Magnetic resonance imaging evaluation of tubercular arthritis of the ankle and foot

BACKGROUND

Ankle and foot tuberculosis is relatively uncommon. Magnetic resonance imaging (MRI) is highly sensitive in detecting the changes but there is limited experience with MRI evaluation and differentiation from other mono-articular arthritis, particularly pyogenic arthritis, is a challenge.

PURPOSE

To report MRI findings in ankle and foot tuberculosis.

MATERIAL AND METHODS

MRI was performed in 17 selected patients with ankle and foot tuberculosis. T1-weighted, proton density (PD) weighted, T2-weighted, and postcontrast sequences were performed in multiple imaging planes. Recorded findings included: number of bones involved; specific bones involved; extent of involvement; erosions; joint effusion, synovial thickening, tenosynovitis; joint effusion; adjacent soft-tissue changes; and involvement of sinus tarsi. Clinical data of all patients were also reviewed. Radiographic correlation at the time of MRI was available in selected patients.

RESULTS

The most common abnormality was synovial thickening. Signal abnormality was noted most frequently in the talus (n = 14). Erosions and intra-osseous abscesses were noted in 10 (58%) and eight (47%) patients, respectively. Tenosynovitis was present in eight (47%) patients. Soft tissue changes were noted in all patients, including abscesses in 13 patients (76%).

CONCLUSION

A multiplicity of findings (both osseous and extra-osseous) on MRI favors the diagnosis of tuberculosis. Three findings (intra-osseous abscess, soft tissue abscess, tenosynovitis), when present together, have a high sensitivity and specificity.

Minimally invasive image-guided interventional management of hepatic artery pseudoaneurysms

BACKGROUND

Hepatic artery pseudoaneurysms (HAPs) are uncommon entities. With the development of interventional techniques, their management has evolved from conventional (surgical) to non-surgical minimally invasive image-guided interventional techniques.

METHODS

Fifteen cases of HAPs who had undergone non-surgical interventional management in our department were reviewed. All patients were comprehensively evaluated for demographic information, morphology of pseudoaneurysm, indication for intervention and means of intervention, approach (endovascular or percutaneous), follow up and complications.

RESULTS

Trauma and iatrogenic injury were most common causes of HAPs. Most of the HAPs (9 out of 10 in whom long follow up was available) managed with image-guided interventional techniques had favorable outcome.

CONCLUSION

Minimally invasive image-guided interventional management is the preferred modality for HAPs.

Significant Incidence of Extra-Articular Tibia Vara Affects Radiological Outcome of Total Knee Arthroplasty

Purpose

To identify and quantify the presence of extra-articular tibia vara that might influence the mechanical axis alignment after total knee arthroplasty (TKA).

Materials and Methods

A total of 48 TKAs in 30 osteoarthritic Indian patients were prospectively evaluated. The hip-knee-ankle angle (HKA), joint line convergence angle, and varus angulation at the femur and tibia were measured from the preoperative and postoperative standing hip-to-ankle radiographs. Four different methods were used to measure the varus angulation at the tibia: metaphyseo-diaphyseal angle (MDA), the angle between the anatomical axis and mechanical axis of the tibia, the angle between the proximal third and distal third of tibia and the angle between the proximal half and distal half of tibia.

Results

Extra-articular tibia vara quantified using MDA had the most positive correlation with HKA. Receiver operating characteristic plotting showed that MDA of >4° predicts abnormal postoperative HKA. Twenty-eight out of 48 knees had MDA of >4°, and 78.6% of these had postoperative HKA under-correction and 21.4% had less than ideal tibial component position.

Conclusions

A significant inherent extra-articular varus angulation best measured using MDA exists in the proximal tibia in osteoarthritic Indian patients undergoing TKA. MDA of >4° is associated with abnormal postoperative HKA. Computer navigation may be useful for achieving ideal correction in such cases.

Pediatric Subtalar Joint Synovial Chondromatosis Report of a Case and an Up-to-date Review

Synovial chondromatosis is a rare, usually benign disorder affecting the population predominantly in the third and fourth decades of life and mainly involving the large weightbearing joints of the lower limb-the knees and the hip. In this report, we highlight an unusual pediatric clinical presentation of synovial osteochondromatosis involving the subtalar joint and discuss its surgical management; we also provide a comprehensive up-to-date literature review of the disorder. This patient was successfully treated with en masse surgical excision. He has been doing well, with complete pain relief and improved range of motion at 1-year follow-up. An exceptional involvement of the subtalar joint and an unusual presentation in the pediatric age group makes this case unique.

