An Approach for Using In Vitro and In Silico Data to Identify Pharmaceuticals with Potential (Anti-)Estrogenic Activity in Aquatic Vertebrates at Environmentally Relevant Concentrations

Endocrine-active pharmaceuticals can cause adverse reproductive and developmental effects in nontarget organisms. Aquatic vertebrates may be susceptible to the effects of such pharmaceuticals given that the structure of hormone receptors and the physiology of the endocrine system are highly conserved across vertebrates. To aid in the regulatory review of the environmental impact of drugs, we demonstrate an approach to screen and support the prioritization of pharmaceuticals based on their ability to interact with estrogen receptors (ERs) at environmentally relevant concentrations. Tox21 in vitro results from ER agonist and antagonist assays were retrieved for 1123 pharmaceuticals. In silico predictions from the Collaborative Estrogen Receptor Activity Prediction Project (CERAPP) models were used to estimate ER agonist and antagonist activity for an additional 170 pharmaceuticals not tested in the Tox21 assay platform. The estrogenic effect ratio (EER) and anti-estrogenic effect ratio (AEER) were calculated by comparing the activity concentration at half-maximal response (AC50) for ER agonism and antagonism, respectively, with estimated pharmaceutical concentrations in fish tissue based on estimates of environmental exposures. A total of 73 and 127 pharmaceuticals were identified as ER agonists and antagonists, respectively. As expected, 17β-estradiol and 17α-ethinylestradiol displayed EERs  > 1, and raloxifene and bazedoxifene acetate displayed AEERs > 1, thus indicating that these pharmaceuticals have the potential to reach fish tissue levels that exceed concentrations estimated to interact with ERs. Four pharmaceuticals displayed EERs between 0.1 and 1, and 6 displayed AEERs between 0.1 and 1. This approach may help determine the need for submission of environmental assessment data for new drug applications and support prioritization of pharmaceuticals with the potential to disrupt endocrine signaling in vertebrates. Environ Toxicol Chem 2019;38:2154-2168. © 2019 SETAC.

Risks associated with the environmental release of pharmaceuticals on the U.S. Food and Drug Administration "flush list"

A select few prescription drugs can be especially harmful and, in some cases, fatal with just one dose when not used as prescribed. Therefore, the U. S. Food and Drug Administration (FDA) recommends that expired, unwanted, or otherwise unused portions of most of these drugs be disposed of quickly through a take-back program. If such an option is not readily available, FDA recommends that they be flushed down the sink or toilet. The goal of the current investigation was to evaluate the ecological and human-health risks associated with the environmental release of the 15 active pharmaceutical ingredients (APIs) currently on the FDA "flush list". The evaluation suggests that even when highly conservative assumptions are used-including that the entire API mass supplied for clinical use is flushed, all relevant sources in addition to clinical use of the API are considered, and no metabolic loss, environmental degradation, or dilution of wastewater effluents are used in estimating environmental concentrations-most of these APIs present a negligible eco-toxicological risk, both as individual compounds and as a mixture. For a few of these APIs, additional eco-toxicological data will need to be developed. Using similar conservative assumptions for human-health risks, all 15 APIs present negligible risk through ingestion of water and fish.

Ethinyl estradiol and other human pharmaceutical estrogens in the aquatic environment: a review of recent risk assessment data

