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Malnutrition is a common problem among hospitalized older patients. Peripheral parenteral nutrition (PN) can improve patient outcomes but can also lead to complications that affect future treatment. Older inpatients, in particular, are expected to be prone to these catheter-related complications. However, the impact of peripheral PN on older inpatients has been rarely investigated. In the current study, the impact of PN on short peripheral catheters (SPCs) was evaluated by comparing signs and symptoms at the time of catheter removal between 22 patients with PN and 27 without. In addition to external clinical assessment, sonographic investigations of the SPC site were performed. The prevalence of external signs and symptoms of complications was similar between the patients (all P > 0.05). However, subcutaneous edema was found by ultrasound in > 80% of patients with PN, compared with 55.6% of those without PN (P = 0.051). Unlike cases without PN, all patients with PN who presented with external signs and symptoms developed subcutaneous edema (P = 0.022). Multivariate analysis demonstrated that administration of PN was independently associated with subcutaneous edema (adjusted odds ratio = 6.88, 95% confidence interval = 1.083-75.486, P = 0.040). For several decades, phlebitis has been the primary focus of complications related to peripheral PN in clinical settings. However, our results imply that peripheral PN causes subcutaneous edema, which can lead to catheter failure in older inpatients. This study contributes to understanding the etiology of catheter failure during peripheral PN in this population. [ABSTRACT FROM AUTHOR]

• We examined lower muscle MRI findings of AMA-positive myositis patients. • In AMA-positive myositis, proximal muscles were severely affected. • The lower leg muscles were relatively spared. • Fascial edema was evident even in lower leg muscles. Anti-mitochondrial M2 antibody (AMA-M2)-positive myositis is an idiopathic inflammatory myopathy (IIM). Of all patients with myositis, 2.5–19.5% have AMA-M2 antibodies. However, the detailed distribution of muscles affected in AMA-positive myositis is unknown. Therefore, we examined lower muscle magnetic resonance imaging (MRI) findings of patients with AMA-positive myositis. Among the 63 patients with IIM at our institute, 5 (7.9%) were positive for AMA-M2 antibodies. However, one was also positive for anti-Jo1 antibodies; therefore, four patients were finally participated in this study. All patients had high-intensity MRI signals in the proximal muscles, including the gluteus maximus and iliopsoas muscles, and in the thigh muscles, including the vastus lateralis, vastus medialis, adductor magnus, and semimembranosus muscles. Lower leg muscles were relatively spared. Fascial edema was observed in all patients and was also present in the lower leg muscles. Subcutaneous edema was observed, particularly in the proximal portion of the lower limbs. In AMA-positive myositis, proximal muscles, including the gluteus maximus, vastus lateralis, adductor magnus, and the semimembranosus, were markedly affected, while the lower leg muscles were relatively preserved. Additionally, fascial edema was evident even in lower leg muscles. Therefore, muscle MRI can be a useful diagnostic aid for AMA-positive myositis. [ABSTRACT FROM AUTHOR]

Background: To evaluate if the sonographic finding of medial ankle subcutaneous (subQ) edema is associated with posterior tibial tenosynovitis (PTTS). Methods: Sonographic images of the medial ankle soft tissues from 40 patients with PTTS and 37 patients with a normal posterior tibial tendon (PTT) were randomized and independently evaluated by two musculoskeletal radiologists for the presence or absence of subQ edema. Both radiologists were blinded to the images and status of the PTT and the patient's history. Statistical analyses included the Chi-square test and Cohen's Kappa statistics for inter-observer agreement. Results: A statistically significant association was seen for the presence of medial ankle subQ edema and PTTS among both radiologists' findings. Of the 40 patients with PTTS, 33 (82.5%) were found positive by the first radiologist for medial ankle subQ edema, while no subQ edema was found in 28 of the 37 (75.7%) patients with a normal PTT (P < 0.001). Similarly, the second radiologist found that 33 of the 40 (82.5%) with PTTS were positive for subQ edema, while no subQ edema was found in 24 of the 37 (64.9%) patients with a normal PTT (P < 0.001). There was also substantial inter-observer agreement between the 2 radiologists (κ-value = 0.79; 95% confidence intervals: 0.65, 0.93). Conclusion: A statistically significant association was present for the association of the sonographic finding of medial ankle subQ edema and the presence of PTTS. Further studies could evaluate if the sonographic finding of medial ankle subQ edema is an early predictor of PTT dysfunction.

