repeated echocardiography a month later showed normal mean gradient and normal functioning prosthetic mitral valve without the need for repeat mitral valve surgery.

Background Despite the advantages of ultrasound (US) in the management of rheumatoid arthritis (RA) patients, power Doppler (PD) US may be highly dependent on the type of US machine used. Purpose To present a method to calibrate the PD signal of two models of US machines by use of a flow phantom and finger joints of patients with RA. Material and Methods For the phantom study, the PD signal count was measured in the flow phantom perfusing blood mimicking fluid at various injection rates and pulse repetition frequencies (PRFs). The quantitative PD index was calculated with ImageJ. For the clinical study, the second and third metacarpophalangeal joints of five consecutive patients with RA were examined. The quantitative PD index was measured at various PRFs by use of two models of machine (the same models as the phantom study). Results For the phantom and clinical studies, negative correlations were found between the PRF and the quantitative PD index when the flow velocity was constant and positive correlations between flow velocity and the quantitative PD index at constant PRF. There was a significant difference in the depiction performance of synovial blood flow between the two models, which can be calibrated by adjusting the PRF values derived from the phantom study in each model. Conclusion Signal calibration of pannus vascularity between US machines may be possible by adjusting the PRF value according to flow phantom data. Different US machines can thus provide equivalent examination results concerning the pannus vascularity.

Purpose To describe a case of unilateral limbal stem cell deficiency (LSCD) with previously failed autologous graft, resolved by ocular surface reconstruction using cultured autologous limbal stem cells from the contralateral eye. Case Report A 35-year-old patient presented to our clinic with LSCD due to a unilateral alkali burn. The patient had received a previous limbal graft from the contralateral eye that had failed to impede corneal conjunctivalization. We decided to repeat limbal stem cell transplantation using an ex vivo cultivation procedure to reduce the risk of tissue harvesting on the healthy fellow eye. A small limbal biopsy (1.5 × 1.5 mm) near the previously excised limbus was performed. Stem cells were then isolated and cultured on fibrin and a 3T3 feeder cell layer using a standard protocol. Four months later, the cultivated cells on fibrin were grafted after pannus removal. In the subsequent months, the ocular surface stabilized and inflammation decreased. Two years later, the patient underwent large tectonic lamellar keratoplasty for severe corneal thinning involving the entire cornea, and 6 months later central penetrating keratoplasty and extracapsular cataract extraction with intraocular lens implantation and pupilloplasty was performed. Following reconstruction, the patient showed improved best-corrected vision from count fingers to 20/200 due to amblyopia, and the ocular surface was stable with a transparent corneal graft. Conclusions Ex vivo limbal stem cell transplantation is a valid technique for treating LSCD and can be utilized for treating patients who have had previous failed limbal grafts.

We describe the case of a 67-year-old Asian female patient suffering from severe systemic lupus erythematosus (SLE), including biopsy-proven glomerulonephritis, since the age of 40 who was admitted for tetraparesis. Neurological examination confirmed proximal muscular weakness, hypoesthesia and diminished tendon reflexes. The patient suffered from extremely severe Jaccoud’s arthropathy. Magnetic resonance imaging (MRI) demonstrated severe narrowing of the upper spinal canal due to a soft tissue mass surrounding the odontoid process, assumed to be a synovial pannus, causing myelopathy. The patient was treated with three intravenous pulses of methylprednisolone with prompt and full clinical recovery. Follow-up MRI confirmed considerable regression of the pannus. Inflammatory transverse myelopathy is the most common explanation for para/tetraparesis in SLE. However, in this case, the symptoms were caused by atlantoaxial synovitis, which is more typical for rheumatoid arthritis.

A 75-year-old immunocompetent man presented to our office with right otalgia. After a comprehensive workup, he was found to have right temporal bone osteomyelitis and was treated with intravenous antibiotics. He then began to experience left-sided otalgia and was diagnosed with and treated for left temporal bone osteomyelitis. Subsequently, he began to exhibit myelopathic symptoms, and imaging revealed a C2 inflammatory process. The patient underwent endoscopic transoral odontoidectomy with resection of a large C1 to C2 pannus and recovered with no neurologic deficit. Skull base osteomyelitis is an uncommon condition that usually occurs in immunocompromised patients. Prompt diagnosis and appropriate treatment are of utmost importance in managing this condition.

