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The purpose of this study is to investigate the efficacy of fractional ablative carbon dioxide laser (AFXL) surgery in patients with pediatric hand scars. This study enrolled hand scar patients who received treatment in our hospital between May 2018 and April 2019. Patients were assigned to undergo AFXL surgery based on their personal intents and condition, whereas the fractional laser was used for stiffness and abnormal texture. Outcomes were as follows: hand function was evaluated using the Michigan hand outcomes questionnaire; scar condition was evaluated using the Vancouver scar scale and UNC4P scar scale. Total 30 pediatric patients (mean age, 11.4 years) were eligible for the study and laser-treated scars were significantly improved in Michigan hand outcomes questionnaire from 52.30 ± 6.14 to 66.91 ± 6.43 (p < 0.001). Provider-rated Vancouver scar scale dropped from 8.80 ± 2.75 to 6.73 ± 2.52 (p < 0.001). Patient-reported UNC4P scar scale declined from7.07 ± 2.02 to 4.73 ± 1.31 (p < 0.001). AFXL surgery can significantly improve hand function and appearance of pediatric hand scars, suggesting its advantages over traditional methods of operative intervention., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

Introduction/objectives: To evaluate the clinical relevance of high-resolution hand and wrist ultrasound (US) findings and their possible associations with anti-citrullinated peptide antibodies in primary Sjögren's syndrome (pSS)., Methods: Ninety-seven consecutive pSS patients (American-European Consensus Group, 2002) without meeting the American College of Rheumatology (ACR) criteria (1987) for rheumatoid arthritis (RA); 20 RA patients (ACR/European League Against Rheumatism (EULAR) criteria, 2010); and 80 healthy individuals with comparable age, gender, and ethnicity were enrolled in a case-control study. Disease activity was assessed by EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI). US was performed by one expert blinded to anti-CCP, anti-MCV, and IgM rheumatoid factor tested by ELISA., Results: Frequencies of grade 3 synovitis (9.3 vs. 0%, p = 0.004), tenosynovitis (36.1 vs. 3.8%, p < 0.001), and erosions (27.8 vs. 7.5%, p = 0.001) on US were higher in pSS patients than in healthy controls. ESSDAI presented a moderate correlation with the synovitis number (p = 0.001) and tenosynovitis (p < 0.001). Most pSS patients with erosions on US (81.5%) had negative anti-CCP. Nevertheless, anti-CCP ≥ 3× cut-off value was associated with the presence of erosions in pSS (p = 0.026). Erosions in pSS were mainly small size contrasting with moderate/large size in RA (p < 0.001), and positive power Doppler synovitis predominated in RA (p < 0.001)., Conclusions: US identified significant frequencies of grade 3 synovitis, tenosynovitis, and erosions in pSS. Synovitis and tenosynovitis numbers were correlated with ESSDAI. Association between erosions on US and anti-CCP (high titers) in pSS possibly identifies a subgroup with severe arthritis. These findings suggest that US is a useful method for assessing joint involvement in pSS.Key Points• US identified significant frequencies of grade 3 synovitis, tenosynovitis, and erosions in pSS patients in comparison with age- and race-healthy individuals.• Numbers of synovitis and tenosynovitis on US were correlated with ESSDAI values.• Most pSS patients with erosions on US were negative for anti-CCP, but anti-CCP ≥ 3× cut-off value was associated with the presence of erosions in this disease.• Erosions in pSS were mainly small size contrasting with moderate/large size in RA, and positive power Doppler synovitis predominated in RA.

Objective: To retrospectively analyze the differences in musculoskeletal ultrasound (MSUS) findings to distinguish patients with remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome and patients with elderly-onset rheumatoid arthritis (EORA)., Methods: We consecutively recruited patients with RS3PE syndrome (n = 7) and EORA (n = 22) who underwent pre-treatment MSUS of both hands. Synovial hypertrophy and vascularity of articular synovitis and those of tenosynovitis of the digital flexor tendons and the carpal extensor tendon were evaluated by gray-scale and power Doppler, respectively on a semi-quantitative scale (0-3). The presence/absence of intra-articular synovial effusion, bone erosion, peritendinitis of the digital extensor tendon, and subcutaneous edema were noted., Results: Compared to the EORA group, mild articular synovitis was observed more extensively, and the frequency of intra-articular synovial effusion was significantly higher in the RS3PE syndrome group. Severe articular synovial hypertrophy was more frequent in the EORA group compared to the RS3PE syndrome group, and bone erosion was observed in some EORA cases. Tenosynovitis of the digital flexor tendon was more frequent and severe in the RS3PE syndrome group compared to the EORA group. Although the frequency and severity of tenosynovitis of the carpal extensor tendon were similar in the two groups, digital extensor tendon peritendinitis was more frequent in the RS3PE syndrome group., Conclusion: To distinguish patients with RS3PE syndrome from those with EORA, it is important to evaluate not only intra-articular lesions but also extra-articular lesions by MSUS.