Hereditary angioedema (HAE) due to C1-inhibitor (C1-INH) deficiency is a rare hereditary disease characterized by recurrent subcutaneous or submucosal angioedema due to uncontrolled bradykinin production caused by C1-INH dysfunction. Submucosal gastrointestinal swellings provoking abdominal attacks are common and mimic acute abdomen, thus constituting a diagnostic challenge. We aimed to investigate the difficulties in diagnosing abdominal attacks in patients with C1-INH-HAE and to assess the diagnostic value of medical history, the course of the attack, abdominal imaging, and treatment efficacy. The retrospective analysis of diagnostic problems and treatment complications of abdominal attacks in 274 patients with C1-INH-HAE were performed. The value of history, laboratory findings, prodromal symptoms and course of attacks and imaging were assessed. Abdominal attacks were confirmed in 274 of the 322 patients (85%; 190 women and 84 men; age, 4–70 years). In 49% of cases, the abdominal attack was the first and the only symptom for years. The simultaneous presence of marginal erythema (45% of cases), subcutaneous edema (30%), and pharyngo-laryngeal edema (10%) facilitated the diagnosis of an abdominal attack due to C1-INHHAE. Abdominal attacks manifested with recurrent acute abdominal symptoms lasting 2 to 5 days. The disease course was characterized by the phase of progressive prodromal symptoms followed by peak symptoms and spontaneous symptom resolution. Abdominal imaging often revealed abundant ascites and limited bowel edema. In 60 cases (22%), the diagnostic difficulties resulted in exploratory laparotomy, which was inconclusive in 48 patients (80%). The attacks usually subsided within 2 hours from the administration of recommended drugs (plasma-derived C1-INH , recombinant C1-INH or icatibant). We conclude that recurrent abdominal attacks lasting a few days and resolving spontaneously were common symptoms of C1-INH-HAE. Abdominal imaging revealed transitional fluid or bowel edema. The effectiveness of recommended drugs as plasma-derived C1-INH, recombinant C1-INH or icatibant confirmed the diagnosis. [ABSTRACT FROM AUTHOR]

Background: To evaluate if the sonographic finding of medial ankle subcutaneous (subQ) edema is associated with posterior tibial tenosynovitis (PTTS). Methods: Sonographic images of the medial ankle soft tissues from 40 patients with PTTS and 37 patients with a normal posterior tibial tendon (PTT) were randomized and independently evaluated by two musculoskeletal radiologists for the presence or absence of subQ edema. Both radiologists were blinded to the images and status of the PTT and the patient's history. Statistical analyses included the Chi-square test and Cohen's Kappa statistics for inter-observer agreement. Results: A statistically significant association was seen for the presence of medial ankle subQ edema and PTTS among both radiologists' findings. Of the 40 patients with PTTS, 33 (82.5%) were found positive by the first radiologist for medial ankle subQ edema, while no subQ edema was found in 28 of the 37 (75.7%) patients with a normal PTT (P < 0.001). Similarly, the second radiologist found that 33 of the 40 (82.5%) with PTTS were positive for subQ edema, while no subQ edema was found in 24 of the 37 (64.9%) patients with a normal PTT (P < 0.001). There was also substantial inter-observer agreement between the 2 radiologists (κ-value = 0.79; 95% confidence intervals: 0.65, 0.93). Conclusion: A statistically significant association was present for the association of the sonographic finding of medial ankle subQ edema and the presence of PTTS. Further studies could evaluate if the sonographic finding of medial ankle subQ edema is an early predictor of PTT dysfunction. [ABSTRACT FROM AUTHOR]