Magnetic resonance imaging findings in tubercular arthritis of elbow

OBJECTIVE

To evaluate magnetic resonance imaging (MRI) features of tubercular involvement of elbow joint.

METHODS

Fourteen patients with tubercular arthritis of elbow were evaluated. The following findings were recorded on MRI (n=12): bones involved; erosions, intraosseous abscesses, synovial thickening, and effusion; hypointensity within the thickened synovium on T2-weighted images; and periarticular soft tissue changes.

RESULTS

The common abnormalities on MRI were synovial thickening and bone erosions (n=12), soft tissue (n=9)/intraosseous (n=5) abscesses, and T2 hypointensity within the thickened synovium (n=5).

CONCLUSIONS

A diagnosis of elbow tuberculosis should be considered if there is a combination of findings involving bone and soft tissue.

Stability and multi-parametric Hopf bifurcation analyses of viral infection model with time delay

Ever since HIV was first diagnosed in human, a great number of scientific works have been undertaken to explore the biological mechanisms involved in the infection and progression of the disease. This paper deals with stability and bifurcation analyses of mathematical model that represents the dynamics of HIV infection of thymus. The existence and stability of the equilibria are investigated. The model is described by a system of delay differential equations with logistic growth term, cure rate and discrete type of time delay. Choosing the time delay as a bifurcation parameter, the analysis is mainly focused on the Hopf bifurcation problem to predict the existence of a limit cycle bifurcating from the infected steady state. Further, using center manifold theory and normal form method we derive explicit formulae to determine the stability and direction of the limit cycles. Moreover the mitosis rate r also plays a vital role in the model, so we fix it as second bifurcation parameter in the incidence of viral infection. Our analysis shows that, while both the bifurcation parameters can destabilize the equilibrium E* and cause limit cycles. Numerical simulations are performed to investigate the qualitative behaviors of the inherent model.

Intra cranial complications of tuberculous otitis media

Tuberculosis is one of the most common infections in the world. It is seen that tuberculous otitis media (TOM) is almost secondary to pulmonary tuberculosis. In this review we have tried to deal with all the aspects of the intra cranial complications of TOM such as tuberculoma, otitic hydrocephalus, brain abscess and tuberculous meningitis. The aspects covered in this review are the pathology, clinical features, and investigations of the intra cranial manifestations.

Rhinosporidiosis and the pond

Rhinosporidiosis is a fungal disease caused by the organism Rhinosporidum seeberi. The life cycle and mode of infection are vague, and there are many hypothesis on it. Its prevalence in the world is unique as it is only limited to certain regions like India, Pakistan and Sri Lanka. We have tried to correlate the various factors, which will probably be associated with this pattern of prevalence of the disease. We have included factors like community practices, climatic conditions, rain fall pattern, water physiochemical properties, zoonotic and the aquatic organism composition in the specified regions. Thus, it serves as a wholesome idea of why the disease must only be prevalent in certain parts of the world.

A rare bronchial anomaly presenting as a paracardiac mass

Abnormal bronchi arising from trachea and main bronchi are rare and usually clinically silent. These bronchial variations, however, pose a significant diagnostic challenge related to their variable presentation and perhaps the low level of awareness among clinicians and radiologists. Complications including recurrent infections, hemoptysis, and rarely malignancies may arise, if the diagnosis is delayed. We came across a patient with chronic cough in whom endoscopic and imaging evaluation, including fine-needle aspiration cytology (FNAC), proved non-diagnostic. Thorough evaluation of multidetector computed tomography (MDCT) performed in our department, however, revealed an accessory cardiac bronchus with rudimentary lung parenchyma in the paracardiac location. This case highlights the importance of meticulous airway evaluation on MDCT in all patients referred with respiratory symptoms.

Spontaneous diabetic myonecrosis: report of four cases from a tertiary care institute

Spontaneous diabetic muscle infarction (DMI) is a rare and under diagnosed complication of diabetes mellitus. Clinically it presents with acute to subacute onset swelling, pain and tenderness of muscle(s) without systemic manifestations. MRI is helpful in diagnosis, exclusion of other causes and for localization of affected muscle for biopsy in atypical cases. Muscles of the thighs are commonly affected in diabetic myonecrosis (DMN). Here we present the summary of four cases seen in the last 3 years in a tertiary care centre with simultaneous or sequential involvement of multiple groups of muscles or involvement of uncommon sites. All these patients had advanced duration of diabetes with microvascular complications and poor glycemic control. Conservative management including rest and analgesics is the treatment of choice. Short-term prognosis is good but there may be recurrence.