Objective: Digital ulcers (DUs) represent one major burden for patients with systemic sclerosis (SSc). The objectives of our study were to evaluate blood flow in SSc-DUs with laser speckle contrast analysis (LASCA) and to correlate the skin perfusion to clinical and laboratory data., Methods: Forty DUs in 31 consecutive patients with SSc according to 2013 ACR/EULAR criteria (20 with limited cutaneous disease, 3 males) were prospectively examined with LASCA. Clinical and laboratory data were collected at the same time. DUs were classified according to clinical features and presence of infection., Results: At LASCA analysis, patients with diffuse SSc had lower mean values of blood flow compared with those with limited disease at the finger affected by DUs (88.80 vs 44.40, p = 0.036) and at the periulcer area (p = 0.041). The presence of infection was associated to a higher flow at the finger with DU (103.02 vs 58.05 p = 0.04), at the level of ulcer (217.63 vs 67.15, p < 0.001), and at the periulcer area (p = 0.001). The ratio between the blood flow at the ulcer area and the finger base (UA/FB) showed a bimodal trend in patients with infected DUs and in those without infections. Infection was positive correlated to the time of healing (HT) (r = 0.648, p = 0.023), while in DUs without infection a negative correlation to HT (r = - 0.46, p = 0.015) was identified., Conclusions: This study demonstrates for the first time that the UA/FB ratio may predict the healing time of DUs in SSc patients and may be crucial for the prognostic stratification of patients. Infection remains one of the main predictors of DU healing.Key Points• The prognostic value of laser speckle contrast analysis (LASCA) in patients with digital ulcers (DUs) in systemic sclerosis remains to be clarified.• LASCA may be able to predict the haling time of the digital ulcers.• The presence of infection of the wound bed may greatly influence the LASCA parameters and the healing time of the digital ulcer.

Introduction/objectives: This randomized controlled intervention study investigated the effect of flaxseed poultice compress application on pain and hand functions in patients with primary interphalangeal hand osteoarthritis (OA)., Method: The study sample consisted of 82 patients who met the inclusion criteria in the Rheumatology Outpatient Clinic at a University Hospital between January 15, 2017, and May 15, 2018. Patients included in the sample groups were selected randomly. Three sample groups were formed: intervention group I (flaxseed poultice compress) (n = 33), intervention group II (hot compress) (n = 29), and control group (n = 20). The interventions were applied once a day for 7 days in a row. These patients also continued their routine pharmacological treatment. descriptive characteristics identification form, visual analog scale (VAS), Australian-Canadian (AUSCAN) Osteoarthritis (OA) Hand Index, and side effect evaluation form were used as data collection tools., Results: The means of VAS scores of patients in the intervention group I were 6.03 ± 0.25 on day 0, 2.2 ± 0.30 on day 8, and 3.39 ± 0.32 on day 15. The means of AUSCAN total scores of patients in the intervention group I were 40.84 ± 1.76 on day 0, 14.03 ± 1.66 on day 8, and 15.78 ± 1.66 on day 15. The present study showed that pain significantly decreased and the hand function efficiency increased in patients treated with flaxseed poultice compress compared with the hot compress and control groups., Conclusions: In addition to pharmacological treatment, flaxseed poultice compress intervention is recommended to be used as a nursing intervention for reducing pain and increasing hand functions for patients with hand OA in cooperation with the physicians and other health professionals.

