Extensive Amyloid Purpura: An Unusual Presentation of Myeloma-associated Light Chain Amyloidosis

Abstract is missing (Short communication)

Tissue-based diagnosis of systemic amyloidosis: Experience of the informal diagnostic center at Uppsala University Hospital

Diagnosis of systemic amyloidosis is a clinical challenge and usually relies on a tissue biopsy. We have developed diagnostic methods based on the presence of amyloid deposits in abdominal subcutaneous fat tissue. This tissue is also used to determine the biochemical type of amyloidosis, performed by western blot and immunohistochemical analyses with the aid of in-house developed rabbit antisera and mouse monoclonal antibodies. Mass spectrometric methods are under development for selected cases. The diagnostic outcome for 2018-2020 was studied. During this period, we obtained 1,562 biopsies, of which 1,397 were unfixed subcutaneous fat tissue with varying degrees of suspicion of systemic amyloidosis. Of these, 440 contained amyloid deposits. The biochemical nature of the amyloid was determined by western blot analysis in 319 specimens and by immunohistochemistry in further 51 cases.

Size of Lumbar Disc Hernias Measured Using Computed Tomography and Related to Sciatic Symptoms

The change in the relative size of lumbar disc hernias and its relation to sciatic symptoms was investigated in 30 consecutive patients after conservative treatment of CT verified lumbar disc herniations. CT and clinical examination were performed before the start of therapy (CT1), as well as 3 months (CT2) and 24 months (CT3) after institution of treatment. In each patient the size of the lumbar disc herniation in relation to the size of the spinal canal was measured on identical CT slices and expressed as an index. The disc herniation index decreased markedly from CT1 to CT2 (p < 0.001). Between CT2 and CT3 the reduction of the hernias was less pronounced and not significant for hernias located centrally but still significant for intermediate (p = 0.03) and lateral (p = 0.04) hernias. The degree of sciatic symptoms also decreased markedly between CT1 and CT2 (p = 0.001) while no further improvement occurred from CT2 to CT3. There was a significant positive correlation between the improvement from sciatic pain and the reduction in the size of the individual hernia (CT1–CT2 p = 0.02, CT2–CT3 p < 0.001). Thus, the disc herniation index provided a method to study the anatomic effect of conservative treatment as well as a method to evaluate sciatic symptoms in relation to anatomic changes.

Microscopic colitis in Uppsala health region, a population-based prospective study 2005-2009

OBJECTIVE

The aim of this study is to report on the incidence of microscopic colitis (MC), any possible relation with inflammatory bowel disease (IBD), concomitant drug consumption, related diseases and the clinical course of the diseases.

METHODS

Both new cases of IBD and MC were registered at the same time in the same geographical area. The study started in the county of Uppsala 2005-2006, and other parts of the surrounding health region were included 2007-2009. Established morphological criteria were used, i.e. a layer of subepithelial collagen band ≥ 10 μm in collagenous colitis (CC) with concomitant inflammation and at least 20 lymphocytes per 100 epithelial cells in lymphocytic colitis (LC).

RESULTS

The authors found 272 new cases of MC, 154 with CC and 118 with LC. The mean age-adjusted incidence was 7.0/1,000,000 for CC and 4.8/100,000 for LC. The clinical course was dominated by single episodes with diarrhea or intermittent symptoms, but 14% suffered from chronic diarrhea. In 10% of the cases, diagnosis was made in individuals without chronic watery diarrhea. Although not systematically tested, concomitant celiac disease was found in approximately 5% of the patients.

CONCLUSIONS

The incidence of MC in Uppsala health region is similar to other studied areas. The majority of patients had a self-limiting or easily treated condition, but 14% need a more or less continuous medication. Ten percent of the patients demonstrate other symptoms than chronic watery diarrhea. The possibility of concomitant celiac disease should be considered in new cases of MC.

Describing the size of lumbar disc herniations using computed tomography. A comparison of different size index calculations and their relation to sciatica

STUDY DESIGN

The study compared different methods to measure the absolute and relative size of lumbar disc herniations on computed tomography scans and their relation to sciatica.

METHODS

Computed tomography (CT) examinations were done before and at 3 and 24 months after nonoperative treatment in 30 patients with lumbar disc herniations. The size of the herniation was described by different indexes and related to the degree of sciatica. One index was formed by the area of the herniation in relation to the spinal canal (A-index), whereas two indexes were formed by linear measurements of the herniation in relation to the spinal canal in either two (ST-index) or one direction (S-index).

RESULTS

Each index was correlated significantly to the degree of sciatica. The area of the herniations decreased markedly over time.

CONCLUSIONS

Linear measurements of the herniation in two perpendicular directions provide a practical and accurate way of describing the size of lumbar disc herniations.

Quantitation of C-reactive protein levels and erythrocyte sedimentation rate after spinal surgery

C-reactive protein and erythrocyte sedimentation rate were prospectively measured after four types of uncomplicated spinal operations. In all patients, preoperative normal C-reactive protein (less than 10 mg/L) increased, reaching peak levels on the second day after microdiscectomy (46 +/- 21 mg/L) and anterior fusion (70 +/- 23 mg/L), and at the third day after conventional discectomy (92 +/- 47 mg/L) and posterolateral intercorporal fusion (173 +/- 39 mg/L), with normalization in 5-14 days. Peak levels were not related to bleeding, transfusion, operation time, administered drugs, age, or sex. Erythrocyte sedimentation rate increased to peak levels about 5 days after surgery, followed by a slow and irregular decrease, and at 21-42 days after surgery often remained elevated. The rapid decline in C-reactive protein will probably be interrupted by a second rise or persisting elevation if infection occurs. C-reactive protein is presumably a better test than erythrocyte sedimentation rate for early detection of postoperative infection.