Introduction: Short peripheral catheters (SPCs) are affected by a high complication rate that leads to catheter failure. Currently, the Visual Infusion Phlebitis score (VIP) is the most used tool to verify the presence of inflammatory complications (phlebitis and thrombophlebitis). However, ultrasound signs (US) may be an attractive alternative., Objective: This study aims to evaluate the sensitivity and specificity of US and VIP score = 1 in identifying and recognizing early signs of SPC failure. The time to positivity for US and VIP scores was assessed as a secondary outcome., Methods: An observational prospective study was conducted. In each patient, US (subcutaneous edema; fibroblastic sleeve; thrombophlebitis) and VIP of the exit site were performed every 24 h until 96 h after insertion. Compared to catheter failure, Sensitivity, Specificity, and Predictive values in both US and VIP were calculated., Results: Two hundred patients were enrolled. The presence of ultrasonic pattern suggestive of edema at 72 h ( p  = 0.018), fibroblastic sleeve at 24, 48, 72, and 96 h ( p <  0.001), thrombosis at 48 ( p <  0.001) and 72 h ( p  = 0.005), and at least one of an abovementioned US at all checkpoints ( p <  0.001) were highly significant predictors of complications. Both US and VIP effectively detect inflammatory events; however, the US showed better sensitivity in overall checkpoints and earlier predictive ability than VIP (1.9 vs 0.47 days)., Conclusions: An ultrasound inflammatory pattern is correlated with SPC failure. An ultrasound protocol-requiring minimal training-is more effective than VIP in recognizing early signs of device failure., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Malnutrition is a common problem among hospitalized older patients. Peripheral parenteral nutrition (PN) can improve patient outcomes but can also lead to complications that affect future treatment. Older inpatients, in particular, are expected to be prone to these catheter-related complications. However, the impact of peripheral PN on older inpatients has been rarely investigated. In the current study, the impact of PN on short peripheral catheters (SPCs) was evaluated by comparing signs and symptoms at the time of catheter removal between 22 patients with PN and 27 without. In addition to external clinical assessment, sonographic investigations of the SPC site were performed. The prevalence of external signs and symptoms of complications was similar between the patients (all P > 0.05). However, subcutaneous edema was found by ultrasound in > 80% of patients with PN, compared with 55.6% of those without PN (P = 0.051). Unlike cases without PN, all patients with PN who presented with external signs and symptoms developed subcutaneous edema (P = 0.022). Multivariate analysis demonstrated that administration of PN was independently associated with subcutaneous edema (adjusted odds ratio = 6.88, 95% confidence interval = 1.083-75.486, P = 0.040). For several decades, phlebitis has been the primary focus of complications related to peripheral PN in clinical settings. However, our results imply that peripheral PN causes subcutaneous edema, which can lead to catheter failure in older inpatients. This study contributes to understanding the etiology of catheter failure during peripheral PN in this population.

Subcutaneous edema as a presenting feature of dermatomyositis has infrequently been described and is thought to signify a more aggressive disease course. We report a case involving a 38-year-old man who presented with significant subcutaneous edema involving his neck and upper body; he later developed clinical features and biopsy results consistent with dermatomyositis. Only sixteen previous cases of dermatomyositis with subcutaneous edema involving adults have been published in the literature and we aim to review disease progression, prognosis, and optimal treatment of the condition.

H syndrome is a recently described autosomal recessive genodermatosis with cutaneous phenotypes of varying severity and multi-system involvement. Patients suffering from this disorder can be easily mistaken for sclerodermoid conditions. The radiological findings of H syndrome are typical but have been described only anecdotally. We present a case of a 29 year old male patient of H syndrome with typical radiological features.

