Calcifying tendinitis of the shoulder: Advances in imaging and management

Calcifying tendonitis of the shoulder is a common, acute or chronic, painful disorder characterized by calcifications in the rotator cuff tendons. A natural cycle exists during which the tendon repairs itself. In chronic calcific tendonitis, however, this cycle is blocked at one of the healing stages. Because chronic presentation with exacerbations is usual, initial treatment should be conservative, including rest, physical therapy, nonsteroidal anti-inflammatory drugs, and, in later stages, subacromial infiltration with corticosteroids. Surgery is recommended when conservative treatment fails. This article discusses advances in imaging and medical, physical, and surgical management, as well as current evidence for the treatment of calcifying tendonitis of the shoulder.     

The skin in primary immunodeficiency disorders

Primary immunodeficiency disorders comprise serious and rare diseases, predominantly in children. The skin may be involved in a primary immunodeficiency and the cutaneous alterations such as infections, eczematous dermatitis, erythroderma, autoimmune dermatoses and vasculitis may be the basis for the ultimate diagnosis. Dermatologists may realize something is wrong with the immunity of their patient and prompt diagnosis of the defect can lead to lifesaving treatment. Since atypical presentations of well known dermatoses are common in immunodeficiency disorders, histopathology and bacterial, fungal or viral tests of the skin lesions are often indispensable. The knowledge of skin findings in primary immunodeficiency diseases may help dermatologists to play a role in the early detection of these diseases. Key findings constitute specific skin symptoms combined with unusual or severe infections.     

Characterization of the effects of reuptake and hydrolysis inhibition on interstitial endocannabinoid levels in the brain: an in vivo microdialysis study

The present experiments employed in vivo microdialysis to characterize the effects of commonly used endocannabinoid clearance inhibitors on basal and depolarization-induced alterations in interstitial endocannabinoid levels in the nucleus accumbens of rat brain. Compounds targeting the putative endocannabinoid transporter and hydrolytic enzymes (FAAH and MAGL) were compared. The transporter inhibitor AM404 modestly enhanced depolarization-induced increases in 2-arachidonoyl glycerol (2-AG) levels but did not alter levels of N-arachidonoyl-ethanolamide (anandamide, AEA). The transport inhibitor UCM707 did not alter dialysate levels of either endocannabinoid. The FAAH inhibitors URB597 and PF-3845 robustly increased AEA levels during depolarization without altering 2-AG levels. The MAGL inhibitor URB602 significantly enhanced depolarization-induced increases in 2-AG, but did not alter AEA levels. In contrast, the MAGL inhibitor JZL184 did not alter 2-AG or AEA levels under any condition tested. Finally, the dual FAAH/MAGL inhibitor JZL195 significantly enhanced depolarization-induced increases in both AEA and 2-AG levels. In contrast to the present observations in rats, prior work in mice has demonstrated a robust JZL184-induced enhancement of depolarization-induced increases in dialysate 2-AG. Thus, to further investigate species differences, additional tests with JZL184, PF-3845, and JZL195 were performed in mice. Consistent with prior reports, JZL184 significantly enhanced depolarization-induced increases in 2-AG without altering AEA levels. PF-3845 and JZL195 produced profiles in mouse dialysates comparable to those observed in rats. These findings confirm that interstitial endocannabinoid levels in the brain can be selectively manipulated by endocannabinoid clearance inhibitors. While PF-3845 and JZL195 produce similar effects in both rats and mice, substantial species differences in JZL184 efficacy are evident, which is consistent with previous studies.     

Pulmonary endarterectomy normalizes interventricular dyssynchrony and right ventricular systolic wall stress

Background

One of the safety concerns when performing electrophysiological (EP) procedures under magnetic resonance (MR) guidance is the risk of passive tissue heating due to the EP catheter being exposed to the radiofrequency (RF) field of the RF transmitting body coil. Ablation procedures that use catheters with irrigated tips are well established therapeutic options for the treatment of cardiac arrhythmias and when used in a modified mode might offer an additional system for suppressing passive catheter heating.

Methods

A two-step approach was chosen. Firstly, tests on passive catheter heating were performed in a 1.5 T Avanto system (Siemens Healthcare Sector, Erlangen, Germany) using a ASTM Phantom in order to determine a possible maximum temperature rise. Secondly, a phantom was designed for simulation of the interface between blood and the vascular wall. The MR-RF induced temperature rise was simulated by catheter tip heating via a standard ablation generator. Power levels from 1 to 6 W were selected. Ablation duration was 120 s with no tip irrigation during the first 60 s and irrigation at rates from 2 ml/min to 35 ml/min for the remaining 60 s (Biotronik Qiona Pump, Berlin, Germany). The temperature was measured with fluoroscopic sensors (Luxtron, Santa Barbara, CA, USA) at a distance of 0 mm, 2 mm, 4 mm, and 6 mm from the catheter tip.

Results

A maximum temperature rise of 22.4°C at the catheter tip was documented in the MR scanner. This temperature rise is equivalent to the heating effect of an ablator's power output of 6 W at a contact force of the weight of 90 g (0.883 N). The catheter tip irrigation was able to limit the temperature rise to less than 2°C for the majority of examined power levels, and for all examined power levels the residual temperature rise was less than 8°C.

