Time Course of Asymptomatic Stenosis in Multiple Lumbar Spinal Stenosis-Five-Year Results of Selective Decompression of Symptomatic Levels

Background: In the diagnosis of lumbar spinal stenosis (LSS), finding stenosis with magnetic resonance imaging (MRI) does not always correlate with symptoms such as sciatica or intermittent claudication. We perform decompression surgery only for cases where the levels diagnosed from neurological findings are symptomatic, even if multiple stenoses are observed on MRI. The objective of this study was to examine the time course of asymptomatic stenosis in patients with LSS after they underwent decompression surgery for symptomatic stenosis. Materials and Methods: The participants in this study comprised 137 LSS patients who underwent single-level L4-5 decompression surgery from 2003 to 2013. The dural sac cross-sectional area at the L3-4 disc level was calculated based on preoperative MRI. A cross-sectional area less than 50 mm2 was defined as stenosis. The patients were grouped, according to additional spinal stenosis at the L3-4 level, into a double group (16 cases) with L3-4 stenosis, and a single group (121 cases) without L3-4 stenosis. Incidences of new-onset symptoms originating from L3-4 and additional L3-4-level surgery were examined. Results: Five years after surgery, 98 cases (72%) completed follow-up. During follow-up, 2 of 12 patients in the double group (16.7%) and 9 of 86 patients in the single group (10.5%) presented with new-onset symptoms originating from L3-4, showing no significant difference between groups. Additional L3-4 surgery was performed for one patient (8.3%) in the double group and three patients (3.5%) in the single group; again, no significant difference was shown. Conclusion: Patients with asymptomatic L3-4 stenosis on preoperative MRI were not prone to develop new symptoms or need additional L3-4-level surgery within 5 years after surgery when compared to patients without preoperative L3-4 stenosis. These results indicate that prophylactic decompression for asymptomatic levels is unnecessary.

Naturalistic symptom trajectories of atypical anorexia nervosa, anorexia nervosa, and bulimia nervosa in a prospective cohort study of United States college students

OBJECTIVE

Research on the natural course of symptoms of atypical anorexia nervosa (AN) relative to AN and bulimia nervosa (BN) is limited yet needed to inform nosology and improve understanding of atypical AN. This study aimed to 1) characterize trajectories of eating disorder and internalizing (anxiety, depression) symptoms in college students with and without a history of atypical AN, AN, and BN; and 2) compare sex and race/ethnicity distributions across groups.

METHOD

United States college students who participated in Spit for Science™, a prospective cohort study, were classified as having a history of atypical AN (n = 125), AN (n = 160), BN (n = 617), or as non-eating-disorder controls (NCs, n = 5876). Generalized and linear mixed-effects models assessed group differences in eating and internalizing symptom trajectories, and logistic regression compared groups on sex and race/ethnicity distributions.

RESULTS

Atypical AN participants demonstrated elevated eating disorder and internalizing symptoms compared to NCs during college, but less severe symptoms than AN and BN participants. Although all eating disorder groups showed signs of improvement in fasting and driven exercise, purging and depression remained elevated. Atypical AN participants showed increasing anxiety and stable binge-eating trajectories compared to AN and/or BN participants. The atypical AN group comprised significantly more people of color than the AN group.

DISCUSSION

Findings underscore that atypical AN is a severe psychiatric disorder. As atypical AN may present as less severe than AN and BN and disproportionately affects people of color, clinicians should be mindful of biases that could delay diagnosis and care.

PUBLIC SIGNIFICANCE

College students with histories of atypical AN, AN, and BN demonstrated improvements in fasting and driven exercise and stable purging and depression levels. Atypical AN students showed worsening anxiety and stable binge-eating trajectories compared to favorable changes among AN and BN students. A higher percentage of atypical AN (vs. AN) students were people of color. Findings may improve the detection of atypical AN in college students.

Non-Pure Intestinal Phenotype as an Indicator of Progression in Sporadic Nonampullary Duodenal Adenomas: A Multicenter Retrospective Cohort Study

INTRODUCTION

We aimed to evaluate the natural course of sporadic nonampullary duodenal adenomas (SNDAs) and determine the risk factors of progression.