Interest in pharmaceuticals in the environment has increased substantially in recent years. Several studies in particular have assessed human and ecological risks from human pharmaceutical estrogens, such as 17α-ethinyl estradiol (EE2). Regulatory action also has increased, with the USA and other countries developing rules to address estrogens and other pharmaceuticals in the environment. Accordingly, the Center for Drug Evaluation and Research at the US Food and Drug Administration has conducted a review and analysis of current data on the long-term ecological exposure and effects of EE2 and other estrogens. The results indicate that mean-flow long-term predicted environmental concentrations (PECs) of EE2 in approximately 99% or more of US surface water segments downstream of wastewater treatment plants are lower than a predicted no-effect concentration (PNEC) for aquatic chronic toxicity of 0.1 ng/L. Exceedances are expected to be primarily in localized, effluent-dominated water segments. The median mean-flow PEC is more than two orders of magnitude lower than this PNEC. Similar results exist for other pharmaceutical estrogens. Data also suggest that the contribution of EE2 more broadly to total estrogenic load in the environment from all sources (including other human pharmaceutical estrogens, endogenous estrogens, natural environmental estrogens, and industrial chemicals), while highly uncertain and variable, appears to be relatively low overall. Additional data and a more comprehensive approach for data collection and analysis for estrogenic substances in the environment, especially in effluent-dominated water segments in sensitive environments, would more fully characterize the risks.

Value of lymphangiography in the staging of Hodgkin lymphoma

PURPOSE

To evaluate the usefulness of lymphangiography in the staging of Hodgkin disease.

MATERIALS AND METHODS

The authors retrospectively evaluated the lymphangiograms of 39 previously untreated patients with Hodgkin disease (clinical stage, 1-2A). The patients had no evidence of bulky mediastinal nodal disease, and results of abdominal and pelvic computed tomographic examination were negative for parenchymal organ disease and retroperitoneal and mesenteric node involvement. The studies were officially interpreted as normal or abnormal. No attempt was made to differentiate benign reactive changes from tumor infiltration. All patients underwent confirmatory staging laparotomy.

RESULTS

Of the 39 patients, 29 had normal lymphangiograms. All 29 had normal lymph nodes at laparotomy. Of the 10 patients with abnormal lymphangiograms, only two had malignant infiltration of lymph nodes at laparotomy. The other eight showed benign reactive hyperplasia.

CONCLUSION

Lymphangiography has no place in the management of Hodgkin lymphoma.

Gastric stump lymphoma

Lymphoma occurring in the post-operative stomach would appear to be very rare with only five previously recorded cases. In three of these, focal lymphoid hyperplasia or pseudolymphoma had been found at the time of the original ulcer surgery, or at subsequent biopsies of the gastric stump or anastomotic sites. These latter three cases developed lymphoma within 11 years of the ulcer surgery as against the 20 years or longer generally found in cases of gastric stump carcinoma. Two cases presenting with gastric stump lymphoma approximately 20 years after Billroth 2 partial gastrectomy are reported. In neither of these two cases, nor in the other two patients previously recorded with post-operative gastric lymphoma 20 or more years following gastric surgery, was luminal focal lymphoid hyperplasia reported at the time of the original gastric surgery. It is postulated that these two small groups may have developed lymphoma due to differing malignant stimuli.

The clinical utility of transrectal ultrasound and digital rectal examination in the diagnosis of prostate cancer

The development of high definition transrectal ultrasound probes has led to an increased interest in the ability of transrectal ultrasound of the prostate (TRUS) to assist in the diagnosis and management of prostate cancer. The present study was designed to examine the correlation of TRUS with digital rectal examination (DRE). The study group comprised 471 patients in whom the results of (a) DRE, (b) TRUS, and (c) histology of tissue obtained by transrectal biopsy of the prostate (TB), were all available. In those patients where both TRUS and DRE were negative, but prostate specific antigen (PSA) was greater than 10 micrograms ml-1, six random biopsies were performed. In all other cases the biopsies were TRUS directed to the suspicious lesion. There were 142 cases in whom both DRE and TRUS were negative or only mildly suspicious of malignancy. TB in these cases was positive for cancer in 17 cases (12%). In a further 126 cases, TRUS was positive for cancer, while DRE demonstrated no suspicious nodule. TB was positive in only 17 of these cases (13.5%). Similarly, in the 31 cases in which DRE was positive but TRUS was negative, TB was positive in only three cases (10%). In the 172 cases in whom both DRE and TRUS were positive, 99 biopsies were positive (57.5%). It was concluded from this study that DRE remains the most valuable single examination in the diagnosis of prostate cancer. TRUS increases the sensitivity of DRE if both are positive. When there is a discrepancy between the two examinations, the biopsy yield is low. When both are positive, a high cancer yield is obtained, TRUS having added value in directing the biopsy needle to the suspicious site. TRUS is thus a valuable adjunct to DRE in the diagnosis of prostate cancer.

