A comparison of the efficacy and safety of adapalene gel 0.1% and tretinoin gel 0.025% in the treatment of acne vulgaris: a multicenter trial

BACKGROUND

Adapalene is a new synthetic retinoid analogue developed for the topical treatment of acne vulgaris.

OBJECTIVE

The study was designed to compare the efficacy and safety and adapalene gel 0.1% with tretinoin gel 0.025% in the treatment of grade II to II facial acne vulgaris.

METHODS

Three hundred twenty-three patients were enrolled in this investigator-masked, randomized, parallel group, multicenter trial. Patients applied the test materials to the entire facial area daily, for a period of 12 weeks. Efficacy and cutaneous tolerance were assessed at baseline and weeks 2,4,8, and 12. Efficacy was determined by investigator counts of noninflammatory open and closed comedones, and inflammatory papules and pustules, as well as global improvement. Cutaneous tolerance was evaluated by erythema, scaling, and dryness, along with burning and pruritus.

RESULTS

Staring at weeks 2 and 4, adapalene gel produced numerically greater lesion reductions than did tretinoin gel for all lesion types. At week 12, the mean percent reduction in the different lesion counts was as follow: 49% versus 37% for total lesions (p<0.01); 46% versus 33% for noninflammatory lesions (p=0.02); 48% versus 38% for inflammatory lesions (p=0.06) in adapalene and tretinoin gel treatment groups, respectively. Cutaneous side effects were limited to a mild "retinoid dermatitis" occurring in both treatment groups; however, patients treated with adapalene gel tolerated this therapy significantly better than those treated with tretinoin gel. Laboratory test evaluations (hematology, blood chemistries, urinalysis) were performed in 54 patients before and after 3 months of treatment. No clinically significant changes were observed.

CONCLUSION

Adapalene gel 0.1% applied once daily was significantly more effective in reducing acne lesions and was better tolerated than tretinoin gel 0.025% in the treatment of acne vulgaris.

Twelve-month evaluation of rhesus monkey dams and infants after relaxin (hRlx-2) infusion in late pregnancy

Pregnant rhesus monkeys received daily i.v. infusions of chemically synthesized human relaxin (hRlx-2) (0.1 mg/kg/day N = 6, 2.0 mg/kg/day N = 6, vehicle control N = 7) from the onset of cervical softening to delivery (0 to 14 infusions) to simulate potential therapeutic use of this agent for cervical ripening. Reproductive fitness of dams was evaluated during the next breeding season, and infants were studied through 12 months of age. Birth weight and size, neonatal heart rate and body temperature and neurobehavioral status were not influenced by intrauterine relaxin exposure. Neonatal muscle tone was greater and responsiveness was lower in the hRlx-2 treated infants than in controls. No group differences were seen in infant postnatal growth, maturation or incidence of health problems. Maternal endpoints including uterine involution, resumption of menses, conception rate, and pregnancy outcome were similar across groups. Systemic exposure of rhesus monkeys to relatively high levels of hRlx-2 in late pregnancy did not have apparent long term effects for the measures evaluated under conditions of the experiment. Conclusions concerning adverse effects are limited by the small sample size.

Synovial hemangioma: imaging features in eight histologically proven cases, review of the literature, and differential diagnosis

OBJECTIVE

This study was undertaken to describe the imaging characteristics of synovial hemangioma, with the goal of improving the disappointing rate (22%) of clinical diagnosis of this condition. A review of the literature and the differential diagnosis of intra-articular lesions, including synovial osteochondromatosis and pigmented villonodular synovitis, are also presented.

PATIENTS

The subjects of the study were 8 patients (4 males, 4 females; age range: 5-47 years; mean age: 19 years) with histologically confirmed synovial hemangioma involving the knee (n = 7) or wrist (n = 1). We retrospectively examined the imaging studies performed in these patients, including plain radiography (n = 8), magnetic resonance imaging (MRI; n = 4), angiography (n = 3), arthrography (n = 2), and contrast-enhanced computed tomography (CT; n = 2).

RESULTS

Plain radiographs showed a soft tissue density suggesting either joint effusion or a mass in all patients. Phleboliths and bone erosions on plain films in four patients with extra-articular soft tissue involvement pointed to the correct diagnosis. Angiography, showing fine-caliber, smooth-walled vessels, contrast pooling in dilated vascular spaces, and early visualization of venous structures, was diagnostic in two patients. Neither arthrography nor CT yielded specific enough findings. MRI was consistently effective in allowing the correct diagnosis to be made preoperatively, showing an intra-articular or juxta-articular mass of intermediate signal intensity on T1-weighted images and of high signal intensity of T2- or T2*-weighted images with low-signal channels or septa within it. A fluid-fluid level was found in two patients with a cavernous-type lesion.