METHODS

We retrospectively analyzed the follow-up outcomes of patients with biopsy-diagnosed SNDA between April 2010 and March 2016 at 13 institutions. All initial biopsy specimens were centrally evaluated. Only those diagnosed with adenomas were included. Mucinous phenotypes were classified into pure intestinal and non-pure intestinal phenotypes. Cumulative incidence rates of carcinoma and tumor enlargement were evaluated. Tumor enlargement was defined as a ≥25% or 5-mm increase in tumor size.

RESULTS

Overall, 121 lesions were analyzed. Within a median observation period of 32.7 months, 5 lesions were diagnosed as carcinomas; the cumulative 5-year incidence of carcinoma was 9.5%. Male sex ( P = 0.046), initial lesion size ≥10 mm ( P = 0.044), and non-pure intestinal phenotype ( P = 0.019) were significantly associated with progression to carcinoma. Tumor enlargement was observed in 22 lesions, with a cumulative 5-year incidence of 33.9%. Initial lesion size ≥10 mm ( P < 0.001), erythematous lesion ( P = 0.002), high-grade adenoma ( P = 0.002), Ki67 negative ( P = 0.007), and non-pure intestinal phenotype ( P = 0.001) were risk factors of tumor enlargement. In a multivariate analysis, an initial lesion size ≥10 mm ( P = 0.010) and non-pure intestinal phenotype ( P = 0.046) were independent and significant risk factors of tumor enlargement.

DISCUSSION

Lesion size ≥10 mm and non-pure intestinal phenotype on initial biopsy are risk factors of cancer progression and tumor enlargement in cases with SNDA. Thus, management effectiveness may be improved by focusing on lesion size and the mucinous phenotype.

Prediction of Interval Growth of Lung Adenocarcinomas Manifesting as Persistent Subsolid Nodules ≤3 cm Based on Radiomic Features

RATIONALES AND OBJECTIVES

To investigate the prognostic value of the radiomic-based prediction model in predicting the interval growth rate of persistent subsolid nodules (SSNs) with an initial size of ≤ 3 cm manifesting as lung adenocarcinomas.

MATERIALS AND METHODS

A total of 133 patients (mean age, 59.02 years; male, 37.6%) with 133 SSNs who underwent a series of CT examinations at our hospital between 2012 and 2022 were included in this study. Forty-one radiomic features were extracted from each volumetric region of interest. Radiomic features combined with conventional clinical and semantic parameters were then selected for radiomic-based model building. To investigate the model performance in terms of substantial SSN growth and stage shift growth, the model performance was compared by the area under the curve (AUC) obtained by receiver operating characteristic analysis.

RESULTS

The mean follow-up period was 3.62 years. For substantial SSN growth, a radiomic-based model (Model 2) based on clinical characteristics, CT semantic features, and radiomic features yielded an AUCs of 0.869 (95% CI: 0.799-0.922). In comparison with Model 1 (clinical characteristics and CT semantic features), Model 2 performed better than Model 1 for substantial SSN growth (AUC model 1:0.793 versus AUC model 2:0.869, p = 0.028). A radiomic-based nomogram combining sex, follow-up period, and three radiomic features was built for substantial SSN growth prediction. For the stage shift growth, a radiomic-based model (Model 4) based on clinical characteristics, CT semantic features, and radiomic features yielded an AUCs of 0.883 (95% CI: 0.815-0.933). Compared with Model 3 (clinical characteristics and CT semantic features), Model 4 performed better than the model 3 for stage shift growth (AUC model 1: 0.769 versus AUC model 2: 0.883, p = 0.006). A radiomic-based nomogram combining the initial nodule size, SSN classification, follow-up period, and three radiomic features was built to predict the stage shift growth.

CONCLUSION

Radiomic-based models have superior utility in estimating the prognostic interval growth of patients with early lung adenocarcinomas (≤ 3 cm) than conventional clinical-semantic models in terms of substantial interval growth and stage shift growth, potentially guiding clinical decision-making with follow-up strategies of SSNs in personalized precision medicine.

Changes in insight throughout the natural four-year course of obsessive-compulsive disorder and its association with OCD severity and quality of life

Objective

Patients with obsessive-compulsive disorder (OCD) and poor insight show higher symptom severity, lower quality of life (QoL), and a reduced treatment response compared to patients with good insight. Little is known about changes in insight. This study explored the course of insight and its association with OCD severity and QoL among 253 patients with OCD participating in the prospective naturalistic Netherlands Obsessive Compulsive Disorder Association (NOCDA) Study.