Introduction: Abdominoplasty can be limited by preexisting scars and is associated with postoperative drains, seromas, and deep vein thrombosis (DVT). The Avelar technique has been described as an alternative to extensive flap dissection. We adopted this technique in 2007. Materials and Methods: The lower abdomen is marked for planned resection. Liposuction is performed throughout the entire abdomen below Scarpa's fascia and superficially in the lower abdomen to thin the redundant pannus. The skin is sharply incised, and the thinned pannus is bluntly avulsed, leaving the subcutaneous fat and vessels intact. The upper abdominal skin can be slid over the deep fascia, preserving the perforating vessels. A narrow tunnel is dissected from the umbilicus to the xiphoid for rectus plication. The umbilicus is transposed in the usual manner. All patients receive DVT prophylaxis with perioperative heparin, sequential compression devices, and Lovenox. Surgery is ambulatory, and drains are not routinely used. Results: Between April 2007 and December 2010, 100 consecutive lipoabdominoplasty procedures were performed. There were no DVTs and no deaths. One patient sustained small-bowel injury during liposuction, which was immediately recognized and successfully repaired. Five hematomas (28 ± 28 mL) occurred within the early postoperative period, 2 of which became infected. Four hematomas responded to local drainage, but 1 required surgical evacuation 3 months later. The incidence of late seroma was 0%. Two marginal skin necroses occurred in patients with preexisting Kocher and laparotomy scars, which healed without ill effect. Conclusions: The incidence of wound dehiscence, seroma, hematoma, and DVT after lipoabdominoplasty is less than that reported for traditional abdominoplasty.

A 78-year-old African-American woman was diagnosed with rheumatoid arthritis (RA) in 1996 after she presented with a symmetrical polyarthritis of the hands. Over the next 4 years, she was treated with multiple disease-modifying antirheumatic drugs including methotrexate, hydroxychloroquine, gold, and leflunomide, all of which were stopped due to side effects or lack of response. She was started on low-dose prednisone in 1998, and was also maintained on low-dose azathioprine, which had been initiated in June. In October 2000, the patient developed a cervical myelopathy, manifested by ataxia and hyperreflexia. Magnetic resonance imaging of the cervical spine showed compression of the ventral cord by an enhancing epidural soft-tissue mass behind the odontoid, which was thought to be pannus, as well as multilevel spondylosis with cord compression at C5– 6. In December 2000, she underwent cervical spine decompression at the C5–6 level but was left with residual ataxia. In early 2000, the patient had begun to lose weight, and this worsened after her spine surgery; she lost 20 lb between August 1999 and April 2001. Computerized tomography (CT) scan of the chest, abdomen, and pelvis without contrast was normal in April 2001. Magnetic resonance imaging of the abdomen was unremarkable except for thickening of the gastric antrum. Endoscopy was normal. Bone-marrow biopsy showed no evidence of malignancy. Testing for antigliadin antibodies and human immunodeficiency virus (HIV) were negative. In May 2001, the patient was started on infliximab for the likelihood that RA activity was contributing to her weight loss and also because of the myelopathy due to the presence of pannus behind the odontoid process. She received the first three infusions but was lost to follow-up. She presented again in September 2001 with a further weight loss of 10 lb and was admitted for further evaluation. The patient_s prior medical history was significant for hypertension, osteoporosis, and a pancreatic cystic mass which, when aspirated in 1998, had revealed no malignant cells. There also was an allergy to contrast dye. Medications at the time of admission were Premarin 0.625 mg daily (qd), prednisone 5 mg qd, furosemide 20 mg qd, and atenolol 50 mg qd. On physical examination, the patient was cachectic, weighing 66 lb. Blood pressure was 110/80 mmHg, and she was afebrile. Significant findings included: chronic swan neck and boutonniere_s deformities of the hands but no active synovitis; hyperreflexia in the lower extremities with mild left-sided dysmetria; and negative Babinski signs. Abdominal examination revealed mild left upper-quadrant abdominal tenderness without masses. Cardiopulmonary examination was within normal limits, and hemoccult stool test was negative. The initial laboratory investigation demonstrated a leukocyte count of 3.7 10/l (normal 3.4–11.2 10/l) with a normal differential, hemoglobin 9.5 g/dl (normal 12–16 g/dl), and platelet count of 201 10/l (normal 150– 450 10/l). Liver, renal, and thyroid function tests, as well as urinalyses, were normal. Serum albumin was 2.9 g/dl, HSSJ (2007) 3: 119–125 DOI 10.1007/s11420-006-9032-1