Background: The diagnosis of subungual melanoma (SUM) can be challenging and SUMs generally have a worse prognosis than melanomas arising elsewhere. Due to their rarity, the evidence to guide management is limited. This study sought to identify clinicopathological features predictive of outcome and to provide guidelines for management., Methods: From a large, single-institution database, 103 patients with in situ (n = 9) or invasive (n = 94) SUMs of the hand treated between 1953 and 2014 were identified and their features analyzed., Results: The most common site of hand SUMs was the thumb (53%). Median tumor thickness was 3.1 mm, and SUMs were commonly of the acral subtype (57%), ulcerated (58%), amelanotic (32%), and had mitoses (73%). Twenty-one patients reported prior trauma to the tumor site. Twenty-two patients were stage III at diagnosis; 7 underwent therapeutic lymph node dissection and 22 underwent elective lymph node dissection (5 positive), while 36 had sentinel node biopsy (SNB), 28% of which were positive. Forty percent of SNB-positive patients had involved non-sentinel nodes (SNs) in their completion lymph node dissection. Five-year melanoma-specific survival (MSS) and disease-free survival (DFS) rates were 70% and 52%, respectively. On multivariate analysis, regional node metastasis and right-hand tumor location were significant predictors of shorter DFS and MSS, whereas mitoses negatively impacted DFS only and increasing Breslow thickness impacted MSS only., Conclusions: This study confirms that SUMs on the hand usually present at an advanced stage. Distal amputation appears safe for invasive SUMs, and SNB should be considered as these patients have a high risk of both SN and non-SN metastasis.

Acral warts are considered as prevalent reasons for dermatologic consultations and remain an important continuing challenge until now because there is no consensus about optimal therapeutic modality. This study investigated the efficacy of long-pulsed Nd: YAG laser therapy and cryotherapy in treatment of acral warts. Patients who underwent treatment with cryotherapy or long-pulsed Nd: YAG laser therapy for symmetrical and bilateral warts on the extremities (hand and foot) that is confirmed by an expert dermatologist from May 2016 until March 2018 were assessed for enrollment in our study. Laser and cryotherapy sessions were applied every 2 weeks for a maximum of six sessions. Patients followed up and evaluated 3 months after the last treatment. Data were analyzed by SPSS (v.21. IBM Inc. IL). The P value less than 0.05 was considered significant. From 60 enrolled patients, 134 lesions were treated using cryotherapy and 114 other lesions treated with laser beam. Thirty-four males (average age 26.85 ± 7.528 years) and 26 females (average age 26.73 ± 5.640 years) participated. Finally, it was a significant reduction in both lesion width (P = 0.000) and length (P = 0.000) after the sessions of cryotherapy. The width and length of lesions is reduced significantly after each session of laser therapy similarly (P = 0.000). Cryotherapy and long-pulsed Nd: YAG laser are effective on the reduction of both width and length of lesions. Clinically, the methods are not different in their ultimate effects.

Multicentric reticulohistiocytosis (MRH) is a rare systemic and devastating disease with main involvement of skin and joints, frequently related with malignancies. Macrophages and TNFα are the main targets of multiple treatment options with variable results. Although MRH has the tendency of self-resolve in an average of 8 years, treatment must be started early to avoid sequelae, mainly in joints with severe deformities and daily life activity impairment. We describe a 50-year-old man with skin and joint involvement, with a non-previously described muscle affectation, that failed to different drugs and achieved skin improvement with infliximab. We review for the first time in medical literature the available therapeutic options of MRH and its outcomes and propose possible future targets.

The objective of this study was to identify risk factors for knee osteoarthritis (OA) development in a young to middle-aged population with sub-acute knee complaints. This, in order to define high risk patients who may benefit from early preventive or future disease modifying therapies. Knee OA development visible on radiographs and MR in 319 patients (mean age 41.5 years) 10 years after sub-acute knee complaints and subjective knee function (KOOS score) was studied. Associations between OA development and age, gender, activity level, BMI, meniscal or anterior cruciate ligament (ACL) lesions, OA in first-degree relatives and radiographic hand OA were determined using multivariable logistic regression analysis. OA on radiographs and MR in the TFC is associated with increased age (OR: 1.10, 95 % 1.04-1.16 and OR: 1.07, 95 % 1.02-1.13). TFC OA on radiographs only is associated with ACL and/or meniscal lesions (OR: 5.01, 95 % 2.14-11.73), presence of hand OA (OR: 4.69, 95 % 1.35-16.32) and higher Tegner activity scores at baseline before the complaints (OR: 1.20, 95 % 1.01-1.43). The presence of OA in the TFC diagnosed only on MRI is associated with a family history of OA (OR: 2.44, 95 % 1.18-5.06) and a higher BMI (OR: 1.13, 95 % 1.04-1.23). OA in the PFC diagnosed on both radiographs and MR is associated with an increased age (OR: 1.06, 95 % 1.02-1.12 and OR: 1.05, 95 % 1.00-1.09). PFC OA diagnosed on radiographs only is associated with a higher BMI (OR: 1.12, 95 % 1.02-1.22). The presence of OA in the PFC diagnosed on MR only is associated with the presence of hand OA (OR: 3.39, 95 % 1.10-10.50). Compared to normal reference values, the study population had significantly lower KOOS scores in the different subscales. These results show that knee OA development in young to middle aged patients with a history of sub-acute knee complaints is associated with the presence of known risk factors for knee OA. OA is already visible on radiographs and MRI after 10 years. These high risk patients may benefit from adequate OA management early in life.