Conclusion

Up to a maximum of 22.4°C, the temperature rise at the tissue surface can be entirely suppressed by using the catheter's own irrigation system. The irrigated tip system can be used to increase MR safety of EP catheters by suppressing the effects of unwanted passive catheter heating due to RF exposure from the MR scanner.     

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures

Background

Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking.

Methods

All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations.

Results

Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6–54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18–68 min) for tibial fractures and 55 min (range 47–150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity.

Conclusion

The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.     

Calcifications in the cuff: take it or leave it?

Objectives

The aim of this study was to evaluate whether removing the calcifications in the rotator cuff tendons during surgical subacromial decompression improves outcome in patients with calcific tendonitis.

Methods

Two groups of 20 patients with a subacromial impingement syndrome and cuff calcifications were operated on. In group A, patients had an anterolateral acromioplasty according to Neer with excision of calcifications. In group B, the same procedure was performed without additional excision of calcifications. After a minimum follow‐up of 3 years the patients were assessed with the disabilities of arm, shoulder and hand score (DASH), the visual analogue scale (VAS) for pain, measurements of range of motion (ROM) in all planes, and satisfaction with treatment.

Results

The results for the DASH score, ROM, VAS and satisfaction with treatement showed no significant difference between the two groups.

Conclusion

The results of our study suggest that removal of calcific deposits with anterolateral acromioplasty does not influence patient outcome. Further prospective studies are needed to determine the optimal surgical treatment for calcific tendonitis.Calcific tendonitis of the shoulder is a common and painful disorder and is characterised by calcifications in the tendons of the rotator cuff (fig 1​1).). The incidence in the healthy population is 2.7%, rising to 6.8% in patients with shoulder pain.^1,2 The predominant age is 30–60 years and women are affected slightly more often than men. The calcifications are most often seen in the tendon of the supraspinatus muscle.¹ Risk factors for shoulder pain due to problems of the rotator cuff include overhead activities and sports.^3,4 The treatment of choice is primarily conservative. This includes rest, physiotherapy, non‐steroidal anti‐inflammatory drugs and at a later stage a subacromial infiltration with corticosteroids. When conservative treatment fails, surgery can be recommended. In most studies on surgical treatment of calcific tendonitis, removal of the calcifications in combination with a subacromial decompression is only recommended when there are signs of subacromial irritation.^{5,6,7,8,9,10,11} However, it has also been advocated that a subacromial decompression alone might be sufficient, stating that the calcifications will dissolve as a matter of natural course.¹² The aim of this study was to evaluate whether it is beneficial for patient outcome to remove the calcifications of the tendons of the rotator cuff when performing a subacromial decompression.Open in a separate windowFigure 1 Example of a calcification in the rotator cuff on an x ray of the shoulder.     

Cytomegalovirus rather than HIV triggers the outgrowth of effector CD8+CD45RA+CD27- T cells in HIV-1-infected children

OBJECTIVE: To analyse the effect of viral coinfections on immune reconstitution in HIV-1-infected children (< 18 years) taking highly active antiretroviral therapy (HAART). METHODS: Absolute lymphocyte numbers of various subsets of CD8 T cells were measured. RESULTS: Prior cytomegalovirus (CMV) infection correlated with an increased number of CD8 effector T cells (i.e., CD45RA+CD27-) at baseline (CMV-seropositive versus CMV-seronegative patients; P = 0.009), as well as an increased state of T cell activation as defined by HLA-DR and CD38 expression. The expansion of effector CD8 T cells persisted over time, independent of the HIV response to HAART. Numbers of CD8 effector T cells were significantly higher in patients with CMV replication as reflected by persistent urinary CMV shedding and periodic CMV DNAaemia (P = 0.02). These patients also showed an increase in CMV-specific antibodies compared with those without CMV shedding (P = 0.007). The number of CMV-specific interferon-gamma (IFN-gamma)-producing CD8 T cells was lower in children who persistently shed CMV compared with those who did not (P = 0.02). In contrast, CMV-specific CD4 T cell responses were detected at similar levels in both groups. CONCLUSIONS: In HIV-1-infected children, CMV infection correlated with the outgrowth of CD8+CD45RA+CD27- effector T cells. Activation of the immune system by persistent CMV secretion resulted in increasing CMV-specific IgG and higher numbers of CD8 effector T cells. Despite these increases, the CMV-specific IFN-gamma-producing CD8 T cell response was diminished, which could explain the inability to suppress CMV completely in 41% of HIV-1-infected children.     

Recurrent missense mutations at the first and second base of codon Arg243 in human lipoprotein lipase in patients of different ancestries

Mutations in the lipoprotein lipase (LPL) gene are the most common cause of familial chylomicronemia. Here we define the molecular basis of LPL deficiency in four patients of German, French, Dutch, and Chinese descent. We show that two of the probands of Dutch and Chinese origin have a previously described Arg²⁴³His mutation while the patients of German and French descent have a novel Arg²⁴³ Cys substitution in their LPL gene. Haplotype analysis is in favour of two separate origins for the Arg²⁴³ Cys substitution which together with the Arg²⁴³ His mutation would implicate three recurrent mutations involving the first and second nuclcotides of the codon encoding Arg²⁴³ of the LPL gene. The recurrent mutations affecting the first and second nucleotide of CGC coding for the normal Arg residue are support for the high mutability of CpG dinucleotides within the LPL gene. © 1994 Wiley-Liss, Inc.