Thrombotic obstruction of prosthetic valves is a serious problem. Early diagnosis and prompt treatment are life-saving in these cases. Three patients presented with subacute and chronic symptoms of prosthetic valve thrombosis of varying duration (7 days to 2 years). All 3 had a Medtronic Hall tilting disc valve implanted in a previous operation in the aortic or mitral position. Diagnosis was established by 2-dimensional echocardiography. Under cardiopulmonary or femorofemoral bypass, thrombectomy and rotation of the disc within the valve housing were performed through a median sternotomy. All the patients had an uncomplicated postoperative course. Pressure gradients fell markedly at discharge 8 to 10 days after surgery. The patients were followed up for between 3 and 11 months, during which they showed excellent prosthetic valve function and reduced gradients. The ability to rotate the valve within the housing allows adequate thrombectomy and pannus excision. Even several years after implantation (more than 10 years in 2 cases), the valve could still be rotated readily to obtain optimum flow and low pressure gradients.

Between 1995 and 2000, 8 patients with St. Jude Medical (SJM) valves in the aortic position required 9 redo valve replacement for prosthetic valve obstruction. Obstruction of the prosthetic valve was diagnosed by simultaneous echocardiography and cineradiography, and process of restricted leaflet movement that progressed to hemodynamic impairment was observed by serial studies in three recent patients. An oral anticoagulation was considered to be adequate in all patients except one patient who had withdrawal of warfrain. Pannus was the sole cause of valve obstruction in seven events in 6 patients, and both thrombus and pannus in 2 patients. Pannus overgrowth was found on the inflow aspect of the SJM valve, and involved the ends of the straight edge of the leaflets over pivot guards. These results suggest that pannus might play the primary role in development of obstruction of aortic SJM valves in patients on adequate oral anticoagulation.

Dysphagia as an initial complaint in rheumatoid arthritis is rare. We describe the case of a 69-year-old woman with rheumatoid arthritis who presented with a 2-day history of acute dysphagia. Our evaluation revealed the cause of the dysphagia was the presence of rheumatoid pannus that involved the anterior cervical spine and compressed the esophagus. Although the otolaryngologic manifestations of rheumatoid arthritis usually relate to synovial involvement of the temporomandibular and cricoarytenoid joints, our case establishes that a rheumatoid pannus on the anterior cervical spine can cause dysphagia. We believe that this may be the first reported case of this clinical entity.

1 Although calcium gluconate (CG) is recommended in the treatment of hydrofluoric acid (HF) eye burn its efficacy seems to be controversial, and controlled human or animal studies are limited. The study's objective is to compare the efficacy of 1% CG and normal saline irrigation for the treatment of HF eye injury in animals. 2 0.05 ml 2% HF was instilled to anesthetized rabbit's eyes. One minute later, four treatment groups were studies: (1) irrigation with normal saline followed by topical antibiotics, corticosteroids and cycloplegics for 48 h ( n=10); (2) irrigation with 1% CG followed by the same topical treatment ( n=9); (3) as group 1 and 1% CG drops over 48 h ( n=10); (4) as group 3, and injection of 1% CG subconjunctivally after irrigation ( n=9). 3 Corneal erosion area, corneal haziness, conjunctival status, vascularization (pannus) and acidity were assessed before injury, immediately after intitial treatment and 1, 2, 7 and 14 days thereafter by slit lamp aided by fluorescein staining. 4 Conjunctival pH dropped from 6.0 - 6.5 to 2.5 - 3 after injury and increased to 6 - 6.5 after irrigation. Corneal erosion: smaller in groups 2, 3, significantly so at 2 days, but not different at 14 days. Corneal haziness: more severe in group 4, at 14 days, insignificant. Conjunctival damage: significantly worse in group 4 at 2, 7 and 14 days. Pannus appeared in 2 - 4 eyes in each group. 5 It seems that for HF injury 1% CG did not have any significant advantage over saline irrigation and topical treatment only. It might have some initial and temporary effect on healing process especially that involving erosion. Given subconjunctivally, 1% CG may be toxic and worsens clinical outcome.