Fibro-osseous pseudotumor (FOPT) is a rare and benign ossifying lesion. Described as the superficial variant of myositis ossificans (MO), this rare entity mostly occurs in the subcutaneous tissues of the digits. The FOPT clinicopathological features may mimic a variety of benign and malignant soft tissue lesions, and the diagnosis can be difficult when it arises in an unusual anatomic location. In this report we describe the clinical and radiological features of a case of an FOPT that involved the hypothenar region of the hand.

Magnetic resonance imaging (MRI) with maximum intensity projection (MIP) is used to evaluate the hand in rheumatoid arthritis (RA). MIP yields clear visualization of synovitis over the entirety of the bilateral hands with a single image. In this study, we assessed synovitis with MIP images, clinical findings, and power Doppler (PD) findings to examine the clinical usefulness of MIP images for RA in the hand. Thirty RA patients were assessed for swelling and tenderness in the joints included in the DAS28, and both contrast-enhanced MRI for bilateral hands and ultrasonography for bilateral wrist and metacarpophalangeal (MCP) joints were performed. Articular synovitis was scored in MIP images, and the scores were compared with those for PD. The agreement on synovitis between MIP and conventional MR images was excellent. Palpation showed low sensitivity and high specificity compared with both MIP and PD images. There were joints that were positive in MIP images only, but there were no joints that were positive in PD images only. A statistically significant correlation between the scores of MIP and PD images was found. Furthermore, the agreement between grade 2 on MIP images and positive on PD images was 0.87 (κ = 0.73) for the wrist and 0.92 (κ = 0.57) for MCP joints. Using MIP images together with palpation makes detailed evaluation of synovitis of the hand in RA easy. MIP images may predict further joint damage, since they allow semiquantitative estimation of the degree of thickening of the synovial membrane.

Objective: To identify palmar cutaneous branches of median nerve and ulnar nerve (PCBMN and PCBUN) and try to find a safe path at wrist and forearm in the decompression procedure of carpal tunnel syndrome., Materials and Methods: Ten formalin-fixed and five fresh-frozen cadaveric forearms were included in the study. The cross point of longitude of middle finger and distal wrist crease was defined as 0 point. Distal wrist crease (DWC) and 0 point were chosen as references for measurements. Several points on the pathway of PCBMN and PCBUN were measured., Results: The average distance between the origin of the PCBMN and PCBUN to the DWC was 4.95 ± 0.88 cm, 10.12 ± 1.50 cm, separately. The average distance between DWC and the point where PCBMN and PCBUN separated from their trunk was found to be 2.09 ± 0.31 cm, 2.90 ± 0.50 cm, separately. The distances between PCBMN, PCBUN and 0 point at DWC level was found to be 0.61 ± 0.12 cm, 0.47 ± 0.31 cm, separately. The diameters of two cutaneous branches were 0.10 ± 0.02 cm, 0.11 ± 0.04 cm, separately., Conclusion: The general longitudinal palmar incision could avoid injuries to recurrent branch of median nerve and distal branches of palmar cutaneous nerve can be avoided macroscopically. The area about 5 mm ulnar and 6 mm radial to 0 point at wrist level was a relatively safe area.