LEARNING POINTS

A high index of suspicion is required for the diagnosis of DMN which can avoid inadvertent use of antibiotics.Acute-subacute onset severe focal muscle pain in the absence of systemic symptoms in a female patient with long-standing diabetes with microvascular complications suggests DMI.MRI is the most sensitive test for diagnosis.Muscle biopsy should be reserved for atypical cases.Conservative management including rest and analgesics has good outcome.Improvement usually occurs within 6-8 weeks, but there may be recurrence.

Leukocyte-poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy

PURPOSE

To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET).

METHODS

25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor.

RESULTS

At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs. 31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (p<0.001).

CONCLUSION

Leukocyte-poor (type-4) PRP injection for recalcitrant LET enabled good improvement in pain and function.

Carotid, aorta and renal arteries intima-media thickness in patients with sporadic idiopathic hypoparathyroidism

BACKGROUND

Alteration in homeostasis of calcium, phosphate and parathyroid hormone (PTH) predispose to vascular calcification that increases the risk of cardiovascular morbidity and mortality. The data on this aspect are scarce in patients with sporadic idiopathic hypoparathyroidism (SIH).

OBJECTIVE

The aim was to assess the effect of altered calcium, phosphate and PTH homeostasis in patients with SIH on intima media thickness (IMT), a surrogate marker of increased vascular risk.

METHODS

In this case-control study, we measured carotid IMT (CIMT), aortic IMT (AIMT) and renal arteries IMT (RIMT) in 30 consecutive patients with SIH, and compared with healthy subjects. IMT was measured by ultrasound by a single operator blinded to subject's details.

RESULTS

CIMT, AIMT, RIMT values in patients with SIH were significantly more than healthy subjects (0.60 ± 0.08 mm vs. 0.52 ± 0.09 mm, P = 0.001; 0.73 ± 0.09 mm vs. 0.65 ± 0.10, P = 0.004; and 0.34 ± 0.04 mm vs. 0.30 ± 0.05, P = 0.003, respectively). Clinical or biochemical parameters did not correlate with CIMT, AIMT and RIMT in patients with SIH.

CONCLUSION

The vascular risk is increased in patients with SIH as assessed by CIMT, AIMT, and RIMT.

Short-term efficacy of recombinant human GH therapy in cured acromegaly patients with GH deficiency: a single-center experience

The effectiveness and short-term safety of recombinant human GH (r-hGH) in acromegaly patients with GH deficiency (GHD) after treatment are not well established. The study includes ten subjects with acromegaly who had GHD treated with r-hGH for 6 months. Control groups consisted of ten age-, gender-, and BMI-matched healthy subjects and ten active acromegaly patients who were treatment naïve. Body composition, quality of life (QoL), muscle strength, lipid profile, and cardiovascular risk factors were assessed in all subjects at baseline, and the same parameters were reassessed after 6 months of therapy with r-hGH in acromegaly with GHD. Repeat magnetic resonance imaging of the sella was performed in treated subjects. Optical colonoscopy was done and biopsies were taken from multiple sites for proliferation indices (Ki67). The median duration of GHD was 17.8 months and dose of r-hGH administered was 5.7±1.5 μg/kg per day. There was improvement in bone mineral content (P=0.01), bone mineral density (P=0.04), muscle strength (P<0.001), total cholesterol (P=0.003), high-density cholesterol (P<0.001), and QoL - score (P=0.005), and reduction in low-density cholesterol (P=0.003) and triglyceride (P=0.004) after treatment. There was no change in lean body mass, total body fat, hsCRP, lipoprotein (a), and fibrinogen levels. There was a modest increase in plasminogen activator inhibitor 1 (P=0.002), but it was lower compared with healthy controls and treatment naïve acromegalics (P=0.007). Six month-r-hGH therapy improves body composition, atherogenic lipid profile, QoL, and muscle strength in GHD patients who had acromegaly. Long-term prospective studies are needed to evaluate the effect of r-hGH therapy in these patients.

Characterization of Znq+–imidazole (q = 0, 1, 2) organometallic complexes: DFT methods vs. standard and explicitly correlated post-Hartree–Fock methods

Benchmarking DFts for the characterization of the Zn^q+–imidazole (q= 0, 1, 2) complexes.

Things you don′t learn in medical school: Caduceus

It is a known fact that every symbol has a unique meaning. In that case what does this unique symbol, Caduceus, which is used, in various forms and modifications, by many medical organizations mean? Is it just a custom or does it have a deeper meaning? The story of this medical symbol started way back in 1400 BC, travelled through time, has undergone many changes, misconceptions and has finally reached the present state. Here we have tried to give you a glimpse of how it has evolved over time, what it actually means, what have we interpreted and what can we learn from it.