CONCLUSION

Despite the limited nature of this study, it shows clearly that MRI is the procedure of choice whenever an intra-articular vascular lesion such as synovial hemangioma is suspected. Nonetheless, phleboliths and evidence of extra-articular extension of plain radiographs point to angiography as an effective procedure of first resort because it can be combined with embolotherapy.

Bone island: scintigraphic findings and their clinical application

PURPOSE

To evaluate bone islands that showed increased uptake of radiotracer on skeletal scintigraphy and to present an algorithm for examining such lesions to avoid misdiagnosis in difficult cases.

PATIENTS AND METHODS

Over an 8-year period, 20 patients (10 men and 10 women ranging in age from 33 to 82 years) with bone islands that showed activity on skeletal scintigraphy were examined with plain radiography (all patients), computed tomography (CT; 5 patients) and magnetic resonance imaging (MRI; 4 patients). For six of the patients the clinical presentation and the radiologic studies suggested malignancy, which prompted biopsy and histopathologic examination. Histopathologic study was also performed for six other patients in whom the bone islands were found incidentally during evaluation for joint replacement surgery for osteoarthritis. In the last eight patients the lesions exhibited the characteristic radiologic features of enostosis, and these patients were followed for up to 3 years without biopsy.

RESULTS

In all cases plain radiography showed the characteristic features of a bone island: a homogeneously dense, sclerotic focus in the cancellous bone with distinctive radiating bony streaks ("thorny radiation") that blended with the trabeculae of the host bone to create a feathered or brush-like border. Histopathologic examination of scintigraphically active bone islands showed increased osteoblastic activity, and the lesions were marked by a mixture of compact and trabecular bone. In the patients who did not undergo biopsy but were followed with radiologic examinations, there was no change in the size or appearance of the lesions.

CONCLUSIONS

The key to the correct diagnosis of bone island lies in the distinctive radiographic features of enostosis. An asymptomatic, isolated sclerotic bone lesion showing feathered or brush borders is most likely an enostosis, regardless of its size or its activity on scintigraphy. Therefore, a practical algorithm for examining bone islands should flow from their morphologic features as observed on radiographs and CT and MRI scans, rather than from their activity on scintigraphy.

Blastic osseous metastases in ovarian carcinoma

A 75-year-old woman with histologically proven ovarian adenocarcinoma and no evidence of other malignant lesions was found to have disseminated blastic (sclerotic) metastases to bone without clinical evidence of gross peritoneal spread or lung involvement. The patient's survival for 28 months after the earliest evidence of bone involvement is noteworthy, because osseous metastasis in ovarian malignancy is usually a late manifestation of the disease.

Traumatic hip dislocation: early MRI findings

PURPOSE

Objective of this study was to present the spectrum of early magnetic resonance imaging (MRI) findings following traumatic dislocation of the femoral head, and to identify any associated injuries that may have therapeutic or prognostic significance and be better delineated by MRI than by conventional radiography.

PATIENTS AND METHODS

Prospective MRI of both hips was formed on 18 patients (14 male, 4 female; age range 14-54 years; average age 30.5 years) within 5 weeks of a traumatic femoral head dislocation. The interval between the time of injury and the time of injury and the imaging studies ranged from 2 to 35 days (average 13.2 days). Posterior dislocation was present in 14 patients and anterior dislocation in 4 patients. In the majority of cases, we performed axial T1, coronal T1, and coronal T2* (MPGR) sequences. Images were retrospectively evaluated by consensus of three radiologists for possible abnormalities of the bone and cartilage, joint space, and soft tissues. Because all patients were treated with closed reduction, surgical correlation was not obtained.

RESULTS

All patients had a joint effusion or hemarthrosis. Of the 14 patients with posterior dislocation, isolated femoral head contusions (trabecular microfractures) were identified in 6 patients. Four patients had small femoral head fractures, and one had an osteochondral defect. Acetabular lip fractures were seen in six patients, and one patient had a labral tear. Four patients had intra-articular loose bodies and one had ligamentum teres entrapment. Twelve patients had iliofemoral ligament injury. All patients had muscle injury involving the gluteal region and medical fascial compartment, and 13 patients had anterior fascial compartment muscle injury. Seven patients with posterior dislocation had posterior fascial compartment injury. Of the four patients with anterior dislocation, two had bony contusion, two had cortical infraction, one had a labral tear, and all four had an iliofemoral ligament injury. All four patients in this group had muscle injury of the gluteal region and of the anterior and medial fascial compartments.