The objective of this study is to assess the role of hand bone mineral density (BMD) as a prospective marker for hand function and the correlation of hand BMD with X-ray findings and hand functioning in patients with established rheumatoid arthritis (RA). Eighty-three female patients diagnosed with RA were enrolled. All BMD measurements were performed on both hands. The radiological evaluation was conducted according to the van der Heijde modification of the Sharp method (Sharp/van der Heijde). Duruöz Hand Index (DHI) was used to establish the disability in the hands. Furthermore, handgrip strength (HGS), pinch strength (PS), lateral pinch (LP), tip-to-tip pinch (TTP) and three-fingered pinch (TFP) on both the dominant and the non-dominant hands was measured. A significant positive correlation between hand BMD and HGS as well as all PSs with p < 0.05 was observed, while no statistically significant relation was observed between BMD and DHI (p > 0.05). The hand BMD and the Sharp/van der Heijde scores were significantly in reverse correlation (p < 0.05). As for other DHI-related variants, HGS and PS and the total DHI scores were reversely correlated, while there was a positive significant association with radiological scores (p < 0.05). HGS and TTP were found significant (p < 0.05) as a result of a multivariant linear stepwise regression analysis among the sub-groups of DHI, HGS, LP, TTP, TFP and radiographic total scores. Our study demonstrated that a one-off hand BMD measurement failed to adequately indicate a loss in hand function as measured by DHI. Ultimately, HGS and TTP were shown to be the most effective indicators for measuring hand functions.

Background: Lipomatosis of the nerve (LN) is a rare disorder characterized by the massive enlargement of peripheral nerves, frequently accompanied by generalized fibroadipose proliferation and skeletal overgrowth. The treatment of this disorder remains controversial, in part because of the rarity and the variability of presentation. Some authors have advocated total resection of this benign lesion including the functioning nerve, while others recommend symptomatic decompression alone., Methods: We have been routinely following a 10-year-old boy for lipomatosis of the median nerve at the wrist noted shortly after birth. He underwent median nerve resection accompanied by sural nerve grafting at another institute. We review the literature on LN and the efficacy of nerve grafting., Results: Clinically, he made a good recovery, with mild loss of thenar function and relatively preserved sensation. Serial magnetic resonance imaging over 5 years has revealed progression of the LN at both coaptation sites, fibrofatty proliferation within the nerve grafts as well as distal digital nerves, and enlargement of a fibrous scar at the coaptation sites. This has never been reported in the 9 decades of study of this disease., Conclusion: We present the first medium-term follow-up of a patient who underwent nerve sacrifice to attempt to cure the LN alongside a historical review of treatment. We believe that macroscopic gross total resection (i.e., microscopic subtotal resection) is insufficient in stopping the potential progression of this hamartomatous lesion because of the persistent effect of trophic factors.

Background: While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood., Materials: We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation., Results: A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts., Conclusion: Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.

Epitrochlear node involvement occurs in a small minority of patients with forearm or hand melanoma. Although in-transit sentinel lymph nodes are identified infrequently, they contain metastatic disease at nearly the same frequency as sentinel lymph nodes in cervical, axillary, and inguinal nodal basins. Positive in-transit sentinel lymph nodes are likely to be the only site of nodal metastasis. Therefore, detailed preoperative lymphoscintigraphy and meticulous intraoperative search for in-transit nodes should be performed. The recovery of nodes from in-transit nodal areas is low; however, there appears to be an increase in the performance of these dissections since the advent of lymphatic mapping and sentinel lymph node biopsy. This streaming video demonstrates the incidence of epitrochlear lymph node involvement and technical considerations associated with epitrochlear lymph node dissection.

The objective of this work is a scalable, real-time visual search engine for medical images. In contrast to existing systems that retrieve images that are globally similar to a query image, we enable the user to select a query Region Of Interest (ROI) and automatically detect the corresponding regions within all returned images. This allows the returned images to be ranked on the content of the ROI, rather than the entire image. Our contribution is two-fold: (i) immediate retrieval - the data is appropriately pre-processed so that the search engine returns results in real-time for any query image and ROI; (ii) structured output - returning ROIs with a choice of ranking functions. The retrieval performance is assessed on a number of annotated queries for images from the IRMA X-ray dataset and compared to a baseline.

Introduction: This cross-sectional study examined the effect of structural changes caused by rheumatoid arthritis (RA) on computer keyboarding style to provide insights on how changes may affect worker performance., Method: Computer keyboarding styles, as measured by the keyboard-personal computer style instrument, were compared between 45 keyboard operators with RA and 29 without. A severity of structural changes score (SSCS) was assigned after recruitment by observing subjects' hands while operating a keyboard. Significant differences between each item of keyboarding style by diagnosis were identified through Chi square analyses. Logistic regression models with age, diagnosis, SSCS, and touch typing training as the predicators further evaluated the effect of structural changes on each item of personal keyboarding style., Results: Significantly more keyboard operators with RA used high force keystrokes, did not use a wrist rest, moved their hands to strike keys, maintained their wrists and fingers in a fixed position and used fewer than two fingers to activate keys. The amount of variance explained by each model varied from 8 to 56%. SSCS was the most common predictor of keyboarding style (54% of significant models), followed by age (35% of significant models), diagnosis (19% of significant models), and touch typing training (15% of significant models)., Conclusion: Severity of structural changes and age are significant predictors of keyboarding style for computer operators with RA. The keyboarding styles used by computer operators with RA appear to reduce typing productivity and have the potential to put stress on joints already affected by RA. Computer operators with RA may benefit from worksite modifications that address keyboarding style such as alternate keyboards.

