Correlation of clinical signs and magnetic resonance imaging findings in patients with lumbar spondylosis

Objectives

The purpose of the study was to contribute further to this debated topic by investigating the correlation of magnetic resonance imaging (MRI) findings with the clinical picture in lumbar spondylosis patients.

Patients and methods

This multicenter retrospective study (as part of the epidemiological project of the TLAR-OASG [Turkish League Against Rheumatism-Osteoarthritis Study Group]) included 514 patients (101 males, 413 females; mean age: 63.6±10.8 years; range, 40 to 85 years) who were diagnosed as lumbar spondylosis by clinical examination and direct X-ray between December 2016 and June 2018. Demographic characteristics of patients, Visual Analog Scale for pain, presence of radiating pain, Roland-Morris disability questionnaire, straight leg raise test, deep tendon reflexes, neurogenic intermittent claudication symptoms, any decrease of muscle strength, and abnormality of sensation were recorded. Lumbar MRI findings of the patients were recorded as positive or negative in terms of disc herniation, intervertebral disc degeneration, root compression, osteophytes, spinal stenosis. Statistical analysis was done to assess the correlation between the clinical symptoms, physical examination, and MRI findings.

Results

Correlation analysis of the MRI results and the clinical findings showed a significant correlation between straight leg raise test and root compression (p<0.001, r=0.328) and a significant correlation between neurogenic intermittent claudication and spinal stenosis (p<0.001, r=0.376). Roland-Morris disability questionnaire had a significant correlation with all MRI findings (p<0.05, r<0.200).

Conclusion

The results of this study corroborate the notion that diligent patient history and physical examination are more valuable than MRI findings, even though a higher incidence of abnormal MRI findings have been obtained in patients with disability and dermatomal radiating pain.

A case of intestinal obstruction due to phytobezoar--an alternative surgical approach

We report a 5-year-old patient with phytobezoar mimicking acute appendicitis preoperatively. During laparotomy, it was detected that terminal ileum was obstructed by several fragments of rubbery material. Bezoar was milked into the large bowel, and phytobezoar including tangerine residues was evacuated via appendix stump because of severe distended cecum, and high risk of the anastomotic leakage and intraperitoneal contamination following enterotomy of the inflamated and ischemic ileum. Postoperative course was uneventful. To date, such a procedure has not been described. We suggest that milking of vegetable fibers into the cecum and then emptying via appendix stump may be an alternative treatment of phytobezoar localizing in terminal ileum.

Arthritis during interferon beta-1b treatment in multiple sclerosis

Interferon beta (IFN-beta) is the most widely prescribed disease-modifying drug for multiple sclerosis (MS). Therapy with IFN-beta may be associated with a number of adverse reactions The development or exacerbation of other autoimmune diseases is a rare but reported side effect of IFN-beta therapy. In this case report, we present clinical and laboratory findings of two MS patients who developed arthritis during IFN-beta1b treatment, probably of autoimmune origin.

Nailfold capillary abnormalities in patients with familial Mediterranean fever

OBJECTIVE

To determine the frequency and the degree of the nailfold capillary abnormalities in patients with familial Mediterranean fever (FMF).

METHODS

We studied 67 (M/F: 28/39) patients with FMF. Thirty-seven healthy subjects (16/21), 19 patients (0/19) with systemic lupus erythematosus (SLE), and 8 patients (0/8) with scleroderma (PSS) were also studied. All participants were questioned for the presence of Raynaud's phenomenon (RP). Capillary loops of eight fingers were evaluated and scored with respect to avascular areas, tortuosity, enlargement and extravasations by the conventional capillary microscopy. Both FMF patients and healthy controls were examined in a blind manner.

RESULTS

FMF patients differed from healthy controls by the presence of increased tortuosity and enlargement of capillary loops, but not by microhemorrhages. Being female and the presence of RP were the factors that correlated with the capillaroscopic findings.

CONCLUSION

Capillary abnormalities are seen in patients with FMF.

A reassessment of the International Study Group criteria for the diagnosis (classification) of Behçet's syndrome

OBJECTIVE

Patients with ulcerative colitis (UC) and Crohn's disease (CD) were not represented in the diseased controls group that had been utilised in the development of the International Study Group (ISG) criteria for the diagnosis of Behçet's syndrome (BS). Having similar features, both of these conditions can pose problems in the differential diagnosis of BS. Moreover, there has been a recent awareness of coexistence of BS and familial Mediterranean fever (FMF). The aim of this study was to reassess the performance of ISG criteria among patients with BS and other rheumatological conditions, specifically including those with CD, UC, and FMF.

