The role of diagnostic imaging in the evaluation of suspected osteomyelitis in the foot: A critical review

The early diagnosis of osteomyelitis in the foot from its clinical presentation alone can be difficult particularly in cases when the early signs are subtle. Early diagnosis and subsequent early intervention are imperative to reduce the risk of chronic infection, associated early lytic changes to bone and potential long term structural complications caused by subsequent deformity and lost anatomy.Diagnostic imaging has a major role to play in the early assessment and diagnosis of bone infection, yet the choice of approach can be controversial.Several imaging modalities have been advocated, imaging of the infected foot is complex and no single test is ideal for every situation. The clinician needs to be aware of the strengths and weaknesses of each imaging modality so that the most appropriate test is selected for the individual case. Factors such as site of infection in the foot, the aggressive nature of the organism, the time since onset, previous associated surgery and co-morbidity may all play apart in the clinician's decision making process to determine the best approach in detecting the sometimes subtle changes which may be seen in some cases of osteomyelitis.This review considers the literature and highlights the advantages and disadvantages of the main imaging techniques used for the evaluation of the foot when osteomyelitis is suspected. An evidence based algorithm for the selection of appropriate imaging techniques is suggested to aid clinicians in there decision making process.     

Whole-body MR imaging in psoriatic arthritis: Additional value for therapeutic decision making

Purpose

In psoriatic arthritis (PsA) multiple locations may show inflammatory changes not always readily accessible to clinical exam. Often, clinical exam is inconclusive and the decision to initiate or adapt therapy is difficult. Whole body (WB)-MRI may help in this situation by providing a comprehensive overview of affected areas/joints. The purpose of this study was to make a proof of concept whether WB-MRI in psoriatic arthritis is feasible and can provide additional information compared to clinical examination alone with regard to therapeutic decision making in patients with PsA and inconclusive clinical situation.

Materials and Methods

30 patients with PsA and diffuse musculoskeletal pain were examined. A WB-MRI protocol was implemented on a 1.5 Tesla scanner using coronal and sagittal STIR- (TR: 5800, TE: 54, matrix 384² pixels, FOV 400 mm) and pre- and steady-state-post-Gadolinium-VIBE sequences (TR: 9.82, TE: 4.53, matrix 384 × 307 pixels, FOV: 400 mm). MRI was evaluated for image quality and inflammatory findings by two readers in consensus and compared to clinical exam.

Results

The WB-MR-exam was well tolerated by all patients. Image quality was rated good to excellent in 26 of 30 patients (86.6%). WB-MRI detected significantly (p < 0.001) more areas of synovitis/enthesitis than clinical exam except for the hands and feet. MRI was able to detect unknown destructive bony changes in 10 patients (53%). In 22 patients (73.3%) the therapy regimen was modified, in 18 patients (62%) TNF-alpha-inhibitors were started.

Conclusion

Whole-body MRI (WB-MRI) may be integrated in the diagnostic work-up of patients with psoriatic arthropathy facilitating individual adaptation of therapeutic strategy.     

特发性视网膜前膜患者黄斑区视网膜厚度及显微结构改变与视力的关系

背景 特发性视网膜前膜(IERM)患者前膜的牵引可引起黄斑区视网膜结构的改变及视力下降,了解两者之间的关系有助于更好地判断疾病的预后. 目的 观察IERM患者黄斑区视网膜厚度及显微结构的改变,分析黄斑区视网膜增厚及中心凹锥体外节尖端(COST)线的完整性与视力的关系.方法 采用回顾性病例分析的方法.收集2011年3-12月在中山大学中山眼科中心确诊的IERM连续病例56例,所有患者均为单眼发病,对侧眼均为正常眼.纳入的患者中男16例,女40例;平均年龄(61.05±6.58)岁.患者双眼均接受频域光学相干断层扫描(SD-OCT)检查,采用黄斑立体程序及高清5线扫描模式进行扫描,记录双眼黄斑厚度地形图中央区(＜1 mm直径)、内环区(1～3 mm直径)、外环区(＞3～6 mm直径)的平均视网膜厚度及COST线状态,比较双眼黄斑各区视网膜平均厚度及中心凹显微结构的差异,分析黄斑区视网膜厚度与视力的相关性,比较IERM患者患眼中COST线完整组与缺失组患者年龄、视力、视网膜厚度的差异. 结果 SD-OCT检查发现IERM患者患眼黄斑中心凹的凹陷变浅或消失,黄斑中央区、内环区和外环区视网膜厚度分别为(446±89)、(418±64)、(328±34)μm,均明显高于对侧正常眼相应区域的(250±22)、(319±17)、(279±17)μm,差异均有统计学意义(t=13.370、9.523、7.769,均P=0.000).黄斑中央区、内环区和外环区视网膜平均厚度与视力均呈负相关(r=-0.686、-0.653、-0.417,P＜0.05).IERM眼中COST线完整者20例,缺失者36例.与COST线完整组患者比较,COST线缺失组患者年龄大,视力差,黄斑各区厚度均增加,差异均有统计学意义(t=2.109,P=0.039;t=-4.093,P=0.000;t=6.669,P=0.000;t=5.376,P=0.000;t=4.247,P=0.000).56例患者的正常对侧眼均未发现COST线缺失. 结论 IERM患者黄斑区视网膜增厚和COST线缺失均可反映IERM眼视功能的损害程度,COST线的缺损可能是光感受器损害的早期标志,与视网膜增厚的进展一致,COST线缺损更多见于年龄较大的患者.     

