Isolated muscle vasculitis (IMV) is an uncommon vasculitic entity restricted to skeletal muscle and may present without weakness or creatine kinase elevation, making diagnosis difficult. A woman in her 60s presented with a 3-week history of migratory myalgia involving the thighs, shoulders and flanks. Laboratory tests showed leukocytosis, normocytic anaemia, thrombocytosis, markedly elevated inflammatory markers, normal creatine kinase and mildly increased aldolase. MRI of the thighs demonstrated patchy muscle oedema, while extensive infectious and autoimmune evaluation was unrevealing. Muscle biopsy revealed perimysial lymphohistiocytic vasculitis composed of CD4+ T cells and histiocytes without myofibre necrosis, confirming IMV. She improved rapidly with oral prednisone, and methotrexate was initiated as a steroid-sparing agent. This case highlights the importance of considering IMV in patients with unexplained myalgia and systemic inflammation despite normal muscle enzymes and underscores the essential role of MRI and muscle biopsy in diagnosis. Early immunosuppressive therapy leads to favourable outcomes.
Abstract Background Amyloidosis is a disease characterized by the accumulation of protein fibrils across the body leading to a wide range of clinical presentations. It can be primary or secondary, related to chronic infection, inflammation or malignancy. Pulmonary amyloidosis is a rare disorder that occurs either as part of systemic amyloidosis or limited to the lung. Diagnosis is often difficult as clinical and radiological features are vague and variable often with limited treatment options. Case Presentation A 77-year-old man with a past medical history of atrial fibrillation with history of amiodarone use, heart failure, 2nd-degree AV block with pacemaker, prior VSD repair in childhood, interstitial lung disease, coming in with recurrent hypoxic respiratory failures and progressive dyspnea over 18 months. Patient had multiple admissions treated for HF exacerbations and ILD exacerbations with mild response to diuretics and prednisone. Extensive workup done including a high-resolution CT of the chest demonstrating diffuse ground-glass opacities (GGOs), interlobular septal, diffuse bronchial wall thickening without honeycombing or traction bronchiectasis [Figure 1]. Autoimmune serologies were negative except for rheumatoid factor, and hypersensitivity panels were unremarkable. Pulmonary function tests revealed a mild restrictive pattern. Echocardiogram revealed a normal LVEF, increased LV and RV wall thickness, moderate RV dysfunction, and elevated estimated RVSP consistent with pulmonary hypertension. Right and left heart catheterization showed normal filling pressures, shunt study with minimal shunt from residual VSD. Technetium-99m pyrophosphate scintigraphy demonstrated grade 3 myocardial uptake, and endomyocardial biopsy confirmed wild-type ATTR amyloidosis (TTR gene negative). The CT scan findings persistent despite appropriate diuresis and a prednisone taper. The discordance between extensive radiographic parenchymal disease and only mild physiologic impairment like normal filling pressure and mild restrictive pattern on PFT raised suspicion for pulmonary amyloid deposition rather than primary ILD or amiodarone toxicity. Bronchoscopic biopsy was deferred given frailty and limited clinical utility. Patient was started on acoramidis (Attruby) with reported functional improvement and no oxygen requirement on follow-up. Discussion Pulmonary amyloidosis is common but is mostly asymptomatic. It mimics other diseases like ILD and cancer. Definitive diagnosis requires a tissue biopsy confirming amyloid deposition with congo red staining. Given the wide spectrum of radiographic patterns and overlapping presentations, a multidisciplinary approach is essential to distinguish localized from systemic disease, as treatment strategies and prognosis differ substantially. This abstract is funded by: None
Most cases of acute kidney injury (AKI) resolve within 72 h. However, a small number of patients with persistent severe AKI have significantly worse outcomes. We sought to describe the occurrence, impact on outcome and risk factors associated with persistent severe AKI in critically ill patients using a standardized definition. Retrospective cohort study, investigating critically ill patients admitted to one of 16 hospitals from October 2010 to June 2018. We defined persistent severe AKI as Kidney Disease: Improving Global Outcomes stage 2–3 AKI that progressed to and persisted at stage 3 for ≥ 72 h. Risk factors for persistent severe AKI and its association with outcomes were assessed using the super learner algorithm, integrating LASSO logistic regression and XGBoost, and multivariate logistic regression or Cox proportional hazards models, using no persistent severe AKI as the comparator. Of 65,119/190,550 (34.2