Measurements of anatomical UV exposure distribution were made using miniaturized polysulfone dosimeters over a four year period between 2005 and 2008 in Toowoomba, Australia (28 degrees S, 152 degrees E). Anatomical UV exposures were expressed relative to the horizontal plane ambient UV. The UV exposures were compared with existing data detailing the anatomical distribution of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and solar keratoses (SK). Surface UV exposures to unprotected skin surfaces have been presented for each of the face, neck, arm, hand and leg assessing a total of 1453 body sites (2491 measurements). Measured exposures are presented for the human facial region to a resolution of 5 mm. The median anatomical UV expressed relative to the horizontal plane ambient UV for each of the face, neck, forearm, hand and leg regions of the body varied from 26%, 23%, 13%, 30% and 12% respectively in the 0 degrees-30 degrees SZA range; 39%, 36%, 17%, 35% and 23% in the 30 degrees-50 degrees SZA range; and 48%, 59%, 41%, 42% and 47% in the 50 degrees-80 degrees SZA range. Detailed positions of UV exposure measured over the face, neck, arm, hand and leg were more closely related to NMSC incidence data for the face and upper limbs. Further analysis with existing facial BCC and SK density data did not however show a direct relationship with the measured UV exposures highlighting the importance of other factors influencing the causation and localisation of facial NMSC.

Object: Nerve regeneration could be monitored by comparing MRI image intensities in time, as denervated muscles display increased signal intensity in STIR sequences. In this study long-term reproducibility of STIR image intensity was assessed under clinical conditions and the required image intensity nonuniformity correction was improved by using phantom scans obtained at multiple positions., Methods: Three-dimensional image intensity nonuniformity was investigated in phantom scans. Next, over a three-year period, 190 clinical STIR hand scans were obtained using a standardized acquisition protocol, and corrected for intensity nonuniformity by using the results of phantom scanning. The results of correction with 1, 3, and 11 phantom scans were compared. The image intensities in calibration tubes close to the hands were measured every time to determine the reproducibility of our method., Results: With calibration, the reproducibility of STIR image intensity improved from 7.8 to 6.4%. Image intensity nonuniformity correction with 11 phantom scans gave significantly better results than correction with 1 or 3 scans., Conclusions: The image intensities in clinical STIR images acquired at different times can be compared directly, provided that the acquisition protocol is standardized and that nonuniformity correction is applied. Nonuniformity correction is preferably based on multiple phantom scans.

Dirofilaria repens, a common parasite of carnivore mammals, is transmitted by mosquitos and may also infect humans accidentally causing a subcutaneous dirofilariosis. Autochthonous infections of dogs, foxes or cats with D. repens has not been found in Austria so far; however, 12 cases of imported subcutaneous dirofilariosis in man were noticed between 1981 and 2005. The recent case report deals with the 13(th) human case, which has to be considered as the first autochthonously acquired in Austria.

One of the most important therapeutic goal in hyperhidrosis treatment is to seek for the underlying cause and to tailor the treatment accordingly. A detailed history and prompt physical examination are needed to clarify the etiological factor. In this study, we report a 34-year-old woman with a diagnosis of thoracic outlet syndrome presenting with complaints of pain, numbness, and fatigue in her left arm and ipsilateral palmar hyperhidrosis. Thus, we want to highlight a specific potential cause of secondary hyperhidrosis, which can otherwise be easily overlooked, and furthermore, which has a completely different treatment strategy.