Diagnostic role of serum interleukin-18 in gastric cancer patients

AIM: To determine the current status in various aspects of gastric cancer patients and to find out the clinical correlation with prognostic role of serum interleukins in Thai patients. METHODS: Sixty-eight patients were enrolled in this study at King Chulalongkorn Memorial Hospital during April 2003 to May 2005. Gastric cancer was histologically proven in 51 patients and gastric ulcer in 17 patients. Serum IL-6, IL-10, IL-12, and IL-18 levels were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: There were 26 males (55.32%) and 21 females (44.68%) with their age ranging from 33 to 85 years (mean age 64.49±13.83 years). The common presentations were weight loss (41.2%), dyspepsia (39.2%), and upper gastrointestinal bleeding (15.7%). A total of 35.3% gastric cancer patients and 6.3% of gastric ulcer patients were smokers (P = 0.029). Moreover, 32.4% of gastric cancer patients and 6.3% of gastric ulcer patients were alcoholic drinkers (P = 0.044). Lesion location was pyloric-antrum in 39.4%, gastric body in 39.4%, upper stomach in 12.2% and entire stomach in 6.1% of the patients. H pylori infection was detected in 44.4%. The poorly-differentiated adenocarcinoma was the most common pathologic finding (60.7%). Surgical treatment was performed in 44.1% patients (total gastrectomy in 5.9%, subtotal gastrectomy in 32.4% and palliative bypass surgery in 5.9%). Systemic chemotherapy was given as an adjuvant therapy in 8.8% patients. Carcinomatosis peritoneii were found in 18.8% patients. The mean survival time was 13.03±9.75 mo. The IL-18 level in gastric cancer patient group (58.54±43.96 pg/mL) was significantly higher than that in gastric ulcer patient group (30.84±11.18 pg/mL) (P = 0.0001) (95% CI was 42.20, 13.19). The cut point of IL-18 for diagnosis of gastric cancer was 40 pg/mL, the positive predictive value was 92.31%. The IL-6 level in gastric cancer patients with distant metastasis (20.21±9.37 pg/mL) was significantly higher than that in those with no metastasis (10.13±7.83 pg/mL) (P = 0.037) (95% CI was 19.51, 0.65). The role of IL-10 and IL-12 levels in gastric cancer patients was to provide data with no significant difference. CONCLUSION: These findings demonstrate that serum IL-6 and IL-18, but not IL-10 and IL-12 levels may be the useful biological markers of clinical correlation and prognostic factor in patients with gastric cancer. Moreover, IL-18 could serve as a diagnostic marker for gastric cancer with a high positive predictive value.     

The value of thoracic computed tomography scans in clinical diagnosis: A prospective study

BACKGROUND:

Computed tomography (CT) scans are used extensively to investigate chest disease because of their cross-sectional perspective and superior contrast resolution compared with chest radiographs. These advantages lead to a more accurate imaging assessment of thoracic disease. The actual use and evaluation of the clinical impact of thoracic CT has not been assessed since scanners became widely available.

OBJECTIVE:

To identify patterns of utilization, waiting times and the impact of CT scan results on clinical diagnoses.

DESIGN:

A before and after survey of physicians who had ordered thoracic CT scans.

SETTING:

Vancouver General Hospital – a tertiary care teaching centre in Vancouver, British Columbia.

SUBJECTS:

Physicians who had ordered CT scans.

INTERVENTION:

Physicians completed a standard questionnaire before and after the CT scan result was available.

MEASUREMENTS:

Changes in the clinical diagnosis, estimates of the probabilities for the diagnosis both before and after the CT scan, and waiting times.

RESULTS:

Four hundred fifty-four thoracic CT cases had completed questionnaires, of whom 80% were outpatients. A change in diagnosis was made in 48% of cases (25% with a normal CT scan and 23% with CT scan findings that indicated a different diagnosis). The largest change in probability scores for the clinical diagnosis before and after the CT scan was 43.9% for normal scans, while it was 36.3% for a different diagnosis and 26.3% for the same diagnosis. High-priority scans were associated with decreased waiting time (−7.89 days for each unit increase in priority).