Case report: asymptomatic aneurysmal intrahepatic porto-hepatic venous shunt--diagnosis by ultrasound

Intrahepatic porto-hepatic venous shunts are rare entities with less than 20 cases reported in the literature. Many are associated with liver cirrhosis, but some appear to be of developmental origin. The rarest type of such a shunt is one via a portal vein aneurysm. A case is reported where the diagnosis was made by colour duplex ultrasound. No further investigation or treatment was deemed necessary. The ability to make such a diagnosis without the many invasive procedures hitherto employed indicates the value of this modality in the investigation of vascular anomalies.

Environmental assessment of avermectins by the US Food and Drug Administration

The Center of Veterinary Medicine (CVM) of the Food and Drug Administration (FDA) is required under the National Environmental Policy Act (NEPA) to include in its decision making, an objective consideration of the potential environmental impacts associated with each contemplated action. As part of the application process for new animal drugs, detailed data must be submitted in order to develop a prediction of the environmental fate and effects of the drug and/or its active metabolites. Ivermectin (22,23-dihydroavermectin B1) is a highly active antiparasitic animal drug utilized in a variety of injectable, oral and topical formulations. Residues of this drug may reach the environment through manufacturing and animal wastes and may potentially have effects on terrestrial and aquatic organisms. A comprehensive data base has been submitted to the FDA in support of the environmental assessments for ivermectin drug products. Detailed information has been submitted on the physical and chemical properties, introduction, fate and effects of the ivermectins in the environment. These data indicate that ivermectin binds tightly to soil and is subject to photodegradation and biotransformation to less active compounds. In contrast, ivermectin is highly toxic to certain aquatic organisms but would not be expected to partition into the aquatic environment. Much lower toxicity has been demonstrated toward bacteria, fungi, earthworms, plants and birds. CVM evaluated ivermectin products based on the use pattern of the product, the metabolism pattern in target animals, calculations of potential ivermectin residue concentrations in the environment and data on persistence, soil sorption and acute toxicity in aquatic and terrestrial environments.

Ossicles anterior to the proximal tibia

Ossicles anterior to the anterior tibia are most usually seen in relation to the tibial tuberosity. While these are usually taken to represent sequelae of previous Osgood-Schlatter disease, they may, on occasion, represent normal variants in ossification of the tuberosity. Ossicles superior to the tuberosity may have similar origins. Representative examples are presented, as is a very large ossicle separated from the anterior tibia by a prolongation of the knee joint space. Theories of causation of such ossicles are discussed.

The ultrasound appearances of intramural bowel gas: the bright ring appearance and the effervescent bowel. A report of three cases

Bowel necrosis is a serious condition with a very high mortality rate. The earlier the diagnosis is made, the better chance for survival. Ultrasound is a primary imaging technique in the diagnosis of the acute abdomen. Three cases are presented in which bowel wall gas could be demonstrated on ultrasound. In all cases there was computed tomographic and either operative or post-mortem correlation. In each case there was a "bright ring" appearance of the affected bowel when the ultrasound examination was carried out in transverse section. In one case, small bubbles were seen arising from the deep surface of the bowel.

On the antiquity of the seronegative spondyloarthropathies: evidence from ancient Judea

A fused pelvis and two specimens of fused vertebrae were found in an ossuary at Ein Gedi, Israel; they date from approximately 2000 years ago. Examination of these bony specimens visually and by computed tomography demonstrated features of the seronegative spondyloarthropathies.

