Cross-Calibration of iDXA and Prodigy on Spine and Femur Scans in Korean Adults

In this study, the authors compared bone mineral density (BMD) determined using GE Lunar iDXA and Prodigy and derived cross-calibration equations for the 2 devices in Korean adults. One hundred subjects (66 women and 34 men) participated in this study. Bone mineral density of spine and femur was measured by iDXA and Prodigy dual-energy X-ray absorptiometry (GE Lunar, Madison, WI). Subjects were divided into 3 groups. The first group (30 subjects) was scanned twice using Prodigy for precision testing and then once using iDXA. The second group (30 subjects) was scanned twice using iDXA and then once using Prodigy. Cross-calibration equations were derived using these results. The derived equations were tested in the third group (40 subjects). Predicted values from calculations based on Prodigy findings were compared with measured iDXA data. A significant difference was found between the BMD determined using the 2 devices (p < 0.001). However, linear regression analysis showed a high level of agreement between the two (r² from 0.984 to 0.994, p < 0.001). Bland-Altman analysis revealed no significant correlations between Prodigy and iDXA. Cross-calibration equations decreased systematic errors between Prodigy and iDXA by 0.4% at the spine, 0.8% at the femoral neck, and 0.1% at the total femur. A high level of agreement was found between Prodigy and iDXA in Korean adults. Cross-calibration equations proved reliable based on comparisons of measured and calculated BMD values.     

Safety of Chemotherapeutic Infusion or Chemoembolization for Hepatocellular Carcinoma Supplied Exclusively by the Cystic Artery

Purpose

This study was designed to evaluate the safety of chemotherapeutic infusion or chemoembolization by way of the cystic artery in patients with hepatocellular carcinoma (HCC) supplied exclusively by the cystic artery.

Methods

Between Jan 2002 and Dec 2011, we performed chemotherapeutic infusion or chemoembolization using iodized oil for the treatment of 27 patients with HCC supplied exclusively by the cystic artery. Computed tomography (CT) scans, digital subtraction angiograms, and medical records were retrospectively reviewed by consensus.

Results

The cystic artery originated from the main right hepatic artery in 24 (89 %) patients, from the right anterior hepatic artery in 2 (7 %) patients, and from the left hepatic artery in 1 (4 %) patient. Selective catheterization of the cystic artery was achieved in all patients. Superselection of tumor-feeding vessels from the cystic artery was achieved in 7 patients (26 %). Chemotherapeutic infusion was performed in 18 patients (67 %), and chemoembolization was performed in 9 patients (33 %). There were no major complications and only 2 minor complications, including vasovagal syncope and nausea with vomiting. Individual tumor response supplied exclusively by the cystic artery at the follow-up enhanced CT scan were complete response (n = 16), partial response (n = 3), and stable disease (n = 8).

Conclusion

HCC supplied exclusively by the cystic artery can be safely treated without severe complications by chemotherapeutic infusion or chemoembolization using iodized oil through the cystic artery.     

Cyclosporin A therapy for severe Henoch-Schönlein nephritis with nephrotic syndrome

To evaluate the efficacy of cyclosporin A (CyA) for treating severe Henoch-Schönlein nephritis (HSN), seven patients with nephrotic syndrome, aged 3.9–13.8 years (mean 6.5 years), were analyzed retrospectively. Mean follow-up times were 5.5 years (range 2–9 years). All underwent renal biopsy before treatment, and follow-up renal biopsy was performed in six of the seven patients. All patients improved, with 24-h protein declining from a mean of 9.2 g/m²/day (range 1.5–16 g/m²/day) to 0.3 g/m²/day (range 0.03–1.2 g/m²/day) (p=0.016) and serum albumin increasing from a mean of 2.1 g/dl (range 1.5–2.4 g/dl) to 4.6 g/dl (range 3.5–5.3 g/dl) (p=0.016) after CyA therapy. The activity index decreased significantly at the second renal biopsies obtained at a mean interval of 11.7 months after the first (6.4±3.3 vs 3.5±1.2, p=0.042, respectively), while the chronicity index and the tubulointerstitial scores did not change. On the immunofluorescent findings at the second biopsies, the degree of deposits of immunoglobulins such as IgA, IgM, C3, and fibrinogen decreased in five of the six patients. Although this case series is without controls, our study suggests that CyA may be beneficial to a subset of HSN patients with nephrotic syndrome.     