CONCLUSIONS:

The CT scan results were associated with a change in diagnosis in 48% of cases. Normal scans constituted 25% of the total and had the greatest impact scores. Waiting times were highly correlated with increased urgency of the presenting problem.     

Longitudinal dimensionality of adolescent psychopathology: testing the differentiation hypothesis

Background: The differentiation hypothesis posits that the underlying liability distribution for psychopathology is of low dimensionality in young children, inflating diagnostic comorbidity rates, but increases in dimensionality with age as latent syndromes become less correlated. This hypothesis has not been adequately tested with longitudinal psychiatric symptom data. Methods: Confirmatory factor analyses of DSM‐IV symptoms from seven common Axis I syndromes – major depression, generalized anxiety, separation anxiety, social anxiety, attention deficient hyperactivity, conduct, and oppositional defiant disorders – were conducted longitudinally, from ages 9 to 16, using the general‐population Great Smoky Mountains Study sample. Results: An eight‐syndrome model fit well at all ages, and in both genders. It included social anxiety, separation anxiety, oppositional defiant, and conduct syndromes, along with a multidimensional attention deficit‐hyperactivity syndrome (i.e., inattention, hyperactivity, and impulsivity) and a unidimensional major depression/generalized anxiety syndrome. A high degree of measurement invariance across age was found for all syndromes, except for major depression/generalized anxiety. Major depression and generalized anxiety syndromes slightly diverged at age 14–16, when they also began to explain more symptom variance. Additionally, correlations between some emotional and disruptive syndromes showed slight differentiation. Conclusions: Marked developmental differentiation of psychopathology, as implied by the orthogenetic principle, is not a prominent cause of preadolescent and adolescent psychiatric comorbidity.     

Use of fibrin glue (Tissucol) as a hemostatic in laparoscopic conservative treatment of spleen trauma

Background This study aimed to evaluate the effect of fibrin glue in laparoscopic spleen-preserving procedures for traumatic rupture. Methods From January 2002 to December 2005, six laparoscopic spleen-preserving procedures were performed for traumatic rupture using fibrin glue. Two of the cases had previous middle and lower abdominal surgery. Survey of the abdominal cavity was performed by inserting two 5- to 12-mm trocars, one 5-mm trocar, and a 30° scope. A complete survey of all the patients was performed. Results None of the patients required laparotomy, and no postoperative bleeding occurred. The fibrin sealant achieved immediate hemostasis, and all the patients recovered without further splenic bleeding. The mean postoperative stay was 4.3 days (range, 4–5 days). All the patients were followed up for 3 to 12 months. Postoperative immunoglobulin scanning, ultrasonography, and computed tomography (CT) results were normal. Conclusions Laparoscopic management of spleen trauma can be used once a positive diagnosis has been made. It is useful for assessing the degree of splenic injury. A laparoscopic spleen-preserving procedure can be used safely for patients with stable vital data. It is an effective procedure for the evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial. The topical application of a fibrin sealant in splenic trauma achieves definitive hemostasis safely, rapidly, and reliably. It also is simple to use in either laparoscopic or open procedures. An erratum to this article can be found at     

Urinary 8-hydroxydeoxyguanosine is elevated in patients with nephrolithiasis

8-hydroxydeoxyguanosine (8-OHdG) is an oxidatively modified guanosine, which has been widely used as an oxidative DNA damage marker in various diseases. The present study aimed to determine urinary 8-OHdG in nephrolithiasis patients and evaluate its clinical significance. Thirty-six nephrolithiasis patients and 30 healthy subjects were recruited. Urine volume, creatinine, malondialdehyde, β-N-acetylglucosaminidase (NAG) activity and proteins were measured in 24 h urine samples. Urinary 8-OHdG was determined by competitive enzyme-linked immunosorbent assay. Mineral composition of stones was analyzed using Fourier-transformed infrared spectroscopy. Nephrolithiasis patients excreted urinary 8-OHdG significantly higher than healthy controls. Urinary 8-OHdG levels compared among patients with calcium oxalate, struvite and uric acid stones were insignificantly different. The urinary NAG activity correlated positively with urinary 8-OHdG. Multiple linear regression showed that urinary NAG activity was an independent predictor of urinary 8-OHdG level. Receiver operating characteristic analysis revealed that the urinary 8-OHdG test was adequate for diagnosing nephrolithiasis. At 10 μg/g creatinine cutoff, the 8-OHdG test imparted high specificity (96.67%) and a positive predictive value (91.67%). In conclusion, this is the first report of elevated urinary 8-OHdG excretion in nephrolithiasis patients indicating increased oxidative DNA damage. Increased renal tubular damage was independently associated with elevated urinary 8-OHdG. Elevated urinary 8-OHdG levels adjunct with metabolic profile may be useful for identifying people at risk of stone development.