METHODS

302 consecutive patients with BS and 438 patients with other rheumatological conditions were surveyed for the presence or absence of the features of BS by means of a standard form which had been prepared according to ISG criteria. All control patients with a history of oral ulcer had a pathergy test and an eye examination by an experienced ophthalmologist with a slit lamp. The sensitivity and specificity of the ISG criteria were calculated.

RESULTS

Seven of 302 patients with BS (2%) did not fulfill the ISG criteria while 5 of 438 controls (1%) fulfilled the ISG criteria.

CONCLUSION

In this study ISG criteria performed well in correctly classifying BS. Further specificity studies might be considered in CD.

The value of 99mTc-HMPAO labelled white blood cell scintigraphy in acute appendicitis patients with an equivocal clinical presentation

Various imaging studies can be performed in the evaluation of patients with a clinical presentation equivocal for acute appendicitis. One of these studies is technetium-99m hexamethylpropylene amine oxime (HMPAO) labelled white blood cell (WBC) scintigraphy. The aim of this study was to evaluate the accuracy and clinical value of 99mTc-HMPAO WBC scintigraphy in the aforementioned group of patients. Forty-one patients who had acute right lower quadrant abdominal pain with a clinical presentation equivocal for acute appendicitis were included in the study. The anterior abdomen and pelvis were imaged up to 4 h after the injection of 125-300 MBq 99mTc-HMPAO WBCs and the results were immediately reported to the surgeon before a decision was taken on whether to perform laparotomy. Diagnostic accuracy was established by the intra-operative findings and the histopathology in operated patients. In non-operated patients, absence of abdominal symptoms 1 month after scintigraphy and/or identification of another cause of abdominal pain was used to rule out acute appendicitis. There were 16 patients with positive scintigraphy and 81% of these patients were positive within 2 h post injection. There were no false-positive or false-negative results. We operated on 17 (41.4%) patients, and only one patient (5.9%) underwent unnecessary laparotomy. We conclude that 99mTc-HMPAO WBC scintigraphy is a rapid, highly accurate method for the exclusion of acute appendicitis and that its use can lower the unnecessarily high laparotomy rate in patients with an equivocal clinical presentation.

A reappraisal of amyloidosis in Behçet's syndrome

OBJECTIVE

To evaluate the clinical features and outcome of patients with Behçet's syndrome (BS) and amyloidosis and to assess the associated risk factors.

METHOD

A chart review was done to determine the frequency of amyloidosis in BS among 4000 patients. Data from 14 BS patients with amyloidosis were compared with data obtained from 718 patients with BS without amyloidosis. Multiple stepwise logistic regression analysis was used to assess the risk factors.

RESULTS

All patients with amyloidosis presented with the nephrotic syndrome or significant proteinuria. The mean time to the onset of amyloidosis was 8.1 yr (range 3-15 yr). The mean duration of follow-up after amyloidosis was 3.4 yr (range 1-11 yr). Seven out of 14 patients were alive at the time of the evaluation. Peripheral and pulmonary arterial involvement and arthritis were associated with amyloidosis (P<0.05).

CONCLUSION

Amyloidosis in BS is rare and has a 50% mortality rate at 3.4 yr (range 1-11 yr). Peripheral and pulmonary arterial involvement and arthritis seem to be the strongest predictors of amyloidosis in BS.

Intestinal permeability in Behçet's syndrome

OBJECTIVE

To measure the intestinal permeability in patients with Behçet's syndrome (BS) and to compare the results with those obtained from healthy and diseased controls.

METHOD

The study group comprised 34 patients with BS without known gastrointestinal disease. Ten patients with ankylosing spondylitis (AS), 6 with inflammatory bowel diseases (IBD), 17 with systemic lupus erythematosus (SLE), and 15 healthy subjects (HC) constituted the controls. All patients received 100 microCi (3.7 MBq) of chromium-51 EDTA ((51)Cr-EDTA) as a radioactive tracer after a 72 hour abstinence from all drugs. The percentage of the isotope excreted in a 24 hour urinary specimen was the measure of permeability.

RESULTS

The percentage (SD) rate of excretion of (51)Cr-EDTA was 4.6 (2.6) in BS, 6 (2.4) in AS, 5.2 (1. 9) in IBD, 5.56 (1.78) in SLE, and 2.3 (1) in healthy controls. (Analysis of variance: f=6.4, p=0.0002. BS v HC, AS v HC, SLE v HC significant.)

CONCLUSION

The intestinal permeability in BS was significantly more than that seen among the healthy controls. Similar results in all the diseased controls cast doubt on its specificity.