Results

In 70% of the participants with available insight data, the level of insight changed during the four-year course. Insight was most variable in participants with poor insight. Improvement of insight scores was statistically significantly associated with improvement of Y-BOCS scores (r = 0.19), but not with changes in QoL scores. Change in insight in the first 2 years was not statistically significantly predictive of OCD severity or QoL at four-year follow-up.

Conclusion

These findings suggest that patients' levels of insight may change during the natural four-year course of OCD and that improvement in the level of insight have a positive association with improvement in OCD severity.

A Progressive Spontaneous Cervical Compression Fracture Over Years Following Long-Term Corticosteroid Use

Spontaneous vertebral compression fractures in the cervical region can have a significant impact on a patient's condition even after surgical management. Due to the rarity of spontaneous cervical vertebral compression fractures and the lack of a comprehensive description of this condition, the establishment of a clear understanding of its natural course remains incomplete. In this case study, a 73-year-old woman on long-term corticosteroid therapy underwent combined anterior and posterior fixation for a spontaneous vertebral compression fracture at the C3-C4 level. The vertebral compression fracture gradually worsened over a span of four years. Following the surgery, the patient experienced a temporary improvement in her neurological symptoms. However, seven months after the second operation, an instrumentation failure resulted in the patient becoming bedridden. This highlights the importance of considering the potential long-term implications and monitoring patients closely even after surgical intervention.

Deconstructing the heterogeneity of alcohol use disorder: lifetime comorbid non-alcohol substance use disorder as a distinct behavioral phenotype?

BACKGROUND

Alcohol use disorder (AUD) is an etiologically and clinically heterogeneous condition. Accumulating evidence suggests that persons with lifetime histories of comorbid AUD and non-alcohol substance use disorder (DRUG) constitute an important subgroup of AUD. This study evaluated the distinctiveness of the comorbid AUD/DRUG behavioral phenotype in a community sample with respect to risk factors, AUD course features, and outcome variables assessed at age 30. Contrast groups included persons with histories of AUD only, DRUG only, and neither AUD nor DRUG.

METHODS

This research utilized a prospective study design with an age-based cohort (n = 732). Participants completed four comprehensive diagnostic evaluations during the high-risk periods of adolescence, emerging adulthood, and young adulthood.

RESULTS

The comorbid AUD/DRUG group was distinguished from the AUD only group by risk factors, AUD course features, and outcomes. Group differences in outcomes were also explained by overall substance use disorder (SUD) severity. Persons with AUD/DRUG comorbidity were indistinguishable from those with DRUG only histories with respect to risk factors and outcomes but demonstrated greater overall SUD severity. Persons with AUD only were indistinguishable from those with neither AUD nor DRUG histories in risk factor endorsements and were mostly similar in outcomes.

CONCLUSIONS

Findings collectively suggest that young adults with histories of AUD only and those with comorbid AUD/DRUG are drawn from dissimilar populations. Similarities between the AUD only group with those absent AUD or DRUG histories are likely related to the former group's developmentally limited AUD course accompanied by relatively few or short-lived alcohol-related problems.

Is the Y90-radioembolization treatment effective on the intermediate-advanced stage of hepatocellular carcinoma and what is the albumin-bilirubin score's prediction factor for survival?

Background and Aim

Radioembolization (RE) is a one of the palliative treatments that have been used to down stage and/or increase the survival time in intermediate-advanced stages of HCC. We aimed to evaluate the clinical impact of RE and the clinical use of the albumin-bilirubin (ALBI) score as a predictor for survival in HCC patients.

Materials and Methods

Fifty-nine unresectable hepatocellular carcinoma (HCC) patients were enrolled. RE was performed in 28 of them (group 1) and 31 patients were followed up in the natural course (NC) (group 2). Patients were classified according to the Child-Pugh score (only cirrhotic patients), Barcelona clinic liver cancer (BCLC) staging, and ALBI scores were also calculated.