Staging of Hepatic Fibrosis: Comparison of Magnetic Resonance Elastography and Shear Wave Elastography in the Same Individuals

Objective

To cross-validate liver stiffness (LS) measured on shear wave elastography (SWE) and on magnetic resonance elastography (MRE) in the same individuals.

Materials and Methods

We included 94 liver transplantation (LT) recipients and 114 liver donors who underwent either MRE or SWE before surgery or biopsy. We determined the technical success rates and the incidence of unreliable LS measurements (LSM) of SWE and MRE. Among the 69 patients who underwent both MRE and SWE, the median and coefficient of variation (CV) of the LSM from each examination were compared and correlated. Areas under the receiver operating characteristic curve in both examinations were calculated in order to exclude the presence of hepatic fibrosis (HF).

Results

The technical success rates of MRE and SWE were 96.4% and 92.2%, respectively (p = 0.17), and all of the technical failures occurred in LT recipients. SWE showed 13.1% unreliable LSM, whereas MRE showed no such case (p < 0.05). There was moderate correlation in the LSM in both examinations (r = 0.67). SWE showed a significantly larger median LSM and CV than MRE. Both examinations showed similar diagnostic performance for excluding HF (Az; 0.989, 1.000, respectively).

Conclusion

MRE and SWE show moderate correlation in their LSMs, although SWE shows higher incidence of unreliable LSMs in cirrhotic liver.     

Randomized, controlled trial of multimodal shoulder injection or intravenous patient-controlled analgesia after arthroscopic rotator cuff repair

Purpose

The aim of this study was to compare the effect of postoperative pain control and adverse effects of intravenous patient-controlled analgesia (IV PCA) and multimodal shoulder injection after arthroscopic rotator cuff repair.

Methods

Seventy patients scheduled for elective arthroscopic rotator cuff repair were prospectively randomized to receive either IV PCA or multimodal shoulder injections. Postoperative pain, nausea, vomiting, and other adverse effects were assessed at 2, 6, 12, 24, and 48 h after surgery. Use of rescue analgesics and antiemetics, level of satisfaction, and cost for both modalities were recorded.

Results

Pain was better controlled in the multimodal shoulder injection group at 2 h postoperatively (P = 0.001). However, the use of additional analgesics was greater in the multimodal shoulder injection group during 12–48 h after surgery (P < 0.001). The incidence of nausea within 12–24 h after surgery in the multimodal shoulder injection group (5.7 %) was less significant compared with that in the IV PCA group (31.4 %, P = 0.012), but no difference in overall incidence of the use of rescue antiemetics was observed between the groups (n.s.). No differences in adverse effects were noted between the groups. Patient satisfaction also showed no differences (n.s.). Costs required for both modalities were $20.3 for the multimodal shoulder injection and $157.8 for the IV PCA.

Conclusions

Multimodal shoulder injection is a safe and effective modality for management of pain after arthroscopic rotator cuff repair. Considering the expense and need of special devices for IV PCA, multimodal shoulder injection may be an effective and safe alternative to IV PCA for postoperative analgesia after arthroscopic rotator cuff repair.

Level of evidence

Randomized, controlled trial, Level I.     

Pullout failure strength of the posterior horn of the medial meniscus with root ligament tear

Purpose

To evaluate the reparability of the posterior horn of the medial meniscus with root ligament tear by measuring the actual pullout failure strength of a simple vertical suture of an arthroscopic subtotal meniscectomized posterior horn of the medial meniscus.

Methods

From November 2009 to May 2010, nine posterior horns of the medial meniscus specimens were collected from arthroscopic subtotal meniscectomy performed as a treatment for root ligament rupture of the posterior horn of the medial meniscus. Simple vertical sutures were performed on the specimens, and pullout failure load was tested with a biaxial servohydraulic testing machine (Model 8874; Instron Corp., Norwood, MA, USA). The degree of degeneration, extrusion, and medial displacement of the medial meniscus were evaluated with magnetic resonance imaging (MRI). The Kellgren–Lawrence classification was used in standing plain radiography, and mechanical alignment was measured using orthoroentgenography. Tear morphology was classified into ligament proper type or meniscoligamentous junctional type according to the site of the torn root ligament of the posterior horn of the medial meniscus during arthroscopy.