BACKGROUND:Poor mental health is difficult to recognize and as a result, its association with recovery from total joint arthroplasty is difficult to assess. The purpose of this study was to investigate the relationship between overall mental health scores and outcomes in the early postoperative period following unilateral total hip arthroplasty (THA).METHODS:This is a retrospective review of prospectively collected data involving 142 patients who underwent primary unilateral THA. Independent variables included patient demographics and preoperative Patient-Reported Outcomes Measurement Information System (PROMIS), Global Physical Health (GPH) and Global Mental Health (GMH) and Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) scores as well as diagnoses of depression or anxiety. Dependent variables included length of stay (LOS), disposition at discharge, narcotic consumption until discharge, 6-week postoperative GPH, GMH and HOOS JR scores and magnitude of change compared to preoperative scores. Preoperative GMH and postoperative outcomes were compared using Pearson correlation coefficient, independent t-tests, Pearson's Chi-Square test, and univariate logistic regression.RESULTS:Patients with preoperative GMH scores below the 25% quartile were less likely to be discharged home and resulted in lower GPH, GMH and HOOS JR scores at 6-week follow-up compared to patients with preoperative GMH scores in the top 25% quartile. However, patients with low preoperative GMH scores demonstrated a greater magnitude of improvement in both the GPH and GMH scores compared to patients in the top 25% quartile. There was no difference in opioid consumption or LOS between either groups. When comparing patients with and without depression/anxiety, no difference was seen in any of the outcomes measured.CONCLUSION:Unilateral THA offers significant improvements in both physical and mental function to patients with hip osteoarthritis and poor mental health, though overall scores remain lower than in those with better mental health.
Introduction Extended offset (EO) stems are commonly used in posterior approach (PA) total hip arthroplasty (THA), but usage rates and complications are not well studied with anterior approach (AA) THA. This study evaluated usage rates, radiographic outcomes and complications following AA THA between patients receiving EO stems and a matched cohort receiving standard offset (SO) stems. Materials and methods This retrospective review evaluated 1515 consecutive AA THA performed between 2014 and 2021. The recent 100 EO were included in radiographic and complication analysis and were matched to 100 SO stems based on stem size, procedure (unilateral/bilateral), sex, body mass index (BMI), and age. Data collection included patient demographics; pre- and postoperative radiographic measurements of leg length difference (LLD) and global hip offset difference (GHOD); and complications within 1 year. Independent t-tests and Chi-squared analyses compared EO and SO groups. Results EO was utilized in 8% of all AA THA. Despite matching procedures, the distribution of racial groups was different between EO and SO groups, respectively: Caucasian (75% vs. 43%), Asian (12% vs. 35%), Native Hawaiian/Pacific Islander (NHPI) (9% vs. 13%), and other (4% vs. 9%) (p < 0.001). No fractures, dislocations, or revisions occurred within 1 year after surgery in either group. One deep infection was noted in the SO group. The proportions of patients following surgery who had a GHOD < 6 mm (76% vs. 82%; p = 0.193) and LLD < 6 mm (81% vs. 86%; p = 0.223) were not significantly different between EO and SO groups, respectively. Conclusions Prioritizing hip symmetry over stability results in a high proportion of patients achieving hip symmetry without high usage of EO stems in AA THA. Furthermore, low use of EO stems did not result in increased dislocations. Due to racial anatomical differences, Caucasian patients required EO stems to achieve hip symmetry more frequently than Asian and NHPI patients.