CONCLUSIONS

MRI can effectively identify and quantify the muscle injury and joint effusion that invariably accompany traumatic hip dislocations. It is also useful for demonstrating trabecular bone contusion (trabecular injury) and iliofemoral ligament injury, which occur commonly with acute hip dislocation.

Carpal scaphoid: radiographic pattern of dislocation

Plain radiographs help establish the diagnosis and pattern of dislocation of the carpal scaphoid. Isolated dislocations can be treated with closed reduction, but dislocations in conjunction with axial carpal disruption must be treated with open reduction to fix the unstable radial half of the carpus to the stable ulnar half. Two case reports illustrate each type of carpal scaphoid dislocation.

Evaluation of meniscal tears: fast spin-echo versus conventional spin-echo magnetic resonance imaging

RATIONALE AND OBJECTIVES

We compared the performance of fast spin-echo (FSE) with conventional spin-echo (CSE) magnetic resonance (MR) imaging sequences in the detection of meniscal tears.

METHODS

Seventy-three patients underwent MR examination of the knee for suspected internal derangement. Each patient was scanned with a CSE sequence and one of two FSE sequences. The primary difference between the two FSE sequences consisted of the echo train length (ETL). Thirty-seven patients (group 1) were scanned with the FSE I sequence (ETL = 8), and 36 patients (group 2) were scanned with the FSE II sequence (ETL = 4). Menisci were graded as torn or not torn on the basis of their MR appearance. The sequences were compared with each other and with the surgical findings in 31 patients who underwent arthroscopy.

RESULTS

In group 1, there was a significant discrepancy between the CSE and FSE I techniques (p = .006). The FSE I sequence detected only 11 of 19 surgically proven torn menisci as opposed to 18 of 19 detected with the CSE sequence. The FSE II sequence performed significantly better in group 2, with an accuracy equal to that of the CSE sequence.

CONCLUSION

FSE sequences are extremely technique dependent with regard to detecting meniscal tears and should not replace CSE sequences in this setting until further studies are performed to optimize the technique.

Bone island (enostosis): current concept--a review

An enostosis or bone island represents a focus of mature compact (cortical) bone within the cancellous bone (spongiosa). Thought by some to be a tumor-like condition and by others a hamartoma, this benign lesion is probably congenital or developmental in origin and reflects failure of resorption during endochondral ossification. A bone island can be virtually diagnosed based on its characteristic clinical and radiologic features. Typically asymptomatic, the lesion is usually an incidental finding, with a preference for the pelvis, femur, and other long bones, although it may be found anywhere in the skeleton, including the spine. Plain radiography reveals a homogeneously dense, sclerotic focus in the cancellous bone with distinctive radiating bony streaks ("thorny radiation") that blend with the trabeculae of the host bone, creating a feathered or brush-like border. On CT scan, a bone island appears as a low-attenuation focus, and on MRI sequences it shows low signal intensity like cortical bone. A distinguishing feature of bone islands is that they are usually "cold" on skeletal scintigraphy. Thus, bone scan has been and continues to be the means of differentiating bone islands from the more aggressive entities. However, reports of histologically confirmed bone islands that were scintigraphically active have raised a note of caution about relying on this modality in the differential consideration of lesions otherwise characteristic of bone islands. Guides to the correct diagnosis should be looked for in the individual clinical situation and in the morphological features of the lesion on plain radiography, CT, and MRI, without regard to the lesions activity on bone scan.(ABSTRACT TRUNCATED AT 250 WORDS)

Chondrosarcoma complicating synovial chondromatosis: findings with magnetic resonance imaging

A 64-year-old man with a tender mass at the ankle was found to have chondrosarcoma complicating synovial chondromatosis. Malignancy was suspected on the basis of the clinical presentation rather than the findings in plain radiographs or magnetic resonance images. Chondrosarcoma arising in synovial chondromatosis is very rare. Misinterpreting the latter condition as malignant and the former as benign can be problematic, and the importance of distinguishing the two entities is discussed.

Severe osteopenia in congenital erythropoietic porphyria

Congenital erythropoietic porphyria is a rare disorder of porphyrin metabolism. The authors describe a 15-year-old boy in whom the radiologic manifestations of this disorder included the known features of osteopenia, acro-osteolysis, soft-tissue calcifications and widening of the diploic space, as well as the previously unreported findings of severe vertebral compression fractures, thoracic kyphosis, and "salt and pepper" skull.