Results

The mean pullout failure strength of the posterior horn of the medial meniscus was 71.6 ± 23.2 N (range, 41.4–107.7 N). The degree of degeneration of the posterior horn of the medial meniscus on MRI showed statistically significant correlation with pullout failure strength and Kellgren–Lawrence classification. Pullout failure strength showed correlation with mechanical alignment and Kellgren–Lawrence classification (P < 0.05).

Conclusions

The measurement of pullout failure strength of the posterior horn of the medial meniscus with root ligament tear showed a degree of repairability. The degree of degeneration of the posterior horn of the medial meniscus on MRI showed a significant correlation with the pullout failure strength. The pullout failure strength was also not only correlated with the degree of degeneration of the posterior horn of the medial meniscus, but also with mechanical alignment and Kellgren-Lawrence classification, which represent bony degenerative change.     

Diagnostic dilemma of tuberculosis in the foot and ankle

BACKGROUND: Isolated involvement of bone in tuberculous infection is uncommon, and the variable clinical and radiological features may mimic pyogenic osteomyelitis, bone tumor or other inflammatory and neoplastic processes of the synovium. We have reported our experiences with the diagnosis of tuberculosis infection in the ankle and foot with the hope of providing sufficient information about these cases to lead to early diagnosis. MATERIALS AND METHODS: We treated 15 patients with tuberculosis involving the foot and ankle between 1995 and 2005. They were followed for a minimum of 24 months, and the average duration of symptoms was 23 months. All patients underwent a physical examination, routine laboratory tests, plain radiographs, and a biopsy of the infection site. MRI studies were performed in 10 patients and a CT scan was done in one patient. RESULTS: The lesions were located in the forefoot (2), midfoot (3) and ankle (10). From the imaging studies, the presumptive preoperative diagnoses were tuberculous osteomyelitis (7), pyogenic osteomyelitis (4), pigmented villonodular synovitis (2), amyloidosis (1), and avascular necrosis of the talus (1). These diagnoses were verified by granulomatous inflammation with or without caseous necrosis on histology and tubercle bacilli were cultured in four cases. In three cases the diagnosis was made by polymerase chain reaction (PCR). CONCLUSION: When a patient presents with a localized, painful swelling and a persistent draining sinus of the foot and ankle, tuberculosis should be considered in the differential diagnosis. Additionally, we highly recommend taking a biopsy of the site of suspected infection because an early diagnosis is the key to successful treatment.     

Treatment Guidelines for Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: When Can We Operate or Observe?

Background The objectives of this study were to investigate the clinicopathological features of branch intraductal papillary mucinous neoplasm (IPMN) and to determine safe criteria for its observation. Most clinicians agree that surgical resection is required to treat main duct-type IPMN because of its high malignancy rate. However, no definite treatment guideline (with respect to surgery or observation) has been issued on the management of branch duct type IPMN. Methods We retrospectively reviewed the clinicopathological data of 138 patients who underwent operations for IPMN between 1993 and 2006 at five institutes in Korea. Results Of 138 patients (mean age, 60.6 years; 87 men, 51 women), 76 underwent pancreatoduodenectomy, 39 distal pancreatectomy, 4 total pancreatectomy, and 20 limited pancreatic resection. There were 112 benign cases: 47 adenoma, 63 borderline cases, and 26 malignant cases, with 9 of these being noninvasive and 17 invasive. By univariate analysis, tumor size and the presence of a mural nodule were identified as meaningful predictors of malignancy. By receiver operating characteristic curve analysis, a tumor size of >2 cm was found to be the most valuable predictor of malignancy. When cases were classified according to tumor size and the presence of a mural nodule, the malignancy rate for a tumor ≤2 cm without a mural nodule was 9.2%, for a tumor of ≤2 cm plus a mural nodule was 25%, and for other conditions such as tumor >2 cm, >25%. Conclusions Many branch duct IPMNs are malignant. Surgical treatment is recommended, except in cases that are strongly suspected to be benign or cases that present a high operative risk. Observation is only recommended in patients with a tumor size of ≤2 cm without a mural nodule.