Results

All patients in Group 1 were cirrhotic and their BCLC stages were as follows: 60.7% stage B and 39.3% stage C. In Group 2, 83.9% of patients were cirrhotic and their BCLC stages were as follows: 9.7% stage B, 51.6% stage C, and 38.7% stage D. Mortality rates were 82% and 100% in Groups 1 and 2, respectively. The median overall survival (OS) was 13.5 months (95% CI: 10.4-16.6 months) and 4.5 months (95% CI: 3.5-5.5 months) in Groups 1 and 2, respectively (p=0.000). When RE was applied to patients with ALBI Grade 1 and 2, the median OS was statistically higher than in the NC group, respectively (p<0.001, p<0.001).

Conclusion

RE is an effective treatment method at the advanced stages of HCC. The ALBI score is a more useful and practical than the other prognostic tools.

LONG-TERM EVOLUTION OF MYOPIC RETINOSCHISIS WITH A DOME-SHAPED MACULA AND PREDICTORS OF PROGRESSION AND VISUAL PROGNOSIS

PURPOSE

To study the long-term natural course of myopic retinoschisis (MRS) with a dome-shaped macula (DSM) and to identify the factors affecting its development and visual prognosis.

METHODS

In this retrospective case series study, we followed 25 MRS eyes with a DSM and 68 MRS eyes without a DSM for at least two years and observed changes in optical coherence tomography morphologic features and best-corrected visual acuity.

RESULTS

During the mean follow-up of 48.3 ± 13.24 months, the difference in the rate of MRS progression between the DSM and non-DSM groups was not significant ( P = 0.7462). In the DSM group, the patients whose MRS progressed were older and had a higher refractive error than those whose MRS was stable or improved ( P = 0.0301 and 0.0166, respectively). The patients whose DSM was located in the central fovea had a significantly higher progression rate than those whose DSM was located in the parafovea ( P = 0.0421). For all DSM eyes, BCVA did not decrease significantly in eyes with extrafoveal retinoschisis ( P = 0.2500), patients whose best-corrected visual acuity decreased more than two lines had a greater central foveal thickness initially than those whose best-corrected visual acuity decreased less than two lines during the follow-up period ( P = 0.0478).

CONCLUSION

A DSM did not delay the progression of MRS. The development of MRS in DSM eyes was associated with age, myopic degree, and DSM location. A higher schisis cavity predicted visual deterioration, and a DSM protected visual function in extrafoveal MRS eyes during the follow-up period.

Long-term follow-up of persistent pulmonary subsolid nodules: Natural course of pure, heterogeneous, and real part-solid ground-glass nodules

BACKGROUND

Previous studies have suggested the applicability of three classifications of subsolid nodules (SSNs). However, few studies have unraveled the natural history of the three types of SSNs.

METHODS

A retrospective study from two medical centers between November 2007 and November 2017 was conducted to explore the long-term follow-up results of three different types of SSNs, which were divided into pure ground-glass nodules (pGGNs), heterogeneous ground-glass nodules (hGGNs), and real part-solid nodules (rPSNs).

RESULTS

A total of 306 consecutive patients, including 361 SSNs with long-term follow-up, were reviewed. The median growth times of pGGNs, hGGNs, and rPSNs were 7.7, 6.0, and 2.0 years, respectively. For pGGNs, the median period of development into rPSNs was 4.6 years, while that of hGGNs was 1.8 years, and the time from pGGNs to hGGNs was 3.1 years (p < 0.05). In SSNs with an initial lung window consolidation tumor ratio (LW-CTR) >0.5 and mediastinum window (MW)-CTR >0.2, all cases with growth were identified within 5 years. Meanwhile, in SSNs whose LW-CTR and MW-CTR were 0, it took over 5 years to detect nodular growth. Pathologically, 90.6% of initial SSNs with LW-CTR >0 were invasive carcinomas (invasive adenocarcinoma and micro-invasive adenocarcinoma). Among patients with rPSNs in the initial state, 100.0% of the final pathological results were invasive carcinoma. Cox regression showed that age (p = 0.038), initial maximal diameter (p < 0.001), and LW-CTR (p = 0.002) were independent risk factors for SSN growth.

CONCLUSIONS

pGGNs, hGGNs, and rPSNs have significantly different natural histories. Age, initial nodule diameter, and LW-CTR are important risk factors for SSN growth.

Modifiable vascular risk factors in patients with cerebral and spinal cavernous malformations: a complete 10-year follow-up study

BACKGROUND AND PURPOSE

The aim was to investigate the effect of modifiable vascular risk factors on the risk of first and recurrent bleeding for patients with a cavernous malformation (CM) of the central nervous system (CNS) over a 10-year period.