This is a case report of an 8-year-old boy who developed an atypical, rare subphenotype of autoimmune inflammatory acute juvenile dermatomyositis (JDM), initially masquerading as viral polymyositis (PM)-like presentation, that was complicated by a hitherto unreported fulminant, life-threatening pediatric systemic capillary leak syndrome (SCLS). We highlight the close differential between viral PM and JDM, the baffling clinical syndromic constellation of hypotension with hemoconcentration – a “shock”-like syndrome, hypoalbuminemia without albuminuria, and generalized edema with the atypical JDM presentation, and stress crucial need to implement early aggressive, multipronged immunomodulatory treatment along with intensive fluid resuscitation which saved the life, this patient from a stormy, and turbulent 4-week clinical illness. This is the first published case description in the current literature of the association of an aggressive subphenotype of JDM and life-threatening pediatric SCLS. This report opens the Pandora's Box to explore the genetic and pathomechanisms of both disorders.

Paclitaxel, a taxane, is frequently administered intravenously as an anticancer agent. When a peripheral intravenous catheter is used for paclitaxel infusion, clinical nurses often observe signs such as slight swelling at the catheter placement site, lack of blood return, and difficulty in continuing the infusion. However, the cause(s) of such phenomena at the puncture site has not yet been elucidated. The aim of this study was to obtain ultrasonography images of subcutaneous tissues and veins of patients undergoing paclitaxel and carboplatin chemotherapy and compare ultrasonography images taken immediately before catheter removal with those of patients receiving other types of taxanes. We studied 24 patients receiving chemotherapy, including seven receiving paclitaxel and carboplatin chemotherapy, through a peripheral intravenous catheter in a chemotherapy unit for outpatients of a university hospital in Japan. Ultrasonography images of venipuncture sites were obtained before catheter insertion and immediately before catheter removal. We observed subcutaneous edema in the absence of visible manifestations at the puncture sites of all patients undergoing paclitaxel and carboplatin chemotherapy, but not in any patients receiving other types of taxanes. When vesicant agents and vehicles have caused subclinical subcutaneous edema, clinical nurses may detect early slight extravasation by using ultrasonography. [ABSTRACT FROM AUTHOR]

Background: Our aim in this study was to determine the ability of ultrasonography (US) to assess and classify the degree of subcutaneous edema caused by infusion via peripheral intravenous catheter, compared to assessment by the Infusion Nurses Society infiltration scale. Methods: This prospective study included 64 adult patients who underwent infusion via peripheral intravenous catheter. All patients underwent US imaging of the subcutaneous tissue just after the insertion of indwelling catheters and just before catheter removal. The grade of swelling was then assessed using the infiltration scale. Subcutaneous edema and edema thickness were analyzed on transverse US images, and the edema was classified as normal, mild, or severe. The relationship between US-determined subcutaneous edema and that determined by using the infiltration scale was evaluated. Results: Among the 64 patients, US images of the subcutaneous edema were classified into three groups: normal in 15 patients, mild subcutaneous edema in 41 patients, and severe subcutaneous edema in eight patients. Thus, US classification of subcutaneous edema could provide more detailed information than the infiltration scale. Conclusion: The results of the present study suggest that US imaging of subcutaneous tissue could help classify the degree of subcutaneous edema.

H syndrome is a recently described autosomal recessive genodermatosis with cutaneous phenotypes of varying severity and multi-system involvement. Patients suffering from this disorder can be easily mistaken for sclerodermoid conditions. The radiological findings of H syndrome are typical but have been described only anecdotally. We present a case of a 29 year old male patient of H syndrome with typical radiological features. [ABSTRACT FROM AUTHOR]

