Performance of the probe-to-bone test in a population suspected of having osteomyelitis of the foot in diabetes

BACKGROUND

We investigated the validity of probe-to-bone testing in the diagnosis of osteomyelitis in a selected subgroup of patients clinically suspected of having diabetic foot osteomyelitis.

METHODS

Between January 1, 2007, and December 31, 2008, inpatients and outpatients with a diabetic foot ulcer were prospectively evaluated, and those having a clinical diagnosis of foot infection and at least one of the osteomyelitis clinical suspicion criteria were consecutively included in this study.

RESULTS

Sixty-five patients met the inclusion criteria and were prospectively enrolled in the study. Forty-nine patients (75.4%) were hospitalized, and the remaining 16 (24.6%) were followed as outpatients. Osteomyelitis was diagnosed in 39 patients (60.0%). Probe-to-bone test results were positive in 30 patients (46.1%). The positive predictive value for the probe-to-bone test was fairly high (87%), but the negative predictive value was only 62%. The sensitivity and specificity of the test were 66% and 84%, respectively. White blood cell counts and mean C-reactive protein levels did not statistically significantly differ between groups. However, erythrocyte sedimentation rates greater than 70 mm/h reached statistical significance between groups. Wound area and depth were not found to be statistically significantly different between groups.

CONCLUSIONS

Positive probe-to-bone test results and erythrocyte sedimentation rates greater than 70 mm/h provide some support for the diagnosis of diabetic foot osteomyelitis, but it is not strong; magnetic resonance imaging or bone biopsy will probably be required in cases of doubt.

Prosthetic vascular graft infection imaging

PURPOSE

We are reporting our experience with imaging of vascular graft infections using computed tomography angiography (CTA), white blood cell (WBC) scintigraphy and software-based fusion imaging.

MATERIAL AND METHODS

Institutional review board approval was obtained. We performed a retrospective review of patients who had clinical signs and symptoms of vascular graft infection in whom both WBC single photon emission computed tomography (SPECT) and CTA was performed between 2005 and 2010. We performed fusion imaging with available data using software coregistration technique and analyzed outcome of the patients.

RESULTS

We had 20 patients; 11 had grafts of the aorta, five had peripheral vascular grafts, three had aortic and peripheral vascular grafts, and one had a thoracic aortic graft. WBC imaging was positive in 10 patients, negative in six patients and indeterminate in 4 patients. CTA was positive in six patients, negative in four patients and indeterminate in 10 patients. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value (NPV) for WBC, CTA and WBC SPECT/CTA fusion were 75/100/80/100/50%, 88/50/80/88/50% and 94/50/85/88/67% respectively.

CONCLUSION

The use of CTA, WBC scintigraphy, and image co-registration influenced the diagnostic confidence of graft infection and the outcome of the patients. Software-based fusion imaging of both modalities resulted in improved sensitivity, accuracy, and NPV.

Endovascular management of fusiform renal artery aneurysm in a patient with refractory hypertension using hydrocoils and embospheres

We are reporting endovascular management of a renal artery aneurysm causing renal hypertension. The aneurysm by mass effect compressed the adjacent artery resulting in a hemodynamically significant stenosis. Endovascular management included embosphere embolization of the renal parenchyma distal to the stenosed segment and hydrocoil embolization of the aneurysm itself.

Management of the thrombosed filter-bearing inferior vena cava

Inferior vena cava (IVC) filter thrombosis is a complex problem. Thrombus within an IVC filter may range from an asymptomatic small thrombus to critical IVC occlusion that affects both lower extremities. The published experience of IVC thrombosis management in relation to filters is either anecdotal or limited to a small group of patients; however, endovascular treatment methods appear to be safe and effective in patients with IVC thrombosis. This review focuses on filter-related IVC thrombosis and its endovascular management.

Endovascular management of iatrogenic native renal arterial pseudoaneurysms

PURPOSE

Our purpose was to evaluate iatrogenic renal pseudoaneurysms, endovascular treatment, and outcomes.