Collagen-induced arthritis in the diabetes-resistant BB (DR BB)/Wor rat is a severe, aggressive disease initiated by immunization with heterologous native Type II collagen. Onset of clinical symptoms reproducibly occurs in 100% of animals between days 10 and 12 following collagen immunization. Hypertrophy of the synovial lining is the first histological manifestation of the early inflammatory arthritis. A mild inflammatory infiltrate in the synovium rapidly becomes a fibrovascular pannus eroding articular cartilage and subchondral bone. Beginning at the joint margins, an active synovitis is present. Light microscopy and immunohistochemical staining show the infiltrate to be comprised of mononuclear (lymphocytes, macrophages) and polymorphonuclear inflammatory cells. In addition, there is histological evidence for chronic inflammatory nodules and necrotizing vasculitis in connective tissue from diseased joints, both morphologic features associated with rheumatoid arthritis in humans. Subchondral bone erosion appears to be mediated largely by the resorptive action of activated osteoclasts. These histological parameters of disease progression in the DR BB/Wor rat are similar to human rheumatoid arthritis. The extensive degree of similarity in the pathology of DR BB/Wor rat collagen-induced arthritis and human rheumatoid arthritis supports the role of this model as an in vivo disease model for human rheumatoid arthritis.

Purpose: To report the results of a postmortem examination in a patient who died of unrelated causes 7 months following endoluminal treatment of an infrarenal abdominal aortic aneurysm (AAA). Methods: As part of an FDA Phase I pilot study, a 73-year-old man underwent successful endoluminal exclusion of an infrarenal AAA using a 9-cm-long endograft (Endovascular Grafting System). Seven months later, he succumbed to complications of a spontaneous esophageal rupture. At autopsy, the aorta was dissected in situ by a vascular surgeon and pathologist before being explanted in order to examine the wound healing characteristics at the aorta-endograft interface. Particular attention was also directed to the hooks composing the attachment system at each end of the endograft. Results: Macroscopic and microscopic examination revealed that the graft had completely excluded the aneurysm sac from the circulation and was incorporated into the aortic wall at the proximal neck and distal cuff. A smooth pannus of endothelial cells covered the proximal end of the endograft at the areas of contact with the aorta, while microscopic examination of the distal end of the graft revealed poorly formed, fibrinous pannus. The neointima deep to the endothelium consisted of a collagenous matrix containing myofibroblasts and histiocytes, providing evidence of healing between the endograft and aorta. Both renal arteries were clear of the proximal end of the endograft, but a previously unrecognized right lower pole renal artery with an extremely caudal origin was excluded from the aortic lumen. Each hook of the attachment system was seen protruding through the adventitia of the aorta. There was no evidence of trauma to the aortic wall or the surrounding tissues caused by these hooks. Conclusion: There appears to be evidence that an endoluminally placed aortic graft may be incorporated by the host aortic tissue.

Findings: the appearance are those of an encysted fluid collection, larger in longitudinal section, with a prominent 'beak' pointing towards the joint. The unruptured cyst, if it is tense, may be associated rarely with thrombus in the subjacent popliteal vein (Fig. 1); but it is the ruptured cyst that may mimic deep vein thrombosis. Hence it is important to look for the sometimes subtle changes that indicate cyst rupture; a crescent of fluid (Fig. 2), which is the remnant of the collapsed Baker's cyst in the usual anatomic location of the bursa, and fluid tracking along the muscle planes. These patients will invariably have an effusion in the superpatellar bursa, and detecting this should be done first as it gives an immediate clue to the diagnosis (v.i.). Ossicles within a Baker's cyst have the typical echogenicity of bone. Pannus, which is hyperechoic to the adjacent fluid, occurs in rheumatoid arthritis; and osteoarthritic knees often have echogenic osteocartilagnous debris. Use of Doppler signals distinguishes between aneurysm of the popliteal artery and Baker's cyst. Haematomas also cause a hypoechoic lesion and swelling in the calf, but history and intramuscular location should differentiate these. Fig. J. Axial image ofthe popliteal fossa showing echogenic thrombus within the distended vein (arrows) superficial to the artery (A) and deep to a Baker's cyst (C).

A morbidly obese 51-year-old woman who was 155 cm tall and weighed 170 kg, and had functional limitation and angina due to her weight and massive pannus, underwent abdominal panniculectomy. The abdominal pannus was pierced with two, 4 mm, nonthreaded Steinmann pins (Synthes, USA) from which the pannus was elevated and suspended with rope. This elevation allowed for traction and simultaneous exposure of both the superior and inferior aspects of the pannus, assisting in surgical resection. The pannus removed weighed 25 kg. Postoperatively, the patient developed cellulitis on the inferior flap that resolved with antibiotics, and the wound healed in two weeks.

