Diagnosis of presence and extent of deep infiltrating endometriosis by preoperative MRI-improvement of staging accuracy by expert training

INTRODUCTION

This study evaluates the clinical utility of magnetic resonance imaging (MRI) for the determination of presence and extent of DIE with special emphasis on effects of MRI reporting training MATERIAL AND METHODS: Data from 80 patients with clinically suspected DIE presented at our certified endometriosis center between 2015 and 2018 were analyzed. For all patients an ENZIAN score (describing DIE related to individual anatomical localizations) was obtained based on the preoperative MRI findings. The intraoperatively determined ENZIAN score served as the reference for assessment of diagnostic performance of the MRI.

RESULTS

Overall, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of DIE by MRI were 76.9%, 53.3%, 87.7% and 34.8%, respectively. Analysis by compartment revealed a sensitivity, specificity, PPV and NPV of 59.5%, 88.2%, 86.2% and 63.9%, respectively, for compartment A, with similar values for compartment B, and 50.0%, 88.9%, 64.7% and 81.4%, respectively, for the less often affected compartment C. Expert training (n = 32 before, n = 48 after) led to a considerable increase in sensitivities for the overall detection of DIE (84.6% vs. 65.4%, p = 0.071) and for the detection of DIE in compartment A (71.4% vs. 35.7%, p = 0.026), compartment B (66.7% vs. 37.5%, p = 0.057) and compartment C (75.0% vs. 20.0%, p = 0.010), without significant loss in specificity (all p > 0.50).

DISCUSSION

After expert training, MRI has a good sensitivity with fair specificity regarding preoperative assessment of presence, location and extent of DIE.

AB0752 CHRONIC RECURRENT MULTIFOCAL OSTEOMYELITIS: A SINGLE-CENTER CASE SERIES

Background:

Chronic recurrent multifocal osteomyelitis (CRMO) is a chronic autoinflammatory disease that primarily affects the skeleton of children and adolescents in the absence of an infectious etiology[1]. CRMO lesions presentation varies widely ranging from episodic bone pain to growth disturbance; lytic and sclerotic bone lesions can be found on X-ray, however magnetic resonance imaging is very useful for evaluating the extent of disease and follow-up [2].

Objectives:

To report demographic, clinical and laboratory characteristics and response to therapy in a single center Italian cohort of CRMO patients.

Methods:

We reviewed retrospectively the clinical records of seven patients affected by CRMO diagnosed between 2008 and 2019 at rheumatologic service of South Tyrol region in Italy.

Results:

We identified 7 patients with CRMO, 4 were female patients, median age of onset of symptoms was seven years. Median delay in diagnosis was seven months; all patients had bone pain as initial symptom and 6 patients presented joint swelling. Median number of lesions was two; all patients had a recurrent pattern, 4 patient had multifocal distribution and 5 had appendicular skeleton involvement. None of our patients had antinuclear antibodies or HLA-B27 positivity. Mean erythrocyte sedimentation rate was 52 mm/h and C-reactive protein 1,96 mg/dL. Regarding other organs involvement one patient presented palmoplantar pustulosis, one psoriatic arthritis and one psoriasis guttata; three patient referred familiarity for psoriasis. Histopathological diagnosis was confirmed in 3 patients. NSAIDs were used in six patients, methotrexate in two patients and bisphosphonates in 6 patients. Among biological DMARDs Adalimumab was used in two patients, one patient was treated subsequently with Secukinumab and Ustekinumab. 3 patients achieved remission (Table 1).

Table 1.

Demographic, clinical and laboratory characteristics of patients with chronic recurrent multifocal osteomyelitis.