This is a case report of an 8-year-old boy who developed an atypical, rare subphenotype of autoimmune inflammatory acute juvenile dermatomyositis (JDM), initially masquerading as viral polymyositis (PM)-like presentation, that was complicated by a hitherto unreported fulminant, life-threatening pediatric systemic capillary leak syndrome (SCLS). We highlight the close differential between viral PM and JDM, the baffling clinical syndromic constellation of hypotension with hemoconcentration -- a "shock"-like syndrome, hypoalbuminemia without albuminuria, and generalized edema with the atypical JDM presentation, and stress crucial need to implement early aggressive, multipronged immunomodulatory treatment along with intensive fluid resuscitation which saved the life, this patient from a stormy, and turbulent 4-week clinical illness. This is the first published case description in the current literature of the association of an aggressive subphenotype of JDM and life-threatening pediatric SCLS. This report opens the Pandora's Box to explore the genetic and pathomechanisms of both disorders. [ABSTRACT FROM AUTHOR]

Background Our aim in this study was to determine the ability of ultrasonography (US) to assess and classify the degree of subcutaneous edema caused by infusion via peripheral intravenous catheter, compared to assessment by the Infusion Nurses Society infiltration scale. Methods This prospective study included 64 adult patients who underwent infusion via peripheral intravenous catheter. All patients underwent US imaging of the subcutaneous tissue just after the insertion of indwelling catheters and just before catheter removal. The grade of swelling was then assessed using the infiltration scale. Subcutaneous edema and edema thickness were analyzed on transverse US images, and the edema was classified as normal, mild, or severe. The relationship between US-determined subcutaneous edema and that determined by using the infiltration scale was evaluated. Results Among the 64 patients, US images of the subcutaneous edema were classified into three groups: normal in 15 patients, mild subcutaneous edema in 41 patients, and severe subcutaneous edema in eight patients. Thus, US classification of subcutaneous edema could provide more detailed information than the infiltration scale. Conclusion The results of the present study suggest that US imaging of subcutaneous tissue could help classify the degree of subcutaneous edema. [ABSTRACT FROM AUTHOR]

Background: Hereditary angioedema (HAE) is a rare autosomal dominant disorder characterized by Cl-INH (Cl esterase inhibitor), low serum levels (type I), dysfunction (type II) or normal serum levels and function (type III), which lead to subcutaneous and submucosal edema attacks. The aim of this study was to investigate the demographic, clinical and laboratory findings of Iranian patients with HAE. Methods: The patients with a history or symptoms of angioedema who were referred to Immunology, Asthma and Allergy Research Institute (IAARI) between Jan 2006 and Jan 2014, were assessed based on a specific questionnaire and laboratory evaluation. The patients with a definite diagnosis of HAE type I and type II were entered into this study. Results: Among 51 patients, 63.3% were diagnosed with HAE type I and 36.7% with HAE type II. Fifteen patients were under 18 years and 36 were adults. The mean age of symptoms onset and diagnosis were 12.33 ± 10.20 years and 24.48 ± 14.64 years, respectively. The mean delay of diagnosis was 11.02 ± 11.60 years. The most commonly involved locations of edema were hands, face and genitalia. Moreover, laryngeal edema was observed in 61.2% of patients, which led to death in two patients during this study. Conclusion: Hereditary angioedema is a life threatening disease with considerable morbidity and mortality. The outcomes of this study can be used to inform clinicians and health care providers about HAE, which can help earlier diagnosis and better management of the patients, specifically in life threatening attacks. [ABSTRACT FROM AUTHOR]

Acute inflammatory myopathy with severe subcutaneous edema is extremely rare and has been reported in only a handful of cases. We describe two similar patients presenting with this disorder and generalized rash. Unlike the five previously reported cases, the clinical and histologic features of our two patients are more suggestive of dermatomyositis than polymyositis. Nevertheless, scrutinizing all seven reported patients, a number of specific characteristics could be defined. All patients were adult males. Dysphagia was present in four. In six patients, acute inflammatory myopathy was idiopathic while malignancy was present in one. Two patients died despite intensive therapy, three improved on corticosteroid treatment, and two recovered spontaneously. In all patients, limb involvement with marked subcutaneous edema was present, clinically mimicking deep vein thrombosis in both our patients. The presence of severe subcutaneous edema may be a hallmark of a distinctive variant of acute inflammatory myopathy. More cases are needed to discern subtypes of this general entity and to establish guidelines for treatment and prognosis. [ABSTRACT FROM AUTHOR]