Radionuclide imaging in forme fruste of melorheostosis

Scintigraphy was instrumental in two histologically proven cases of forme fruste melorheostosis. Radionuclide bone scans demonstrated a moderately increased uptake of radiopharmaceutical localized to the "flowing" cortical hyperostosis of melorheostosis observed radiographically. The medullary portion of the affected bones showed no increase in tracer activity. In one case, imaging with Tl-201 chloride demonstrated increased focal activity of the lesion. These scintigraphic findings can help distinguish the mildest manifestation (forme fruste) of melorheostosis from the well-ossified lesions of myositis ossificans and parosteal or periosteal osteosarcoma. The findings of MRI are also described in one patient.

Treatment of kyphotic deformity in ankylosing spondylitis

This article reviews the available literature on the surgical options for the correction of kyphosis in ankylosing spondylitis and presents the radiologic appearance of the post-operative spine. In the postsurgical evaluation of the spine, the focus is on appreciation of the patterns of correction, early and late determination of angular correction, recognition of various complications (infection, nonunion, improper location, or breakage of hardware), and alertness to the possibility of complications at all levels of the spine.

Osteomyelitis of the clavicle: clinical, radiologic, and bacteriologic findings in ten patients

Most lesions of the clavicle are traumatic and pose few diagnostic difficulties. Nontraumatic clavicular lesions, on the other hand, are rare and frequently present problems in diagnosis. This report reviews the clinical, radiologic, and bacteriologic findings in ten patients, six of whom were diagnosed as having acute osteomyelitis and four chronic osteomyelitis. The differential diagnosis of clavicular osteomyelitis is also discussed. The clinical duration of the infectious process in these patients ranged from 2 weeks to 1.5 years. All patients presented with pain; six had fever, three had localized swelling or a mass, and three had soft tissue abscesses. The radiographic findings also varied: the lesion was predominantly sclerotic in four patients, lytic in three, and mixed in two patients; in the one patient in whom magnetic resonance imaging was the only imaging study performed, these features could not be properly evaluated. Periosteal reaction was detected in three patients. Staphylococcus aureus was the causal organism in four patients, while in the remaining six patients different microorganisms were cultured, including Coccidiodes immitis and Mycobacterium tuberculosis. Six patients required biopsy for final diagnosis. Although clavicular osteomyelitis is rare, particularly in adults, it should be considered in the differential diagnosis of a clavicular lesion. The final diagnosis often depends on the results of biopsy and cultures.

Negative bone scintigraphy with diffuse osteoblastic breast carcinoma metastases

A patient with diffuse osteoblastic metastases from invasive lobular carcinoma of the breast is presented in whom radionuclide bone scan was negative for skeletal lesions. Skeletal metastases were documented by plain radiography, CT, MRI, and bone marrow biopsy. This case report points to the value of plain-film, CT, and MRI findings in situations of high clinical suspicion of metastatic disease despite a normal scintigraphy.

Three-dimensional sonographic evaluation of developmental dysplasia of the hip: preliminary findings

PURPOSE

To determine the value of three-dimensional (3D) sonography in the evaluation of developmental dysplasia of the hip.

MATERIALS AND METHODS

3D reconstruction and section analysis were performed on 38 data acquisitions obtained in nine patients with a clinical diagnosis of developmental dysplasia of the hip. Data were obtained mostly in the coronal plane, and section-analysis and 3D volume reconstruction images were generated.

RESULTS

Of the 32 image sets obtained in the coronal plane, the technical quality of 27 (84%) section-analysis images and 25 (78%) spatial-revolving images was judged to be satisfactory.

CONCLUSION

In addition to permitting global visualization of the hip, 3D sonography offers imaging in the sagittal and craniocaudal projections, something no other modality can offer. 3D sonography can also demonstrate the relationship of the femoral head to the acetabulum and femoral head containment more thoroughly than does conventional sonography.

Extraskeletal myxoid chondrosarcoma: an unusual tumour in a 6-year-old boy

Extraskeletal (soft-tissue) myxoid chondrosarcoma is an uncommon malignant tumour that usually develops in the fifth, sixth or seventh decade of life. The authors describe its occurrence in a 6-year-old boy. Histologically, the tumour must be differentiated from parachordoma and epithelioid hemangioendothelioma, with which it shares some features.