Breast metastases to bones of the extremities: simultaneous involvement of all four limbs

Metastases to bones of the hands and feet are unusual, and simultaneous metastases to the bones of more than one extremity in a given patient is an extremely rare occurrence with only five previous case reports. In each of these cases the bones of two extremities were affected. A case is presented where the bones of both hands and both feet exhibited bone metastases. A second case with foot bone metastases is recorded. In both cases the primary tumour was a breast carcinoma. Theories of causation of such metastases are discussed.

The active abduction view: a new maneuvre in the diagnosis of rotator cuff tears

The plain film views of the shoulder in the case of a fresh rotator cuff tear are usually normal. Reduction of the space between the under surface of the acromion process of the scapula and the humeral head occurs only in late, neglected cases. A new projection is described, the active abduction view of the shoulder, where in many patients with a complete rotator cuff tear the humeral head is closely apposed to the acromion, obliterating the subacromial space. In such a situation, the medial portion of the torn rotator cuff retracts during active abduction, allowing approximation of the two bones.

Abdominal wall lipoma--CT and MRI appearance

Although soft tissue lipomata are common tumours, a large lipoma arising from the deep layers of the abdominal wall would appear to be excessively rare and the site of origin may be difficult to determine. The CT and MRI appearances of such a tumour are described.

The infracalcaneal os peroneum

There is some confusion in the literature regarding the nature of the os peroneum. It has been claimed to be either a supranumerary os or a sesamoid in the tendon of the peroneus longus muscle. Its position in the foot is also a subject of dispute. Most authors state that it is related to the cuboid bone, and it has in the past been termed the 'cuboidum secundarius.' Occasionally an ossicle is seen inferior to the distal calcaneus distal to the calcaneocuboid articulation. This may represent a developmental anomaly of position of the os peroneum or be the sequel of a rupture of the peroneus longus muscle.

Lymphatic opacification in the prosthetic hip

A retrospective analysis of 52 patients with hip pain following total hip replacement was made. Each of them was evaluated by plain radiographs, technetium 99m pyrophosphate scans, arthrography with plain film subtraction technique, and culture of joint fluid. In 30 cases there was evidence of prosthetic loosening, and in 21 of these lymphatic opacification during arthrography was seen. In 15 cases with lymphatic opacification the diagnosis of prosthetic loosening was subsequently confirmed by prosthetic revision. In none of the 22 cases in which no evidence of prosthetic loosening was seen was there lymphatic opacification. It is concluded that lymphatic opacification during arthrography for pain following total hip prosthesis is a valuable ancillary sign of loosening.

The psoas sign in normal subjects without bowel preparation: the influence of scoliosis on visualisation

The lumbar spine films of 1494 subjects who were examined for low back pain or prior to job placement were studied to assess psoas muscle visualisation. The study group were almost all aged 18-39 years. None of the subjects had prior bowel preparation for a contrast examination. In the subjects without scoliosis only 36% had well seen psoas shadows on both sides. Taking the psoas shadows separately, 72% of left psoas shadows were well seen, while only 40% were seen on the right side. In the scoliotic group, the psoas shadow was seen bilaterally in 30% of subjects while in another 50% the muscle was seen only on the convex side of the curve. In no case was it seen only on the concave side. The direction of the curve to left or right did not influence visualisation. Thus in 80% of subjects with scoliosis of 5 degrees or more, the psoas was seen on the convex side, while in only 30% was it seen on the concave side.

Survival after ultrasonographic demonstration of portal venous gas due to mesenteric artery occlusion

Portal vein gas as a result of bowel necrosis following occlusion of the superior mesenteric artery has an extremely grave prognosis. Only two previous cases have been recorded as having survived. In both those cases the diagnosis of portal vein gas was made on an abdominal radiograph. The present report is of the first such case surviving after ultrasonic demonstration of portal gas. In this case, no evidence of portal gas was seen on the abdominal radiograph. The increased sensitivity of ultrasound over plain radiography mandates urgent liver and portal ultrasound in all cases of suspected mesenteric event.