We have reported a case of a 44-year-old woman with anti-signal recognition particle (SRP) antibody-positive immune-mediated necrotizing myopathy triggered by human parvovirus B19 (PVB19) infection. She was admitted to the hospital because of lower leg edema and muscle weakness after erythema infectiosum. Magnetic resonance imaging of the lower extremities revealed high signals in the proximal muscles and subcutaneous edema on STIR. Muscle biopsy showed myofiber regenerative changes and variation in fiber size. A myositis-specific autoantibody profile indicated a positive result for anti-SRP antibodies. We diagnosed the patient with immune-mediated necrotizing myopathy (IMNM). Muscle strength and subcutaneous edema improved gradually in 3 months following immunotherapy. This is the first case report of an IMNM associated with PVB19 infection.

Extravasation incidence is exceptionally low; however, ulceration or necrosis occurs in severe cases, possibly requiring surgical treatment. Early extravasation signs and symptoms are not always evident on treatment day, and inflammation, which leads to ulceration or necrosis, may appear several days later. Therefore, to minimize damage, identification of high-risk groups is required. This study aims to investigate the relationship between subcutaneous edema which is an early extravasation sign, and skin surface temperature using a thermosensitive liquid crystal film. Patients receiving chemotherapy through a peripheral intravenous catheter were recruited. Subcutaneous tissue around the catheterization site was observed for the presence of subcutaneous edema by ultrasonography. During chemotherapy initiation, a thermosensitive liquid crystal film was placed on the catheterization site. Color changes of the film were observed, and each case was classified according to low-temperature distribution patterns. To investigate the factors associated with temperature distribution pattern, logistic regression analysis was performed using clinically selected independent variables. Data from 63 patients were analyzed. No obvious extravasation was observed. Film analysis revealed 34 cases of broadening low-temperature area from the vein and 23 cases of non-broadening low-temperature area from the vein. Subcutaneous edema was observed in 18 patients: 17 with broadening low-temperature area from the vein and 1 with non-broadening low-temperature area from the vein. Subcutaneous edema was positively correlated with broadening low-temperature area from the vein. Catheter site skin temperature distribution pattern during chemotherapy was associated with subcutaneous edema which is the early extravasation sign immediately after chemotherapy. [ABSTRACT FROM AUTHOR]

Background: To evaluate if the sonographic finding of medial ankle subcutaneous (subQ) edema is associated with posterior tibial tenosynovitis (PTTS)., Methods: Sonographic images of the medial ankle soft tissues from 40 patients with PTTS and 37 patients with a normal posterior tibial tendon (PTT) were randomized and independently evaluated by two musculoskeletal radiologists for the presence or absence of subQ edema. Both radiologists were blinded to the images and status of the PTT and the patient's history. Statistical analyses included the Chi-square test and Cohen's Kappa statistics for inter-observer agreement., Results: A statistically significant association was seen for the presence of medial ankle subQ edema and PTTS among both radiologists' findings. Of the 40 patients with PTTS, 33 (82.5%) were found positive by the first radiologist for medial ankle subQ edema, while no subQ edema was found in 28 of the 37 (75.7%) patients with a normal PTT ( P < 0.001). Similarly, the second radiologist found that 33 of the 40 (82.5%) with PTTS were positive for subQ edema, while no subQ edema was found in 24 of the 37 (64.9%) patients with a normal PTT ( P < 0.001). There was also substantial inter-observer agreement between the 2 radiologists (κ-value = 0.79; 95% confidence intervals: 0.65, 0.93)., Conclusion: A statistically significant association was present for the association of the sonographic finding of medial ankle subQ edema and the presence of PTTS. Further studies could evaluate if the sonographic finding of medial ankle subQ edema is an early predictor of PTT dysfunction., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Medical Ultrasound.)