Total (n=7)Demographics Female (%)4 (57) Age at disease onset, years, median (range)7 (6-24) Delay in diagnosis, months, median (range)7 (2-14) Follow-up, months, median (range)69 (11-151)Initial symptoms Bone pain, n (%)7 (100) Swelling, n (%)5 (71) Limp, n (%)3 (43) Fever, n (%)1 (14)Clinical features Number of lesions, median (range)2 (1-10) Axial skeleton involvement, n (%)2 (29) Appendicular skeleton involvement, n (%)5 (71)Distribution of involvement Femur, n (%)3 (43) Radius/ulna, n (%)2 (29) Humerus, n (%)1 (14) Tibia/fibula, n (%)5 (5) Tarsal bones, n (%)1 (14) Others, n (%)3 (43)Laboratory tests Hemoglobin, g/dL, mean ± SD13.1±0.6 Leukocytes × 103/mm3, mean ± SD8.48 ±1.7 Platelets × 103/mm3, mean ± SD384±130 Erythrocyte sedimentation rate mm/h, mean ± SD52±37 C-reactive protein, mg/dL, mean ± SD1.96±2.35 Positive antinuclear antibodies, n (%)0 (100) HLA-B27 positive, n (%)0 (100)Comorbidities Any type of autoimmunity, n (%)2 (29) Others, n (%)3 (43) Histological confirmation, n (%)3 (43)Treatment NSAIDs, n (%)6 (86) Glucocorticoids, n (%)0 (0) Bisphosphonates, n (%)6 (86) TNF blocking agents, n (%)2 (29) Biological DMARDs, n (%)1 (4) Methotrexate, n (%)2 (29) Antibiotics, n (%)3 (43) Reached remission, n (%) 3 (43)

Conclusion:

CRMO remains a rare diagnosis. From our experience most of the patients had delay in diagnosis, laboratory tests showed mild elevation of inflammatory parameters, was found association with psoriatic arthritis and psoriasis, remission was achieved with combination of bisphosphonate and immunosuppressive therapy in less than half of the cohort

References:

[1]A. Taddio, F. Zennaro, S. Pastore, e R. Cimaz, «An Update on the Pathogenesis and Treatment of Chronic Recurrent Multifocal Osteomyelitis in Children», Pediatr. Drugs, vol. 19, n. 3, pagg. 165–172, giu. 2017.

[2]S. J. Menashe et al., «The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics», J. Magn. Reson. Imaging JMRI, pag. e27299, ago.2020

Disclosure of Interests:

None declared

Diagnostic findings in adenomyosis: a pictorial review on the major concerns

Adenomyosis is a benign pathology with a marked impact on women in reproductive age. The prevalence of adenomyosis ranges from 5 to 70%. Dysmenorrhea, metrorrhagia, chronic pelvic pain, dyspareunia and infertility often occur, while a third of the women is asymptomatic. This pictorial review focuses on the peculiar patterns of presentation in adenomyosis. They are identified by means of non-invasive or minimally invasive techniques, with particular reference to 2D- and 3D-transvaginal sonography, sonohysterosalpingography, magnetic resonance imaging, and endoscopic techniques (i.e. hysteroscopy and laparoscopy).

Liver and Iron Metabolism - A Comprehensive Hypothesis for the Pathogenesis of Genetic Hemochromatosis

It is hypothesized that a homozygous C282Y mutation of the HFE gene prohibits the assembly of the transferrin-receptor 1 (TFR1) with the divalent metal transporter (DMT1) as the main iron update complex in hepatocytes membrane. Thus, the cellular influx of transferrin-bound iron from the endosomal compartment into the cytasol is compromised. As a consequence, transferrin saturation increases while concomitantly a cytosolic iron deficiency state develops. This in turn triggers the suppression of hepcidin synthesis in hepatocytes. Its impaired release into the bloodstream, causes the increased intestinal iron absorption of hemochromatosis. Excessively absorbed iron cannot be used by the erythron as a surplus for hemoglobin synthesis and is therefore trapped in ferritin complexes of RES macrophages. The ferritin is thereafter released into the bloodstream and taken up by hepatocytes for final disposal. In the lysosomal compartment ferritin is degraded to hemosiderin. Here, the release of excessive iron molecules may induce cellular injury via free radicals. The phenotypic expression of genetic hemochromatosis may depend on the activity of the erythron to use transferrin-bound-iron for heme synthesis. Therefore, a high erythron requirement for iron can utilize excess iron and may represent the rationale of phlebotomy therapy in this disease.

Delusional parasitosis and the dopamine transporter. A new insight of etiology?