We report two young female patients who developed sudden-onset nonpitting edema in both hands and lower legs in early autumn with no significant previous or family history. One of these patients showed arthralgia in both wrists and ankles. The clinical symptoms improved without treatment, and they were diagnosed as having nonepisodic angioedema with eosinophilia (NEAE) based on laboratory investigations and the lack of recurrence. The clinical picture of this disease is often similar to that of rheumatologic disorders with tenosynovitis with regard to edema and pain in the distal portion of the extremities. When edema is seen in the bilateral hands and lower legs, particularly in young women, NEAE should be actively considered as a possible diagnosis.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is characterized by symmetrical synovitis and swelling of both the upper and lower extremities. The anatomical determinant of RS3PE is predominantly extensor tenosynovitis as revealed by magnetic resonance imaging (MRI). Given the cost constraints, time, and expertise required in carrying out MRI and ease in diagnosing tenosynovitis by ultrasound, we utilized high-frequency ultrasonography (USG) for evidence of tenosynovitis of the distal tendons in patients with RS3PE. Diagnosis of tenosynovitis was made on the basis of anechoic or hypoechoic signals around the tendon sheaths in both transverse and longitudinal planes. Flexor and extensor tendons at the wrist and metacarpal heads and extensor digitorum longus (EDL) tendons at the ankle were evaluated with a 7.5-10-MHz linear probe. There were ten patients (seven males) with a mean age of 59.5 years (range: 52-78 years) and mean disease duration of 6.1 months (range: 1.5-12 months). Disease onset was acute in all of the cases. Pitting edema of the hands was present in all except two patients whereas four patients, in addition, had edema of the feet. Edema was symmetrical in seven patients. Inability to make a complete fist was noted in all. Tenosynovitis of extensor and flexor tendons at the wrist and the metacarpal heads was documented in all patients with edema of the hands. In seven cases extensor tendon tenosynovitis was more prominent compared to the flexor tendons. Tenosynovitis of EDL tendons was detected in six cases. Dramatic relief with low-dose prednisolone was noted in all patients within 6 weeks of therapy. At a mean follow-up of 10.1 months all patients had marked relief in edema of extremities and improvement in the grip strength. Our study confirms that tenosynovitis of both flexor and extensor tendons at the wrist and extensor tendons of the feet is the hallmark of RS3PE syndrome. USG is a reliable and cost-effective modality for evaluation of patients with suspected RS3PE.

Idiopathic inflammatory myopathies, mainly polymyositis (PM) may occur in the course of several autoimmune diseases. The overlapping forms of myositis, when the patient also meets the criteria for rheumatoid arthritis (RA), affect 3%-5% of myositis patients [1]. To the best of our knowledge this is the first report on the overlapping form of RA, antiphospholipid syndrome (APS) and the serological subgroup of PM, the antisynthetase syndrome (ASS).

This is the first description of the development of rheumatoid nodules in 3 rheumatoid arthritis patients following leflunomide therapy. The nodules were localized at typical sites with preference of the extensor side of hands and elbow. One nodule examined histologically revealed the typical architecture of RA nodules. In all 3 patients the time of onset of nodulosis was about 6 months after initiating the leflunomide therapy. In all 3 patients leflunomide was clinically efficacious concerning RA: remission or near remission was achieved. Due to the extent of nodulosis, the leflunomide therapy had to be stopped in 2 patients. Progression and acceleration of nodulosis is well known following MTX therapy in RA patients. It is caused by adenosine A1 receptor promotion of multinucleated giant cell formation by human monocytes. Leflunomide has no known influence on adenosine metabolism, so different pathogenetic mechanisms must be assumed for the induction of nodulosis by leflunomide.

Distal extremity swelling with pitting oedema due to altered lymphatic drainage has been reported in some patients with rheumatoid arthritis (RA). The resistant-to-therapy oedema usually affected the upper limbs in an asymmetrical pattern. Until now, extensor tenosynovial involvement has not been described in RA patients suffering from distal extremity swelling with pitting oedema. Three patients are described: two of them had predominant extensor tenosynovial involvement in their hands, with impaired lymphatic drainage demonstrated by (MRI) and lymphoscintigraphy, respectively. In both cases the oedema was chronic and not responsive to treatment. One patient had extensor tenosynovial involvement without impaired lymphatic drainage. In this case, the oedema remitted completely after a few days of corticosteroid therapy. None of them showed differences in serum levels of vascular endothelial growth factor (VEGF), whether they were RA patients with no pitting oedema or healthy volunteers.

A patient with tenosynovial tuberculosis affecting the extensor tendons of the wrist and hand is presented. This case highlights the clinical and magnetic resonance features of tuberculous tenosynovitis, and seeks to increase awareness of what may represent a resurgent musculoskeletal entity.

