Carpal tunnel syndrome grading system in rheumatoid arthritis

The grading system of Hashizume and Hirooka for carpal tunnel syndrome (CTS) was modified to refine the system for surgical treatment selection for specific subsets of CTS in patients with rheumatoid arthritis (RA). The grading system uses clinical signs and symptoms of CTS, including pain indications, to identify surgical subsets of patients to facilitate treatment selection. Retrospective analysis of the system included radiographic and electromyographic findings. Twenty-nine hands of 21 adult patients with CTS in RA were graded in the current study. Eight hands with mild synovitis received conservative treatment only. Endoscopic carpal tunnel release (ECTR), using Okutsu's universal subcutaneous endoscopic system with a clear cannula, was performed in 11 hands with moderate synovitis. Open carpal tunnel release (OCTR) combined with flexor tenosynovectomy was performed in 9 hands with severe synovitis. One more hand required OCTR after ECTR when malignant RA was diagnosed. Clinical results, evaluated using Kelly's criteria, were: excellent in 19 hands, good in 5, fair in 4, and poor in the 1 patient with malignant RA. Clinical symptoms of CTS improved in all but the latter patient. Although the sample size in the current study is small, the results appear to warrant further study to determine the clinical utility of the grading system. Received: April 2, 2001 / Accepted: November 1, 2001     

Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: the complication-specific approach

BACKGROUND: Endovascular stent-graft placement for the treatment of patients with aortic dissection is emerging as an attractive alternative to conventional cardiac operations. However, there has been no report of longer-term follow-up. The purpose of this study is to describe our midterm results with endovascular stent-graft repair for the treatment of patients with aortic dissections. METHODS: Thirty-eight patients with aortic dissections with descending tears were treated with endovascular stent-grafting. Ten patients had acute type A, 14 patients had acute type B, and 14 patients had chronic type B dissection. Stent grafts fabricated from expanded polytetrafluoroethylene-covered Z stents were placed to close entry tears in all patients through the delivery systems introduced from the femoral or the iliac arteries. RESULTS: Two patients with complicated acute type B dissection, who would have required surgical intervention, died within 30 days of the procedure, although no other patients died within the same period. There were no late deaths during the mean follow-up period of 27 months. Early and late complication rates were 33% and 36%, respectively, in patients with acute dissection, whereas rates were 4% and 0% (P <.05 vs patients with acute dissection) in patients with chronic dissection. CONCLUSIONS: Entry closure with endovascular stent-graft placement may be a safe and effective method for the treatment of patients with aortic dissection. It could be an alternative to conventional surgical intervention in selected patients with chronic dissection. However, strict patient selection and close follow-up seem mandatory in patients with acute dissection receiving Z stent-based stent-grafts. Stent-graft repair should be delayed for acute type B dissection without complications.     

Current status of hip bone densitometry in Japan: a nationwide survey

Hip fracture greatly impairs quality of life in patients with osteoporosis. Measurement of bone mineral density (BMD) in the hip, which is closely related to fracture risk, is therefore diagnostically important. Furthermore, since in some elderly individuals lumbar BMD may be overestimated because of vertebral fracture or spondylosis deformans, measurement of hip BMD is also important. However, hip BMD is unlikely to be measured as often as lumbar BMD in Japan. A questionnaire survey was conducted to determine how many institutions measure hip BMD. A total of 861 institutions responded to the survey, 596 (69%) of which performed hip bone densitometry. The number of such institutions per million population was calculated to be 4.7. Measurement of hip BMD was more frequent in university hospitals than in general hospitals, clinics, and non-medical institutions. Furthermore, 298 (51%) of 590 institutions measured hip BMD in more than 75% of all bone densitometry examinees. This is the first report on the current status of utilization of hip bone densitometry in Japan.     

A case of dense deposit disease associated with a group A streptococcal infection without the involvement of C3NeF or complement factor H deficiency

A 14-year-old girl presented with acute glomerulonephritis. Tests revealed hypocomplementemia and elevated Antistreptolysin-O titers, and renal biopsy revealed endocapillary and mesangial proliferative glomerulonephritis with double contours of the glomerular basement membrane (GBM). Despite methylprednisolone pulse therapy and the administration of oral prednisolone, overt proteinuria and hypocomplementemia persisted. A second renal biopsy 6 months later confirmed the initial diagnosis of dense deposit disease (DDD) based on electron-dense deposits in the GBM. C3 nephritic factor (C3NeF) and a deficiency of complement factor H (CFH) were not evident. A nephritis-associated plasmin receptor (NAPlr), nephritogenic group A streptococcal antigen, and the plasmin activity by in situ zymography were been in both the first and second biopsy specimens. The patient received combined immunomodulatory therapy with prednisolone and mizoribine, and the urinary protein decreased to a mild level at 27 months after disease onset. These findings suggest that persistent glomerular NAPlr deposition may be associated with the pathogenesis of DDD in some patients without the involvement of C3NeF or CFH mutation and that DDD patients of this type may respond to immunomodulatory treatment.     