Delusional parasitosis (DP) is a psychotic condition in which a person has the unshakeable and mistaken belief (delusion) and/or aberrant perception (hallucination) of being infested with parasites. The disorder will be usually classified in a primary DP-group without a detectable cause (so-called pure forms), while secondary DP-groups are associated with general organic conditions, psychiatric illnesses and drugs (substance induced). Etiology and pathophysiology of DP remain however unknown. In the present paper we hypothesize for the first time a decreased striatal dopamine transporter (DAT)-functioning (corresponding with an increased extracellular dopamine-level) as etiologic condition for DP (primary and secondary groups). The DAT as key regulator of the dopamine-reuptake in the human brain is well known (regulation of the extracellular dopamine concentration). It is a presynaptic plasma membrane protein highly dense represented in the striatum. The hypothesis of a decreased DAT-functioning as etiologic condition by DP is revealed in case reports which show that DAT-inhibitors, such as cocaine, pemoline, methylphenidate and other amphetamine-derivatives can induce the clinical expression of DP. Several other associated causes of secondary DP-groups (medications, parkinson, chorea huntington, multiple system atrophy, diabetes, cerebrovascular diseases, alcoholism, traumatic brain injury, hyperuricemia, human immunodeficiency virus, iron deficiency, schizophrenia, depression) suggest that the clinical expression of DP may be related to a decreased striatal DAT-functioning (blocking, reduced ligand binding, reduced density, reduced activity). Our examined DP-cases (2-females) show means of magnetic resonance imaging a structurally damaged striatum. Furthermore, we presume that by the primary DP-group, the physiologically age-related decline of the DAT-density is pathologically elevated. Based on this hypothesis we show in the present paper the relation between DP and decreased striatal DAT-functioning, trying to give a new insight into the pathophysiologically mechanism involved. The hypothesis provides supporting evidence that increased levels of extracellular dopamine in the striatum of DP-patients is likely to be the result of decreased DAT-functioning and not increased rates of release. The hypothesis can be investigated simply by dopamine transporter imaging in patients with DP.

Telomerase activity in fine needle aspiration biopsy samples: Application to diagnosis of human thyroid carcinoma

BACKGROUND

The diagnosis of thyroid follicular carcinoma by fine needle aspiration biopsy is a well known problem in thyroid pathology.

METHODS

We evaluated telomerase activity (TA) in 85 fine needle aspiration biopsy (FNAB) samples from patients with thyroid nodules. Surgery samples from patients with tumor or follicular adenomas were also analyzed.

RESULTS

Twenty of the FNAB samples corresponded to carcinomas and were positive to telomerase assay (TA >10 Units). Among them, 4 follicular carcinomas and 1 papillary carcinoma were labeled as indeterminate by FNAB cytological examination. Four percent false positive cases and no false negative cases for TA in FNABs were reported. FNAB samples from follicular adenomas were diagnosed as indeterminate by cytological examination, but they showed no detectable TA. Tumor tissues from patients with follicular or papillary thyroid carcinomas presented TA >10 Units, whereas follicular adenoma tissues (benign nodules) showed no TA.

CONCLUSION

Our results showed a good correlation between TA in FNAB samples and tumor/nodule thyroid tissue. This suggested that use of TA as a biological marker of malignancy might be a useful tool in the diagnosis of follicular thyroid carcinomas or follicular thyroid adenomas using FNAB samples.

Kinematical analysis of handwriting movements in depressed patients

OBJECTIVE

Motor disturbances are a relevant aspect of depression. Kinematical analysis of movements can be applied to explore which type of motor dysfunction is associated with depression. We hypothesized that depressed patients draw and write significantly slower than controls and that motor disturbances become more pronounced under bi-manual demands.

METHOD

We examined 37 depressed patients and 37 healthy controls using a digitizing graphic tablet and subsequent kinematical analysis of handwriting and rapid drawing movements.

RESULTS

Depressed patients performed drawing with significantly less regular velocity than controls (P < 0.001), but normal velocity. Motor differences between patients and controls did not increase under bi-manual demands. Handwriting of patients was abnormally slow (P = 0.04).

CONCLUSION

Irregular patterns of velocity peaks in depressed patients point to basal ganglia dysfunction and/or deficient activity of the sensorimotor cortex and the supplementary motor area as a possible substrate of hand-motor disturbances in depression.