In total artificial heart replacement the pumps are attached to the vascular system with the help of connectors. These consist of a woven Dacron vessel graft to which a short silastic segment is vulcanized. In 36 calves surviving total artificial heart replacement between one and seven months (average 85 days) the morphological alterations due to interfacial reactions were studied: thrombus formation and neointimal fibrous hyperplasia at the anastomoses. In 15 calves (41.7%) thrombus growth within the outflow tract led to anastomotic stenosis: pulmonary artery 14 (93.3%), aorta-anastomosis 1 (2.8%), both vessels 1 (2.8%), in combination with pannus growth in atrial location 13 (86.7%). In 73.3% the pannus consisted of infected organized thrombus imitating the course of septic vegetative endocarditis. Two calves were reoperated in order to remove the vegetative thrombi, one successfully. In five animals pulmonary stenosis was the main cause of death. The presence and location of excessive tissue growth and thrombus formation within the outflow tract are also inherent to the fluid mechanical design of the valve. Neointimal fibrous hyperplasia at the anastomoses of the grafts seems to be a reparative process started up by platelet-induced subendothelial cell proliferation in response to intimal injuries.

ConclusionsStudies of the immunologic properties of native type II collagen in the past decade have delineated a new field in connective-tissue disease. The opinion that cartilage injury may not be merely the result of pannus but that the origin of synovial hyperplasia could, in some way, be related to cartilage is no longer iconoclastic. The recent advances in the field of collagen immunology have provided data which are clear cut, but the proper interpretation of the experimental results is, at present, only partially evident. In the near future, additional work may answer the questions posed in this review; out of controversy could come certainty.

The objective of this experiment was to investigate the healing of thin-walled reinforced expanded polytetrafluoroethylene (PTFE) vascular graft (thin graft) . In 12 dogs (30-35 kgm), a 4 cm segment of each common iliac artery was excised and replaced with an equal length of PTFE vascular graft, 6mm internal diameter. Standard graft was used on one side and thin graft on the other. Dogs were sacrificed at intervals up to 12 weeks. Pannus extension started at both ends after the first week. The degree of pannus extension and pannus thickness showed no difference between both grafts at each interval. It was covered by a monolayer of endothelial-like cells as seen by scanning electron microscopy. Anastomotic hyperplasia and the growth rates of endothelialization measured from the proximal anastomosis were simi lar. No significant difference was noted in the healing between the thin-walled and standard PTFE vascular grafts for up to 12 weeks.

Indirect immunofluorescent technique directed at factor VIII-related anti gen was used to examine the cellular lining of short PTFE vascular grafts re placing a portion of common iliac artery in dogs. The innermost cellular monolayer was determined as true endothelium. The pannus developed from both anastomotic ends of the host artery and strongly supported the overlying endothelium. Endothelial damage occurred in the areas without tissue support underneath. Complete endothelialization played an important role in maintain ing graft patency.

The influence of supporting rings on the healing of the ringed expanded polytetrafluoroethylene (ePTFE) vascular graft (ringed graft) was studied. In 12 dogs (32-42 kgm), a 4cm segment of each common iliac artery was excised and replaced with an equal length of 6mm ePTFE vascular graft. Ringed graft was used on one side and plain on the other. Dogs were sacrificed at intervals of 1, 2, 4, 6, 8 and 12 weeks. All grafts remained patent. The degree of pannus extension and pannus thickness showed no differences between both grafts at each interval. It was covered by a monolayer of endothelial-like cells as seen by scanning electron microscopy. The growth rates of endothelialization measured from the proximal anastomosis were 1.3 and 1.4 mm/week in the plain and ringed grafts, respec tively. Anastomotic intimal hyperplasia (> 50 microns) was noted in 25% and 33% at the proximal and distal anastomoses, respectively, in both grafts. The outer surface was covered by adherent connective tissue particularly encapsu lating the rings without affecting the non-ringed portion in the ringed grafts. We conclude that the supporting rings of the ePTFE graft have no significant influence on the healing and neointimal development.

This preliminary report is concerned with the description of a disease of the conjunctiva and cornea of sheep, of natural occurrence, which results in the formation of a pannus, not unlike that in human trachoma.The farmer from whom I obtained my diseased sheep first noticed the non-purulent infection of the conjunctiva and nictitating membrane, evidenced by congestion, edema, epiphora, as fall weather and near-freezing temperatures prevailed. Examination by him of the large flock allowed about 200 infected animals to be isolated, 10% of which had marked vascularization of the cornea. Two weeks later, when I was asked to examine the flock, less than 1% were not infected. Probably 80% suffered clinical pannus formation, and 5% superficial ulcers at the tip of the pannus. Hypopyon ulcer was seen in only those that were so blinded as to be unable to prevent injury to the cornea in trying to graze and follow the flock. No perforation of the cornea was seen. A representative animal, moderately infected, was re...