Lumbar spine MRI in upright position for diagnosing acute and chronic low back pain: statistical analysis of morphological changes

Background

Patients with low back pain frequently demonstrate recumbent magnetic resonance imaging (MRI) alterations not always related to homogeneous clinical symptoms. The purpose of this study was to evaluate and quantify the statistical significance of variations of some anatomical parameters of the lumbosacral spine and reveal occult disc pathologies from recumbent to upright position in patients with acute and chronic low back pain.

Materials and methods

Fifty-seven patients complaining of low back pain (27 women, 30 men) underwent dynamic lumbosacral MRI with a 0.25-T tilting system (G-scan Esaote). We settled five parameters for which variations have been evaluated: lumbosacral angle, lordosis angle, L3–L4 intersomatic disc height, L3–L4 interspinous processes distance, and widest anteroposterior dural sac diameter. Images were obtained in both recumbent and upright positions.

Results

Statistically significant differences [one-way analysis of variance (ANOVA), p = 0.0043] were found between each pair of values of parameters sampled in recumbent and upright positions. In 70 % of patients, on visual qualitative analysis only, an increment of disc protrusions and/or spondylolisthesis was found in the upright position; in three cases, in the upright position only, an interarticular pseudocyst was found.

Conclusions

Dynamic MRI with an open-configuration, low-field tilting MRI system is a feasible and promising tool to study degenerative pathology of the spine. Moreover, in cases of low back pain with negative MRI in the recumbent position or in patients with pain in the upright position only, tilting MRI permits visualization of occult spine and disc pathologies in patients with acute or chronic low back pain.     

Laparoscopic Appendectomy in Women Without Identifiable Pathology Undergoing Laparoscopy for Chronic Pelvic Pain

Objectives:

To assess the effectiveness of appendectomy in women undergoing laparoscopy for chronic pelvic pain without identifiable pathology.

Methods:

This retrospective cohort study included women aged 15 to 50 years who underwent laparoscopic surgery for chronic pelvic pain without identifiable pathology. The cohort was divided into 2 groups: women who underwent appendectomy and women who had not undergone appendectomy at laparoscopic surgery. Postoperative pain was assessed at 6-week follow-up and by subsequent mailed questionnaire.

Results:

Women who underwent appendectomy (n = 19) were significantly more likely to report improvement in pain at 6-week follow-up than women who did not undergo appendectomy (n = 76) (93% vs 16%; P < .001). Thirty-six patients (38%) responded to the questionnaire at a median of 4.2 years after surgery, when the median change (improvement) in reported pain was greater in the appendectomy group than in the nonappendectomy group.

Conclusion:

Appendectomy is effective therapy for patients with chronic pelvic pain of unknown etiology who are undergoing laparoscopy.     

Transanal Endoscopic Microsurgery for Rectal Neoplasms. How I Do It

Introduction

Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer.

Methods

A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips.

Results

Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2 % and 15 %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6 %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life.

Conclusion

TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.     

Cell-Based Therapy for the Deficient Urinary Sphincter

When sterile culture techniques of mammalian cells first became state of the art, there was tremendous anticipation that such cells could be eventually applied for therapeutic purposes. The discovery of adult human stem or progenitor cells further motivated scientists to pursue research in cell-based therapies. Although evidence from animal studies suggests that application of cells yields measurable benefits, in urology and many other disciplines, progenitor-cell-based therapies are not yet routinely clinically available. Stress urinary incontinence (SUI) is a condition affecting a large number of patients. The etiology of SUI includes, but is not limited to, degeneration of the urinary sphincter muscle tissue and loss of innervation, as well as anatomical and biomechanical causes. Therefore, different regimens were developed to treat SUI. However, at present, a curative functional treatment is not at hand. A progenitor-cell-based therapy that can tackle the etiology of incontinence, rather than the consequences, is a promising strategy. Therefore, several research teams have intensified their efforts to develop such a therapy for incontinence. Here, we introduce candidate stem and progenitor cells suitable for SUI treatment, show how the functional homogeneity and state of maturity of differentiated cells crucial for proper tissue integration can be assessed electrophysiologically prior to their clinical application, and discuss the trophic potential of adult mesenchymal stromal (or stem) cells in regeneration of neuronal function.     