Antioxidants in the treatment of Graves disease

An antioxidant mixture (LAROTABE) was evaluated in the treatment of Graves disease. Fifty-six hyperthyroid patients were treated with methimazol (MMI) (A), LAROTABE (B), or MMI plus LAROTABE (C). According to a clinical score, improvement was obtained at 8 weeks in A and 4 weeks in B and C. Group A diminished their thyroid hormone concentration to normal levels, while patients with LAROTABE did not reduce T3 and T4 unless MMI was introduced. Hyperthyroid patients had increased malondialdehyde (MDA) content and SOD activity and decreased catalase activity compared to controls. Within group A, MDA decreased to control values while SOD was reduced 38.3% and catalase increased 21.6%. Similar results were obtained for MDA and for both enzymes after treatment with LAROTABE. Signs and symptoms of Graves disease might be related to an increase in free radicals; antioxidants could be a new therapeutic tool to improve the clinical manifestation of this illness.

Determination of Active Marine Bacterioplankton: a Comparison of Universal 16S rRNA Probes, Autoradiography, and Nucleoid Staining

We compared several currently discussed methods for the assessment of bacterial numbers and activity in marine waters, using samples from a variety of marine environments, from aged offshore seawater to rich harbor water. Samples were simultaneously tested for binding to a fluorescently labeled universal 16S rRNA probe; (sup3)H-labeled amino acid uptake via autoradiography; nucleoid-containing bacterial numbers by modified DAPI (4(prm1),6-diamidino-2-phenylindole) staining; staining with 5-cyano-2,3-ditolyl tetrazolium chloride (CTC), a compound supposed to indicate oxidative cell metabolism; and total bacterial counts (classical DAPI staining), taken as a reference. For the universal-probe counts, we used an image intensifying and processing system coupled to the epifluorescence microscope. All of the above-mentioned methods yielded lower cell counts than DAPI total counts. Universal-probe counts averaged about half of the corresponding DAPI count and were highly correlated to autoradiography counts (r(sup2) = 0.943; n = 7). Nucleoid-containing cell counts could be lower than DAPI counts by as much as 1 order of magnitude but sometimes matched autoradiography or probe counts. CTC counts were 2 orders of magnitude below DAPI counts. Universal 16S rRNA probe counts correlated well with autoradiography results, indicating a population with at least minimal metabolic activity. The greater variability of the nucleoid-containing cell counts calls for further investigation of the processes involved, and CTC counts were well below the range of the other methods tested.

Bacterial activity along a trophic gradient

Bacterial biomass, secondary production, and extracellular enzymatic activity [α-glucosidase and leucine-aminopeptidase, measured as cleavage of artificial fluorogenic substrates 4-methyl umbelliferyl (MVF) α-D-glucopyranoside and L-leucine 7-amido-4-methyl coumarin (MCA)] were measured along a trophic gradient in the Northern Adriatic Sea in four ecologically different situations. Bacterial parameters were compared with chlorophyll a and inorganic and organic nutrient concentrations. Bacterial secondary production and extracellular enzymatic activity markedly changed among different seasons and along the trophic gradient. Average bacterial secondary production increased from 0.61 to 2.09 µg Cl(-1) hour(-1) preceding a bloom, to 2.09 µg Cl(-1) hour(-1) during the bloom, decreasing again to 0.81 and 0.83 µg Cl(-1) hour(-1) in the post-bloom and summer periods, respectively (values from 0.5 m depth). Leucine-aminopeptidase activity showed more consistent trends than α-glucosidase activity. Average values of leucine-aminopeptidase activity, measured by enzymatic release of MCA, increased from a pre-bloom value of 164.0 to 1,712.0 (nM MCA) hour(-1) released during a bloom, decreasing to 298.5 and 133.7 (nM MCA) hour(-1) released for the post-bloom and summer situation, respectively (values from 0.5 m depth). Average growth rates decreased during the bloom, whereas average extracellular enzymatic activity levels expressed on a cell basis increased by an average factor of 2. Along the trophic gradient, a consistent increase in bacterial secondary production could be observed in all but the summer situation (values from 0.5 m depth). Leucine-aminopeptidase activity also showed positive trends along the gradient, while α-glucosidase activity did not exhibit such a clear trend. Bacterial biomass trends were less obvious considering both seasonal changes and the tropic gradient. Highly significant interrelations were detected between bacterial proteolytic activity, secondary production, chlorophyll a content, and nitrate concentrations, especially in the surface horizon.