The incidence of recurrence following surgical treatment of solitary tumours of the hand ranges from 12% to 50%. Examination of the reports in the literature reveals that different methods of histological typing have been used and that most of the publications available are case reports or refer to studies of small numbers of patients, so that direct adequate comparison of the rates in the literature is not possible. In an attempt to find out the reasons for local recurrence of retrospective clinicopathological study was performed. All histological specimens examined within one decade were analysed. The tumours they were taken from included 46 glomus tumours (female: male ratio 28:18, age range 9-82, average 52.3 years) of different locations, 30 of them affecting the upper extremity. We had operated on 13 solitary, digitopalmar glomus tumours (8 vascular type, 3 epitheloid solit type, 1 myxoid, 1 neural) in our institution, in most cases with the aid of either a magnifying lens or an operating microscope. The mean follow-up period was 76 months, and we had no recurrences. Therefore, we conclude that regardless of the histological type, optical magnification during surgical resection of solitary glomus tumours of the hand prevents recurrences. In our opinion, early recurrences are due to incomplete excision of tumours of the types mentioned above or to misdiagnosis because of the multiple forms of glomus tumours that can occur, especially during childhood.

Radiography of hands and feet is a standard measure of outcome in rheumatoid arthritis. We hypothesised that this radiological information can be reproduced by clinical evaluation. A rheumatologist examined 78 patients with rheumatoid arthritis and tried to predict the radiological Larsen score, for the proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, ankle, and metatarsophalangeal (MTP) joints. Spearman correlation between clinical Larsen and X-ray Larsen was 0.79 for hands and 0.66 for feet. There was no significant difference in scores for PIP, MCP, wrists, or ankles, but MTP joints were underscored by clinical Larsen relative to X-ray Larsen (median of 20 vs 22 respectively, p = 0.04). Categorical data for index finger MCP joints showed significant proportional agreement of 37% (Kappa 0.24, p < 0.0001). In conclusion, the Larsen X-ray score can be predicted by clinical examination with surprising accuracy in the small hand joints but less so in the feet. Although the favourable agreement shown in this study does not make X-rays redundant, we suggest that clinical examination of the hands should be further refined and standardised as a measure of outcome.

The authors describe a rare case of melorheostosis of the hand occurring at an early age but which was already present during early childhood. The patient came to our clinical observation only for cosmetic reasons. Because there were no other disorders no therapy was carried out.

The authors describe the anatomopathological and clinical findings of 24 cases of benign hemangioma of the hand. The instrumental methods used to diagnose hemangioma are discussed, and MRI imaging is given particular importance in the preoperative evaluation of the site, size, extent, and relationship with the surrounding tissues and any multiple locations of the vascular tumor. This evaluation is essential to perform a wide resection of the tumor, which is the only means of avoiding recurrence. After an average follow-up of 33 months (14-54) recurrence was observed in 7% of the cases treated.

We investigated the rheumatic and laboratory features in 25 patients with Hansen's disease. Sixteen (64%) developed a broad range of rheumatic manifestations, the most common being a distinctive syndrome of swollen hands observed in 10 patients (66.5%). These manifestations were more frequent in patients with lepromatous leprosy. There was no correlation between articular clinical findings and X-ray or laboratory abnormalities. A careful clinical history and the recognition of rheumatic features will help to differentiate patients with leprosy and rheumatic manifestations from those with a primary rheumatic disease.

Flexor tendon synovitis caused by Mycobacterium terrae resulted in considerable permanent functional impairment of the hand in six patients. Initial symptoms were subtle and uncharacteristic. Cortisone injections aggravated the condition. Surgical treatment including synovectomy was combined with antimycobacterial chemotherapy. Early diagnosis obtained by culture of synovial biopsy material to detect mycobacteria may result in an improved outcome in chronic synovitis.

Amyloid arthropathy is said to be distinguished roentgenographically from rheumatoid arthritis by the absence of joint space narrowing and the absence of articular erosions. We present a patient with multiple myeloma with swelling, stiffness and firm synovial thickening of the wrists, metacarpophalangeal joints and proximal interphalangeal joints whose hand radiographs showed articular erosions of the carpal joints and ulnar styloid and joint space narrowing of the proximal interphalangeal joints and metacarpophalangeal joints. Synovial biopsy of the left wrist showed amyloid deposits with no inflammation. Previous reports of X-ray changes in amyloid arthropathy note preservation of joint spaces or widening. Erosions when noted are of non-articular bone rather than of the articular surface. This is the first case report of erosive articular disease in amyloid arthropathy.