Hilar interneuron vulnerability distinguishes aged rats with memory impairment

Hippocampal interneuron populations are reportedly vulnerable to normal aging. The relationship between interneuron network integrity and age‐related memory impairment, however, has not been tested directly. That question was addressed in the present study using a well‐characterized model in which outbred, aged, male Long‐Evans rats exhibit a spectrum of individual differences in hippocampal‐dependent memory. Selected interneuron populations in the hippocampus were visualized for stereological quantification with a panel of immunocytochemical markers, including glutamic acid decarboxylase‐67 (GAD67), somatostatin, and neuropeptide Y. The overall pattern of results was that, although the numbers of GAD67‐ and somatostatin‐positive interneurons declined with age across multiple fields of the hippocampus, alterations specifically related to the cognitive outcome of aging were observed exclusively in the hilus of the dentate gyrus. Because the total number of NeuN‐immunoreactive hilar neurons was unaffected, the decline observed with other markers likely reflects a loss of target protein rather than neuron death. In support of that interpretation, treatment with the atypical antiepileptic levetiracetam at a low dose shown previously to improve behavioral performance fully restored hilar SOM expression in aged, memory‐impaired rats. Age‐related decreases in GAD67‐ and somatostatin‐immunoreactive neuron number beyond the hilus were regionally selective and spared the CA1 field of the hippocampus entirely. Together these findings confirm the vulnerability of hippocampal interneurons to normal aging and highlight that the integrity of a specific subpopulation in the hilus is coupled with age‐related memory impairment. J. Comp. Neurol. 521:3508‐3523, 2013. © 2013 Wiley Periodicals, Inc.     

General anxiety symptoms after acute lung injury: Predictors and correlates

Objective

Acute lung injury (ALI) is common in the intensive care unit (ICU), typically requiring life support ventilation. Survivors often experience anxiety after hospital discharge. We evaluated general anxiety symptoms 3 months after ALI for: (1) associations with patient characteristics and ICU variables, and (2) cross-sectional associations with physical function and quality of life (QOL).

Methods

General anxiety was assessed as part of a prospective cohort study recruiting patients from 13 ICUs at four hospitals in Baltimore, MD using the Hospital Anxiety and Depression Scale — Anxiety Subscale (HAD-A), with associations evaluated using multivariable linear and logistic regression models.

Results

Of 152 patients, 38% had a positive screening test for general anxiety (HAD-A ≥ 8). Pre-ICU body mass index and psychiatric comorbidity were associated with general anxiety (OR, 95% confidence interval (CI): 1.06 (1.00, 1.13) and 3.59 (1.25, 10.30), respectively). No ICU-related variables were associated with general anxiety. General anxiety was associated with the number of instrumental ADL dependencies (Spearman's rho = 0.22; p = 0.004) and worse overall QOL as measured by EQ-5D visual analog scale (VAS) (rho = − 0.34; p < 0.001) and utility score (rho = − 0.30; p < 0.001), and by the SF-36 mental health domain (rho = − 0.70; p < 0.001) and Mental Component Summary score (rho = − 0.73; p < 0.001).

Conclusion

Many patients have substantial general anxiety symptoms 3 months after ALI. General anxiety was associated with patient characteristics and impaired physical function and quality of life. Early identification and treatment of general anxiety may enhance physical and emotional function in patients surviving critical illnesses.     

Reduced thickness of anterior cingulate cortex in obsessive-compulsive disorder

IntroductionObsessive-compulsive disorder (OCD) is characterized by a pattern of repetitive, intrusive thoughts and behaviours that patients do not want to but feel they have to perform. Functional brain imaging revealed dysfunctional pathways in OCD involving the anterior cingulate cortex (ACC), orbitofrontal cortex (OFC), and basal ganglia. Structural alterations in OCD have been discussed but analysis tools focussing on specific morphometric aspects such as cortical thickness have rarely been employed.MethodsWe acquired MRI scans from 101 OCD patients and 95 healthy control subjects. FreeSurfer analysis software was employed to model the individual grey–white and pial surfaces to compute cortical thickness as our target measure.ResultsRelative to controls, OCD patients demonstrate cortical thinning in dorsal and subgenual ACC (false discovery rate corrected at p < .001), as well as in several other regions within the fronto-parietal network (false discovery rate corrected at p < .05). Cortical thickness could not be predicted in whole brain analyses from symptom state, but there was a modest correlation of left dorsal ACC thickness with the obsession subscore of the Yale-Brown Obsessive-Compulsive Scale as well as with the Beck Depression Inventory score.ConclusionsThe findings confirm and extend previous reports showing that OCD is associated with morphometric alterations. The location of the most robust cortical thinning in ACC regions matches the previously reported topography of functional alterations at resting state and during cognitive task execution.