Primary thymic adenocarcinoma coexisting with type AB thymoma: a rare case with long-term survival

Thymic carcinoma is a rare tumor. The most common histological subtype is squamous cell carcinoma, and only a few cases of thymic adenocarcinoma have been reported. A case of papillary adenocarcinoma of thymic origin that coexisted with type AB thymoma as a separate nodule is presented herein. The patient was found to have an abnormal mediastinal shadow on chest X-ray. A computed tomography scan revealed a round, 6.5-cm-diameter mass in the right anterior mediastinum. The preoperative diagnosis was thymoma, and thymothymectomy was performed. On pathological examination, two tumors, which were diagnosed as papillary adenocarcinoma and type AB thymoma, respectively, were present in the thymus without any connection with each other. The patient has been alive without any signs of recurrence for 11 years after surgery. We diagnosed the adenocarcinoma in this case was a primary thymic carcinoma.     

Repeated General Anesthesia in a Patient With Noonan Syndrome

Noonan syndrome (NS) is an autosomal dominant disorder characterized by facial anomalies, short stature, chest deformity, congenital heart diseases, and other comorbidities. The challenges faced during anesthetic management of patients with NS could be due to congenital heart diseases, hemostatic disorders, and airway anomalies. Here we describe dental treatment under general anesthesia performed for a 28-year-old man with NS. He had characteristic features of NS along with mild pulmonary valve stenosis. Dental treatment under general anesthesia was performed successfully on 13 occasions with nasotracheal intubation under curve-tipped suction catheter guidance or insertion of a reinforced laryngeal mask airway. This case suggests that for patients with NS, who might present several challenges, dental anesthesiologists should consider the extent of the patient''s disorders to enable them to perform dental treatment safely under general anesthesia.Key Words: Repeated general anesthesia, Noonan syndromeNoonan syndrome (NS) is an autosomal dominant disorder and was first reported by Noonan and Ehmke.¹ The primary features of this multisystem disorder include hypertelorism, low-set ears, down-slanting eyes, a webbed neck, congenital heart diseases, short stature, chest deformity, and intellectual impairment.^2,3 NS affects males and females equally and has an estimated incidence of 1 in 1000 to 1 in 2500 live births.^2,4The challenges faced during anesthetic management of patients with NS could be due to congenital heart diseases, hemostatic disorders, and airway anomalies.^5–8 The present report describes repeated administration of general anesthesia performed by adopting nasotracheal intubation or reinforced laryngeal mask airway insertion for a patient with NS at the time of dental treatment in our hospital.     

Characteristics affecting cervical sagittal alignment in patients with chronic low back pain

BackgroundSagittal spino-pelvic malalignment in patients with chronic low back pain (CLBP) have been reported in the past, which may also affect cervical spine lesions. The purpose of this study is to investigate the cervical alignment in patients with CLBP.MethodOf the patients who visited an orthopedic specialist due to low back pain lasting more than three months, 121 cases (average 71.5-years-old, 46 male and 75 female) with whole standing spinal screening radiographs were reviewed (CLBP group). Cervical parameters included cervical lordosis (CL), C2–C7 sagittal vertical axis (C2-7 SVA), and the T1 slope minus CL (T1S-CL). Cervical spine deformity was defined as C2-7 SVA >4 cm, CL <0°, or T1S-CL ≧20°. We compared the cervical alignment of these patients with 121 age and gender matched volunteers (control group).ResultsThe prevalence of cervical spine deformity was significantly higher in the CLBP group than in the control group (20.7% vs. 10.7%, P = 0.034). The mean CL was smaller in the CLBP group than in the control group (16.1° vs. 21.4°, P = 0.002). The mean C2-7 SVA was 17.6 mm vs. 18.7 mm in the CLBP group and in the control group, respectively (P = 0.817). The mean T1S-CL was larger in the CLBP group than in the control group (9.1° vs. 3.5°, P < 0.001). Multivariate analysis showed that people with CLBP were more likely to have cervical deformities than people without CLBP (odds ratio 2.16, 95% confidence interval 1.006 to 4.637).ConclusionsThis study results suggest that people with CLBP present with worse cervical sagittal alignment and higher prevalence of cervical spine deformities than age and gender matched volunteers with no CLBP. This means CLBP impacts cervical spine lesions negatively.Level of evidenceⅣ     

ROC Analysis of Detection of Metastatic Pulmonary Nodules on Digital Chest Radiographs with Temporal Subtraction

RATIONALE AND OBJECTIVES: The authors' purpose was to evaluate the effect of temporal subtraction on digital chest radiographs in the detection of metastatic pulmonary nodules. MATERIALS AND METHODS: The study included 21 cases with metastatic pulmonary nodule and 21 cases without metastatic nodule. Eleven radiologists, including eight residents and three certified radiologists, provided their confidence levels for the presence or absence of pulmonary nodules without and with temporal subtraction. Their performances without and with temporal subtraction were evaluated by means of receiver operating characteristic analysis with both independent and sequential tests. RESULTS: For the independent test, the radiologists' Az (area under the receiver operating characteristic curve) values were 0.871 without and 0.954 with temporal subtraction, compared with 0.882 and 0.955, respectively, for the sequential test. Diagnosis accuracy was significantly improved with the use of temporal subtraction. There was no significant difference in Az values between the independent and sequential tests. CONCLUSION: Temporal subtraction is useful in the detection of metastatic pulmonary nodules, and this technique augments the value of digital chest radiography.