METHODS

This retrospective study (2003-2011) reported the technical and clinical outcomes of endovascular therapy for renal pseudoaneurysms in eight patients (mean age, 46 (range 24-68) years). Renal parenchymal loss evaluation was based on digital subtraction angiography and computed tomography.

RESULTS

We identified eight iatrogenic renal pseudoaneurysm patients with symptoms of hematuria, pain, and hematoma after renal biopsy (n = 3), surgery (n = 3), percutaneous nephrolithotomy (n = 1), and endoscopic shock-wave lithotripsy (n = 1). In six patients, the pseudoaneurysms were small-sized (<20 mm) and peripherally located and were treated solely with coil embolization (n = 5). In one patient, coil embolization was preceded by embolization with 500-700 micron embospheres to control active bleeding. The remaining two patients had large-sized (≥50 mm), centrally located renal pseudoaneurysms treated with thrombin ± coils. Technical success with immediate bleeding cessation was achieved in all patients. There were no procedure-related deaths or complications (mean follow-up, 23.5 (range, 1-67) months).

CONCLUSIONS

Treatment of renal pseudoaneurysms using endovascular approach is a relatively safe and viable option regardless of location (central or peripheral) and size of the lesions with minimal renal parenchymal sacrifice.

Can procalcitonin predict bone infection in people with diabetes with infected foot ulcers? A pilot study

AIMS

The diagnosis of osteomyelitis is a key step of diabetic foot management. Previous studies showed that procalcitonin (PCT), a novel infection marker, is superior to conventional infection markers in the diagnosis of diabetic foot infection. This study aimed to investigate the serum levels of PCT and other conventional infection markers in diabetic persons with and without osteomyelitis.

METHODS

Twenty-four patients (18 male, mean age: 61.9±10.8 years) with infected foot ulcers were prospectively enrolled. Clinical characteristics of the wounds were noted. Blood samples were obtained for biochemical analysis. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis.

RESULTS

Osteomyelitis was found in 13 of 24 (54%) patients. PCT levels were 66.7±43.5 pg/ml in patients with osteomyelitis and 58.6±35.5 pg/ml in patients without osteomyelitis. The difference did not reach statistical significance (p=0.627). Erythrocyte sedimentation rate, but not C-reactive protein and white blood cell count, was found significantly higher in patients with osteomyelitis.

CONCLUSION

In this group of patients, PCT failed to discriminate patients with bone infection. Erythrocyte sedimentation rate can be used as a marker of osteomyelitis in diabetic persons.

Increased P wave dispersion in patients with liver steatosis

AIM

Hepatic steatosis is associated with metabolic and hemodynamic abnormalities induced by insulin resistance and inflammatory state. Since abnormalities of P wave dispersion may be accompanied with latter issues we evaluated this subject in patients with hepatic steatosis.

METHODS

Total of 106 patients and 56 healthy subjects were enrolled and performed hepatic ultrasonography, echocardiography, electrocardiogram, and biochemistry tests. Clinical features, laboratory and echocardiographic parameters, P wave dispersion were compared between groups and analyzed for any correlation among parameters.

RESULTS

Body mass index (BMI), waist circumference, systolic and diastolic blood pressure, levels of total and LDL cholesterol, and fasting blood glucose (FBG), and left atrial diameter were significantly higher in patients with hepatic steatosis. Peak velocities of mitral E and A waves and their ratio were abnormally changed in patients compared to normals. In multiple linear regression analysis, approximately all of the variables previously correlated within Pearsons' correlation test were found to be significantly correlated with P wave dispersion [ waist circumference (ß=0.151, p=0.048), LDL cholesterol (ß=0.234, p=0.000), FBG (ß=0.402, p= 0.000), alanine aminotransferase (ALT) (ß=0.205, p= 0.006), alkaline phosphatase (ALP) (ß=0.277, p=0.000), γ-glutamyl transferase (γ-GT) (ß=0.240, p=0.000), left atrial diameter (ß=0.204, p=0.003), heart rate (ß=0.123, p=0.037)].

CONCLUSIONS

Increased P wave dispersion may indicate a risk of atrial arrhythmia which may be complicated with disabling symptoms and thromboembolism in patients with hepatic steatosis. Consequently, hepatic steatosis is associated with increased risk for cardiovascular disease due to metabolic and hemodynamic abnormalities probably induced by insulin resistance and inflammaory state.