DNA restriction patterns and DNA-DNA solution hybridization studies of Frankia isolates from Myrica pennsylvanica (bayberry)

Sixteen Frankia strains were isolated from Myrica pennsylvanica (bayberry) root nodules collected at diverse sites in New Jersey. Restriction pattern analysis of total genomic DNA was used to group the isolates into gel groups, and the genetic relatedness among the isolates was evaluated by DNA-DNA solution hybridization studies. Restriction pattern analysis provided a distinctive reproducible fingerprint for each isolate. Isolates fell into nine separate groups (strain types). More than one strain type was isolated from most sites. Isolates from two different gel groups were found in 3 of 10 nodules examined. Of the 16 isolates, 10 contained extrachromosomal DNA. Six different extrachromosomal DNA banding patterns were found. Genomically similar isolates carried related, but different, banding patterns. DNA hybridization studies indicated that isolates from a single plant species can be minimally related as determined by total genome homology. Homology ranged from 12 to 99%. Highly divergent strains were isolated from the same plant and found to cohabit the same nodule. Thus, this study demonstrated that Frankia strains which infect the same host plant are not only phenotypically different but also genetically diverse.

Small bowel phytobezoars: detection with radiography

The authors reviewed the radiographic findings in 19 patients with phytobezoars of the small bowel. The most common predisposing causes were previous gastric outlet surgery and persimmon ingestion. Twelve patients underwent contrast material-enhanced studies of the upper gastrointestinal tract, and one patient underwent a barium enema study. These examinations revealed four gastric, two duodenal, and eight small bowel phytobezoars in 10 patients. The obstruction caused by small bowel phytobezoars frequently occurred in the jejunum or proximal ileum, more proximally than has been reported in previous series. Barium studies are useful in differentiating obstruction due to postoperative adhesions from obstruction caused by bezoars. In addition, barium studies enable the detection of residual gastric bezoars. This information has important implications in patient treatment because bezoar obstruction is unlikely to respond to conservative treatment, and concurrent gastric bezoars must be removed to prevent recurrent bowel obstruction.

Physiological, chemical, morphological, and plant infectivity characteristics of Frankia isolates from Myrica pennsylvanica: correlation to DNA restriction patterns

The filter exclusion method was used to isolate Frankia strains from Myrica pennsylvanica (bayberry) root nodules collected at diverse sites in New Jersey. A total of 16 isolates from five locations were cultured. The isolates were characterized by morphological, chemical, physiological, and plant infectivity criteria and compared with genomic DNA restriction pattern data, which were used to assign the isolates into gel groups (see accompanying paper). The isolates from M. pennsylvanica evaluated in this study were characteristic of Frankia physiological group B strains and were indistinguishable on the basis of whole-cell wall chemistry and diaminopimelic acid isomer analysis. Distinct differences in the spectrum of utilized organic acids and carbohydrates were observed among the isolates and were the only phenotypic criteria by which the isolates could be separated and assigned into separate groups. In general, isolates within a restriction pattern gel group had identical utilization patterns, whereas intragroup isolates had different utilization patterns. Correlation of these phenotypic characteristics with the results of molecular analysis revealed an exclusive carbohydrate and organic acid utilization pattern for each gel group as established by restriction pattern analysis.

Sonographic demonstration of hepatic venous gas in mesenteric arterial thrombosis

Hepatic portal venous gas is an ominous prognostic sign in bowel necrosis from mesenteric arterial occlusion. Ultrasonic examination is a sensitive and accurate method of demonstrating portal venous gas. We describe a case where the ultrasonic diagnosis of portal venous gas led to the rapid diagnosis of bowel infarction. Ultrasound is an appropriate emergency examination in all patients with suspected mesenteric artery occlusion.