A survey of phenotype II in familial Mediterranean fever

OBJECTIVE

Phenotype II in familial Mediterranean fever (FMF) is the onset of amyloidosis before the onset of FMF with its typical attacks, or as an isolated finding in a member of an FMF family. Its presence was investigated by looking for proteinuria among the asymptomatic relatives of patients with FMF complicated by amyloidosis and among the asymptomatic relatives of patients with juvenile chronic arthritis (JCA) complicated by amyloidosis, used as controls.

METHODS

The relatives of the index patients (13 with FMF and amyloidosis) and controls (6 with JCA and amyloidosis) were screened for proteinuria. Rectal biopsies were performed when proteinuria was significant (>/=300 mg/d).

RESULTS

461 relatives were screened in the FMF group and 269 among the controls. Two of the FMF relatives and one JCA relative had no symptoms of FMF but had significant proteinuria. Rectal biopsy for amyloidosis was negative in all instances of significant proteinuria.

CONCLUSION

Phenotype II is uncommon among the relatives of patients with FMF and amyloidosis.

Ultrasound-guided percutaneous sclerotherapy of hydatid liver cysts in children

To evaluate the efficacy of ultrasound (US) guided percutaneous sclerotherapy in the pediatric population, 14 hydatid liver cysts (HLC) in eight male patients whose ages ranged between 6 and 16 years (mean 9.9 years) were treated. The maximum diameter was 110 mm. Albendazole was administered orally to all patients for 1 week before percutaneous treatment and for 3-6 months after the procedure to prevent dissemination of the disease. Cyst puncture was performed with 20 G Chiba needles using US guidance. More than one-half of the estimated cyst volume was aspirated, then 20% hypertonic saline (7 cysts) or sterile 96% alcohol (7 cysts) equivalent to one-third of the estimated cyst volume was injected into the cavity and left for 5-15 min. Finally, all the fluid in the cavity was reaspirated. Catheterization was not performed. Follow-up US examinations were performed every month during the first 6 months and every 3 months thereafter. The follow-up period ranged between 6 and 51 months (mean 15 months). No major complications were seen during or after the procedures. Two cysts in two patients completely disappeared. Volumes of the 11 cysts in five patients who were followed for 6-21 months were markedly reduced (22%-64% of the initial volume) and thick septations and solid debris-like structures were seen within the cyst cavities. There was no significant change in 1 cyst. US-guided percutaneous sclerotherapy is thus a safe and effective treatment of HLC in children.

Prophylactic ranitidine in experimental fetal distress: acute phase effects on the fetal stomach

Fetal distress (FD) adversely affects fetal gastric physiology and histology, increasing gastric acid secretion and disturbing gastric protective mechanism. Considering these findings, an experimental study was planned to test whether ranitidine prevents FD-related gastric physiological and histological changes during late gestational period. In this study, a rabbit model of FD was created by way of intermittent maternal aortic occlusion. In group 1 (SC), saline treated animals underwent control operation. In group 2 (SD), FD was created in saline treated animals. In group 3 (RC), ranitidine treated animals underwent control operation. In group 4 (RD), FD was created in ranitidine treated animals. Blood lactic acid levels of the fetuses were 2.3 +/- 1.0 mg/L in SC group and 4.7 +/- 1.8 mg/L in group SD (p < 0.01); 2.5 +/- 0.9 mg/L in group RC and 6.7 +/- 2.5 mg/L in group RD (p < 0.01). Fetal gastric acid secretion was 5.94 +/- 2.13 microEq/h in group SC and 8.26 +/- 2.24 microEq/h in group SD (p < 0.05); 6.63 +/- 2.3 microEq/h in group RC and 6.04 +/- 2.43 microEq/h in group RD (p < 0.05). Fetal gastric PGE2 level was 16.4 +/- 2.65 microg/g-wet weight in group SC and 7.62 +/- 1.86 microg/g-wet weight in group SD (p < 0.01); 15.6 +/- 2.61 microg/g-wet weight in group RC and 8.44 +/- 1.44 microg/g-wet weight in group RD (p < 0.01). In addition, histopathological examination showed normal gastric structure in groups SC and RC, but there were mild erosive and hemorrhagic changes in groups SD and RD. Because prophylactic ranitidine significantly decreased gastric acid secretion, but did not prevent harmful histopathologic effects in FD, it is suggested that gastric damage cannot be avoided by decreasing gastric acid secretion alone. However PGE2 analogs with or without H2 receptor blockers may have a potential role to prevent FD-related gastric damage.