Abnormal aortic elasticity in patients with liver steatosis

AIM

Non-alcoholic fatty liver disease (NAFLD) may be associated with insulin resistance. We aimed to evaluate elastic properties of aorta in patients with NAFLD.

MATERIAL AND METHOD

Ninety-two patients with NAFLD and 47 healthy subjects were performed ultrasonographic and echocardiographic examination. Aortic stiffness index (ASI), aortic distensibility (AD) and aortic strain (AS) were compared between healthy subjects and patients and also among grade I and II liver steatosis. Statistical analysis was performed by Independent-Samples t-test, Pearson's correlation test using SPSS 11.0.

RESULTS

ASI was significantly increased whereas AS and AD were reduced (p>0.05) in patients compared to normal ones. ASI was significantly increased while AD and AS slightly increased in patients with grade II liver steatosis compare to grade I. SBP and DBP, cholesterol levels, fasting blood glucose (FBG) were also increased and doppler flow parameters of mitral inflow were abnormally changed in those patients. ASI was positively correlated with FBG, ALT and ALP levels, LDL cholesterol, heart rate and deceleration time of mitral E wave.

CONCLUSION

Elastic properties of aorta were abnormally changed in patients with NAFLD. Multiple hemodynamic abnormalities probably associated with insulin resistance may be accountable for abnormal elastic properties of aorta.

A magnetic resonance spectroscopy study of antisocial behaviour disorder, psychopathy and violent crime among military conscripts

BACKGROUND

Prefrontal and/or temporo-limbic abnormalities associated with antisocial personality disorder (APD), high psychopathy scores and violent behaviours can readily be evaluated by neuroimaging methods.

OBJECTIVES

In this study, we compared the brain metabolites in adult male military conscripts with APD, high psychopathy scores and serious violent crimes (n = 15) with age- and educational-level-matched healthy controls (n = 15) by means of magnetic resonance spectroscopy.

METHODS

All cases were diagnosed by means of the Diagnostic Statistical Manual-IV APD module of the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II) semistructured questionnaire in Turkish. The psychopathy scores were evaluated by means of the Hare Psychopathy Checklist-Revised translated into Turkish (PCL-R). PCL-R is a 20-item, reliable and valid instrument for assessment of psychopathy, both in categorical and dimensional natures. All patients had a total score of 29 (of possible 40) or higher from PCL-R, indicating a high degree of psychopathy.

RESULTS

Our results showed no significant differences in ratio of N-acetyl aspartate (NAA), creatine (Cr) and choline-related compounds in the right dorsolateral prefrontal cortex, anterior cingulate cortex (ACC) and amygdala-hippocampus regions of cases compared with controls. ACC NAA/Cr was significantly negatively correlated with both the PCL-R total score and the PCL-R factor I score (interpersonal/affective problems) among the cases.

CONCLUSION

As ACC plays an important role in decision-making and emotional information processing, we postulate that the lower NAA/Cr ratio, suggesting impaired neural integrity, may increase the severity of interpersonal/affective problems of the psychopathy factor in male subjects exhibiting APD, high psychopathy overall scores and violent crimes.

Soft-tissue masses

The purpose of this study was to show the qualitative and quantitative MRI characteristics of soft-tissue masses in differentiation of benign and malignant lesions. A total of 90 soft-tissue lesions were reviewed in this study. The scoring system presents a more objective diagnostic performance in the prediction of benign or malignant masses. With the use of this scoring system, unnecessary biopsy can be precluded in benign lesions.

Cervical Radiculopathy Caused by Vertebral Artery Loop Formation

Vertebral artery tortuosity and loop formation are rare causes of cervical radiculopathy. The criterion standard for the detection of vertebral artery loop formation is digital subtraction angiography. Computed tomography (CT) and magnetic resonance imaging provide good accuracy in the evaluation of vertebral arteries. A case of vertebral artery loop formation is reported. The diagnosis was confirmed by 16-row multisection CT angiography findings of vertebral artery loop formation.