The tooth-root sign: a characteristic appearance of distal ureteric calculi

Diagnostic accuracy in identifying calculi in patients with ureteric colic is poor. Lower ureteric calculi may be confused with other pelvic calcific opacities. A characteristic appearance of some larger lower ureteric calculi is described and likened to the root of a tooth. It is hoped that the tooth-root sign will be of assistance in the diagnosis of distal ureteric stones.

Widespread Castleman disease: CT and US findings

The widespread form of Castleman disease is a rare condition that has been recognized only recently as a disease with an aggressive, often malignant course. The authors present computed tomographic (CT) findings in six patients with this condition and ultrasound (US) findings in four of the six. CT demonstrated splenomegaly and retroperitoneal lymphadenopathy in all six patients. In one patient, CT also showed additional widespread mesenteric and peripancreatic lymphadenopathy, a large mesenteric mass adherent to the descending colon in another, and mediastinal lymphadenopathy in a third. Three patients had peripheral axillary or inguinal lymphadenopathy. Enlarged lymph nodes were 1-4 cm in diameter, and none displayed contrast enhancement on CT scans obtained with drip infusion of contrast media. On US scans, the nodes were poorly echogenic in all four cases. In no case was focal liver or splenic infiltration seen on either CT or US scans.

The periosteal sunburst reaction to bone metastases. A literature review and report of 20 additional cases

The periosteal sunburst reaction is an unusual response to metastatic bone tumours. Fifty such cases are reported in the literature, and 20 additional cases are reported in this study. The most common primary tumour showing this response is prostatic carcinoma, and the majority of cases are associated with osteoblastic metastases. Twenty percent of sunburst metastases occur in bones distal to the elbow and knee, a much higher prevalence than is found overall in bone metastases.

Spondylolysis in the upper lumbar spine. A study of 32 patients

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae.

Metastatic tumours of bones of the hand and foot. A comparative review and report of 43 additional cases

Metastases in the bones of the hands and feet are rare. The literature relating to these tumours has been reviewed, and 43 new cases are reported. In the cumulative total of cases, metastases to the hand outnumber those to the foot 2:1 (196 cases as against 94). Bronchial carcinoma is the most common neoplasm metastasising to the hand. Subdiaphragmatic neoplasms such as gastrointestinal, vesical, renal and uterine malignancies, metastasize more frequently to the foot. A possible explanation for this latter finding is the retrograde spread of tumour emboli from the vertebral venous plexus down incompetent leg veins.

Mediastinal lymph node metastases from gastrointestinal carcinoma

Mediastinal and hilar lymphadenopathy secondary to gastrointestinal metastases rarely have been reported and have been considered to occur only in conjunction with lymphangitic lung spread. The current report is of 15 cases of hilar and mediastinal metastases secondary to pancreatic, gastric, and colonic primary tumors. In only three of these cases was lymphangitic lung involvement noted. Possible pathways of spread of these tumors to the mediastinal lymph nodes are discussed.

The assimilated os sustentaculi

The assimilated os sustentaculi is a projection of bone from the medial aspect of the sustentaculum tali which is surmounted by a similar projection from the medial tubercle of the talus. The accessory joint so formed may develop secondary osteoarthritis changes. This congenital anomaly is very rare. The present report is of 2 additional cases.

Granulocytic sarcoma (chloroma) of bone: the CT appearance

Granulocytic sarcoma (chloroma) is an unusual tumour usually seen in cases of myelogenous leukemia. The tumour is most commonly located in the skull, orbits and sinuses. Extracranial tumours occur mainly in the soft tissues of the body and bone involvement is uncommonly seen and is almost invariably lytic in nature. We describe the first case of CT demonstration of bone involvement by such a tumour. A mixed sclerotic and lytic pattern was seen.