CEA, CA125 and CA19-9 levels in congenital gastrointestinal anomalies

Preoperative and postoperative serum samples of 35 patients with different congenital gastrointestinal anomalies were analyzed for the markers CEA, CA 125 and 19-9 by immunoradiometric assay during a period of three years. The majority of the anomalies were aganglionic megacolon and hypertrophic pyloric stenosis. CA 125 and CA 19-9 were likely to indicate logistic model probabilities for babies with anomalies, while CEA was not (F=35.78, p<0.05 for CA CA 125 and F=4.36, p<0.05 for CA 19-9). Probability of no congenital anomaly for babies was: p (Normal)=e4.41-0.13CA125 - 0.05CA19-9/1+e4.41-0.13CA125- 0.05CA19-9 Using CA 125 as a marker, babies with congenital anomalies were determined with 83.3 percent probability (F= 11.33, p<0.05). On the other hand, it was not possible to predict the type of anomaly with these three markers. CEA, CA 125 and CA 19-9 seem to be prognostic variables associated with congenital anomalies. These biological markers provide information that can be incorporated into the diagnosis of anomalies but without doubt results of markers should be supported by clinical findings.

An uncommon association relating to cloacal maldevelopment: bladder agenesis, anorectal atresia, and absence of vulva, vagina, and uterus

The authors report on a newborn girl with complex urogenital and hindgut abnormalities. Urogenital anomalies consisted of absence of vulva and vagina, uterine and urethral atresias, bladder agenesis with ectopic ureteric opening, and bilateral pelvic ectopic kidneys. In addition, the baby had anorectal atresia without fistula as a hindgut anomaly. Herein, clinical evaluation and embryological review are made to explain the concomitant occurrence of these rare malformations.

Acute physiopathological and histopathological effects of fetal distress on the fetal stomach: an experimental study

Although effects of stress on the stomach have been extensively investigated in children and adults, our knowledge about effects of fetal distress (FD) on the fetal stomach is quite limited. Therefore, an experimental study was planned to evaluate the effects of FD on fetal gastric physiology and histology. In this study, a model of FD was created by way of intermittent maternal aortic occlusion in pregnant rabbits. In total, 21 fetuses of 6 pregnant rabbits were available for surgical and laboratory procedures. Laboratory examinations showed that (1) fetal gastric acid secretion was 4.24 +/- 2.68 muEq/h in the control group and 18.08 +/- 6.34 muEq/h in the distress group (p < 0.01) and (2) fetal gastric PGE2 level was 16.59 +/- 6.15 mg/g wet weight in the control group and 9.86 +/- 3.46 mg/g wet weight in the distress group (p < 0.05). Histopathologically, there were mild hemorrhagic and errosive changes in the distressed fetuses, but not in control fetuses. These findings support that FD adversely affects fetal gastric physiology through two mechanisms consisting of increased gastric acid secretion and decreased fetal gastric protection in rabbits. Consequently, gastric injury should be noted as a potential problem among hypoxia-associated abnormalities encountered in the distressed fetus.

A case of thoraco-omphalo-ischiopagus bipus conjoined twins

A case of thoraco-omphalo-ischiopagus bipus conjoined twins is reported. The twins shared a common lower chest and abdominal wall, a single pelvis and two lower extremities. Our initial approach was to determine the detailed anatomy of the viscera and then to outline a surgical plan. However, the twins' general condition gradually deteriorated, and the approach was not completely realized despite maximal supportive therapy for cardiorespiratory failure. After the death of the twins, it was detected that they had a single pericardial cavity, and shared an abdominal aorta and vena cava. Furthermore the right twin had Bochdalek hernia and left ventricular hypoplasia. Consequently, such cardiovascular pathologies, coupled with major additional anomalies, may threaten the twins' life. Therefore further management plans are required considering urgent surgical correction of the life-threatening anomalies before the definitive procedure.

Percutaneous sclerotherapy of a symptomatic simple renal cyst in a child: observation of membrane detachment sign

A 6-year-old girl with a symptomatic renal cyst underwent successful percutaneous aspiration and sclerotherapy with hypertonic saline under US guidance. Although membrane detachment sign was seen clearly during aspiration, it was confirmed to be a simple cyst. In contrast to previous reports, membrane detachment sign is not pathognomonic for hydatid cysts and may be seen after simple cyst aspiration. Therefore, differentiation of a symptomatic renal cyst from a hydatid cyst should not depend solely on membrane detachment sign. In either case US- or CT-guided percutaneous sclerotherapy should always be considered before surgery.

Two unusual cases of wandering spleen requiring splenectomy

The occurrence of wandering spleen is rarely referred to in the pediatric surgical literature. We treated two unusual cases with this anomaly. The first case had an acute abdominal problem associated to a wandering spleen and a diaphragmatic eventration. Splenectomy was performed because of splenic infarction. In the second case the wandering spleen was associated with gastric bleeding due to left-sided portal hypertension, and splenectomy was inevitable.