Straight leg raising test versus radiologic size, shape, and position of lumbar disc hernias

In 30 patients with a computed tomography-verified lumbar disc herniation, the relation between the straight leg raising test and the size, shape, and position of the hernia was evaluated before, 3, and 24 months after inception of nonoperative treatment. Hernia size was expressed as an index relating it to the size of the spinal canal. The limitation of the straight leg raising test was not related to size or position of the hernia. Before treatment, straight leg raising was equally restricted in patients with sharply pointed or blunt hernias, but after 3 months straight leg raising was less limited in patients with sharply pointed hernias, whereas after 24 months straight leg raising was regularly normalized. Size index was lower for sharply pointed hernias at all three computed tomography scans. A decrease in hernia size over time, irrespective of shape, was not correlated to a concomitant improvement in straight leg raising. It must be presumed that additional factors, such as inflammatory reactions affecting the nerve roots, are of importance for the magnitude of straight leg raising.

C-reactive protein (CRP) levels after elective orthopedic surgery

The levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were determined by serial measurements after four types of uncomplicated elective orthopedic surgery. The type of operations chosen for this study were total hip arthroplasty (primary, n = 109; and revisions caused by aseptic loosening, n = 9), unicondylar knee arthroplasty (n = 39), and lumbar microdiskectomy (n = 36). In all patients, CRP levels increased after surgery, reaching peak levels on the third day after hip arthroplasties (primary, 116 +/- 43 mg/l; revisions, 136 +/- 58 mg/l) and on the second day after knee arthroplasties (140 +/- 46 mg/l) and lumbar microdiskectomy (48 +/- 27 mg/l). C-reactive protein levels usually dropped to normal (less than 10 mg/l) within 21 days after surgery. No correlations were found between CRP response and the type of anesthesia, amount of bleeding, transfusion, operation time, administered drugs, age, or gender. Erythrocyte sedimentation rate increased to peak levels about five days after surgery, followed by a slow and irregular decrease. Still, 42 days after uncomplicated operations ESR often remained elevated. In conclusion, the level of CRP must be considered a better diagnostic aid for the early detection of postoperative infections than ESR. It can be assumed that the rapid decline in CRP after uncomplicated orthopedic surgery will be interrupted by a second rise or by a persisting elevated level if infectious complications occur.

Size of lumbar disc hernias measured using computed tomography and related to sciatic symptoms

The change in the relative size of lumbar disc hernias and its relation to sciatic symptoms was investigated in 30 consecutive patients after conservative treatment of CT verified lumbar disc herniations. CT and clinical examination were performed before the start of therapy (CT1), as well as 3 months (CT2) and 24 months (CT3) after institution of treatment. In each patient the size of the lumbar disc herniation in relation to the size of the spinal canal was measured on identical CT slices and expressed as an index. The disc herniation index decreased markedly from CT1 to CT2 (p less than 0.001). Between CT2 and CT3 the reduction of the hernias was less pronounced and not significant for hernias located centrally but still significant for intermediate (p = 0.03) and lateral (p = 0.04) hernias. The degree of sciatic symptoms also decreased markedly between CT1 and CT2 (p = 0.001) while no further improvement occurred from CT2 to CT3. There was a significant positive correlation between the improvement from sciatic pain and the reduction in the size of the individual hernia (CT1-CT2 p = 0.02, CT2-CT3 p less than 0.001). Thus, the disc herniation index provided a method to study the anatomic effect of conservative treatment as well as a method to evaluate sciatic symptoms in relation to anatomic changes.

Size of lumbar disc hernias measured using computed tomography and related to sciatic symptoms

The change in the relative size of lumbar disc hernias and its relation to sciatic symptoms was investigated in 30 consecutive patients after conservative treatment of CT verified lumbar disc herniations. CT and clinical examination were performed before the start of therapy (CT1), as well as 3 months (CT2) and 24 months (CT3) after institution of treatment. In each patient the size of the lumbar disc herniation in relation to the size of the spinal canal was measured on identical CT slices and expressed as an index. The disc herniation index decreased markedly from CT1 to CT2 (p less than 0.001). Between CT2 and CT3 the reduction of the hernias was less pronounced and not significant for hernias located centrally but still significant for intermediate (p = 0.03) and lateral (p = 0.04) hernias. The degree of sciatic symptoms also decreased markedly between CT1 and CT2 (p = 0.001) while no further improvement occurred from CT2 to CT3. There was a significant positive correlation between the improvement from sciatic pain and the reduction in the size of the individual hernia (CT1-CT2 p = 0.02, CT2-CT3 p less than 0.001). Thus, the disc herniation index provided a method to study the anatomic effect of conservative treatment as well as a method to evaluate sciatic symptoms in relation to anatomic changes.

Alprazolam compared to amitriptyline in the treatment of major depression

In a double-blind randomized study the therapeutic effect and safety of alprazolam was compared with amitriptyline in 81 outpatients suffering from major depression. Variable dosages of both drugs were used, the mean final dose of alprazolam being 3.05 and that of amitriptyline 130 mg. Both treatment groups improved steadily, assessed weekly with the use of the Hamilton Rating Scale for Depression, and no significant differences were found between the groups, either on comparison between single items or total scores. On several of the criteria used for assessment of treatment response, however, more patients responded to amitriptyline than to alprazolam. In an analysis of specific subgroups, patients whose depression was accompanied by retardation, those in whom there were no precipitating factors and those with low levels of anxiety, responded better to amitriptyline. Considerably fewer side effects were reported by patients receiving alprazolam. In particular, there was a significantly lower incidence of dry mouth, light-headedness, tremor and tachycardia in patients receiving alprazolam compared with amitriptyline.