Relationship of psoas width to osteoporosis

We have related the radiographic width of the psoas muscle to age, degree of osteoporosis, height, and weight, and to constitution in 234 subjects. The psoas width correlated well with age. When the subjects were grouped according to age, an association was observed between narrowing psoas width and increasing osteoporosis. Narrowing of the psoas was evident some years prior to radiographic evidence of osteoporosis.

Preventing osteoporosis: current practices and problems

A lateral x-ray of the thoracic and lumbar spine should be part of the routine examination of any woman aged 40 or older. Similarly, an anteroposterior x-ray of the hand as a first assessment may suggest a need for further investigation for osteoporosis. Estrogen treatment reduces the incidence of vertebral compression and has proven protective against central as well as peripheral bone loss. However, rapid bone loss after termination of estrogen therapy implies that the protective effect may last no longer than 2 to 3 years.

Evaluation of the excretory urogram in adult enuresis

Excretory urograms in 216 primary enuretic adult males aged between 18 and 20 years were retrospectively evaluated. In no patient was there a finding considered relevant to the complaint. It is considered that, in the absence of urinary infection or other urological complaint in a patient with normal neurological status, excretory urography is a non-contributory examination in the investigation of adult male enuresis.

Renal sonography in American Burkitt lymphoma

Renal involvement is a common finding at necropsy in patients with American Burkitt lymphoma, but its in vivo sonographic features have received little attention in the literature. Of 29 patients with American Burkitt lymphoma who underwent sonography, 10 were found to have renal involvement. The 10 patients demonstrated a range of abnormalities, notably renomegaly (nine patients), diffuse increase in cortical echogenicity (six), and focal renal masses (three). The focal infiltrations were, unexplicably, hypoechoic in two patients and hyperechoic in one. Hydronephrosis was seen in five patients. One patient had evidence of calcium phosphate renal stones. Response to therapy can be assessed by changes in renal size and cortical echogenicity, as well as disappearance of focal lesions.

Hypertrophic osteoarthropathy and primary intestinal lymphoma

Hypertrophic osteoarthropathy (HOA) in association with primary bowel disease is rare, but is usually seen in patients with chronic diarrheal states, such as Crohn's disease and ulcerative colitis. We record the first case of HOA associated with primary intestinal lymphoma in a patient who presented with chronic diarrhea.

Prevalence of Paget's disease of bone in hospital patients in Jerusalem: an epidemiologic study

Epidemiological studies have revealed the widely varied prevalence of Paget's disease of bone. The highest rates have been found in parts of England. The disease has been reported only infrequently in Jews and no previous studies of prevalence have been performed in the Middle East or Asia. In the present study an age- and sex-standardized rate of 1% was found among Jews, which is similar to that in many southern European populations. No case of Paget's disease of bone was found among Arabs in this study.

Calcified mucinous adenocarcinoma of the stomach--the CT appearances

The CT appearances of calcified mucinous adenocarcinoma of the stomach have not been previously reported. This is a rare tumour with a high propensity to calcify, the calcifications typically are small and spiculated. A case is described where the condition was suspected in the plain films of the abdomen and confirmed by CT examination of the stomach.

Complete ureteral triplication with ectopia

A case of complete ureteral triplication is reported and a brief review of the literature is presented.

Seeding of cholangiocarcinoma along T-tube tracts

A fungating cutaneous tumor arising at the site of exit of a T-tube is described. The tube had been inserted to bypass an adenocarcinoma of the common bile duct. The tumor arose 30 months after operation and is the first such case recorded. Multiple percutaneous changes of the T-tube may be the causative factors.

Oral cholecystosonography: a method for facilitating the diagnosis of cholesterol gallstones

During the past two years, floating stones within the gallbladder have been demonstrated in five patients, by both oral cholecystography and sonography. We suggest coupling administration of an oral cholecystographic contrast agent with ultrasound examination in cases of equivocal sonographic findings. The combined study--oral cholecystosonography--can facilitate the demonstration of small cholesterol stones by inducing the phenomenon of layering.

Scoliosis in young men with spondylolysis or spondylolisthesis. A comparative study in symptomatic and asymptomatic subjects

While an increased incidence of scoliosis in symptomatic spondylolysis and spondylolisthesis has been established previously, a comparison of its occurrence in symptomatic and asymptomatic individuals has not been performed. The present study is a comparison of symptomatic and asymptomatic young men with analysis as to the incidence of scoliosis. Idiopathic scoliosis was not found and all cases were due to spasm scoliosis or olisthetic scoliosis with the spasm type being much more common. Scoliotic curves were divided into mild (0-9 degrees) and moderate (10-20 degrees). No case of a curve greater than 20 degrees was seen. Scoliosis incidence in asymptomatic individuals without a pars break was 6.65%. In the groups of: (1) asymptomatic unilateral spondylolysis, (2) asymptomatic bilateral spondylolysis, (3) symptomatic bilateral spondylolysis, and (4) asymptomatic spondylolisthesis the scoliosis incidence was similar, ranging from 13.3-23.8%. These figures are significantly higher than those seen in the asymptomatic subjects without a pars break, but they are in the same range as in symptomatic patients without a pars break, suggesting that muscle spasm is the principal cause of the scoliosis.

Soft-tissue thickness of the wrist

Increase in the soft-tissue thickness of the wrist is said to be a sensitive indicator of early oedema due to generalised or local arthritic disease. No normal values are available. Measurement of the soft-tissue thickness opposite the radial and ulnar styloid processes in a random population demonstrated a large normal range which was not related to obesity. This large normal variation calls into question the accuracy of radiological evaluation of early wrist oedema.

Oblique lumbar spine radiographs: importance in young patients

Spondylolysis is a direct precursor of spondylolisthesis and can lead to crippling back pain. Of 1,743 patients surveyed, including 936 who were asymptomatic and 807 with back pain, 165 (including 91 who were asymptomatic and 74 with back pain) had spondylolysis, which was seen only on oblique lumbar views in 20% of cases. Because of the high false-negative rate of AP and lateral views, oblique views are essential in children and young adults. As spondylolysis is rare above L3, radiographs can be limited to L3-S1. Significantly less spondylolysis was seen in persons older than 30, with back pain usually caused by disk degeneration; thus routine oblique views could be safely omitted in older patients.

Bile duct tumours: prolonged survival by radiological management of T-tubes

Carcinoma of the common bile duct is generally a slow-growing tumour which causes death by hepatic failure and ascending cholangitis secondary to obstruction. Internal drainage by surgical placement of a T-tube bypassing the tumour is widely employed, but survival times are generally short, averaging 9.9 months. The interventional radiologist can offer considerable prolongation of life with reduced hospitalization by means of percutaneous tube cleaning and catheter replacement. A case is presented where survival has been prolonged to 37 months by routine radiological catheter care.

Sigmoid-appendiceal fistula in diverticular disease

Sigmoid-appendiceal fistulae are unusual. A case in which such a fistula occurred secondary to diverticulitis is reported.

The prevalence of ankylosing hyperostosis in a Jerusalem population--with description of a method of grading the extent of the disease

The prevalence of ankylosing hyperostosis in a Jewish hospital population is presented. In individuals over the age of 40 years the overall prevalence was 22.4% in males and 13.4% in females. The prevalence increased with age to a maximum of 46% in males and 30% in females over the age of 80 years. A method of grading the disease according to extent is described. The most extensive grade III is seen almost exclusively in males.

Bilateral symmetrical clavicular periosteal reactions in a child

A case of bilateral symmetrical periosteal reactions of the lateral halves of the clavicles in a child with subacute sclerosing panencephalitis is presented. The appearances correspond with no previously recorded condition. The differential diagnosis most likely lies between aborted Salmonella osteomyelitis or a form fruste of subacute symmetrical osteomyelitis.