METHODS

A retrospective review of our CM institutional database was performed spanning from 2003 to 2021. The inclusion criteria were non-missing serial magnetic resonance imaging studies and clinical baseline metrics such as vascular risk factors. The exclusion criteria were patients who underwent surgical CM removal and patients with less than a decade of follow-up. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative risk (10 years) of hemorrhage.

RESULTS

Eighty-nine patients with a CM of the CNS were included. Our results showed a non-significant increased risk of hemorrhage during 10 years of follow-up in patients using nicotine (hazard ratio 2.11, 95% confidence interval 0.86-5.21) and in patients with diabetes (hazard ratio 3.25, 95% confidence interval 0.71-14.81). For the presence of modifiable vascular risk factors at study baseline different cumulative 10-year risks of bleeding were observed: arterial hypertension 42.9% (18.8%-70.4%); diabetes 66.7% (12.5%-98.2%); hyperlipidemia 30% (8.1%-64.6%); active nicotine abuse 50% (24.1%-76%); and obesity 22.2% (4%-59.8%). Overall cumulative (10-year) hemorrhage risk was 30.3% (21.3%-41.1%).

CONCLUSIONS

The probability of hemorrhage in untreated CNS CM patients increases progressively within a decade of follow-up. None of the modifiable vascular risk factors showed strong indication for an influence on hemorrhage risk, but our findings may suggest a more aggressive course in patients with active nicotine abuse or suffering from diabetes.

Natural course and risk factors of moyamoya disease with unruptured intracranial aneurysm

Background and objective

The natural course and risk factors of moyamoya disease (MMD) associated with unruptured intracranial aneurysms involving stenosed parental arteries are scarcely studied. This study aimed to elucidate the natural course of MMD and its associated risk factors in patients with MMD with unruptured aneurysms.

Methods

Between September 2006 and October 2021, patients with MMD with intracranial aneurysms at our center were examined. The natural course, clinical features, radiological features, and follow-up outcomes after revascularization were analyzed.

Results

This study included 42 patients with MMD with intracranial aneurysms (42 aneurysms). The age distribution of MMD cases ranged from 6 to 69 years, with four children (9.5%) and 38 adults (90.5%). A total of 17 male and 25 female subjects were included (male-to-female ratio: 1:1.47). The first symptom was cerebral ischemia in 28 cases, and cerebral hemorrhage occurred in 14 cases. There were 35 trunk aneurysms and seven peripheral aneurysms. There were 34 small aneurysms (<5 mm) and eight medium aneurysms (5-15 mm). During the average clinical follow-up period of 37.90 ± 32.53 months, there was no rupture or bleeding from aneurysms. Twenty-seven of these patients underwent a cerebral angiography review, in which it was found that one aneurysm had enlarged, 16 had remained unchanged, and 10 had shrunk or disappeared. A correlation exists between the reduction or disappearance of aneurysms and the progression of the Suzuki stages of MMD (P = 0.015). Nineteen patients underwent EDAS on the aneurysm side, and nine aneurysms disappeared, while eight patients did not undergo EDAS on the aneurysm side and one aneurysm disappeared.

Conclusion

The risk of rupture and hemorrhage of unruptured intracranial aneurysms is low when the parent artery already has stenotic lesions, thus, direct intervention may not be necessary for such aneurysms. The progression of the Suzuki stage of moyamoya disease may play a role in the shrinkage or disappearance of the aneurysms, thereby decreasing the risk of rupture and hemorrhage. Encephaloduroarteriosynangiosis (EDAS) surgery may also help promote atrophy or even the disappearance of the aneurysm, thus reducing the risk of further rupture and bleeding.

Central nervous system cavernous malformations: cross-sectional study assessing rebleeding risk after a second haemorrhage

BACKGROUND AND PURPOSE

The purpose of this study was to investigate the 5-year risk of a third bleeding event in cavernous malformations (CMs) of the central nervous system.

METHODS

Patients with cerebral or spinal CMs treated between 2003 and 2021 were screened using our institutional database. Patients with a complete magnetic resonance imaging dataset, clinical baseline characteristics, and history of two bleeding events were included. Patients who underwent surgical CM removal were excluded. Neurological functional status was obtained using the modified Rankin Scale score at the second and third bleeding. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for a third haemorrhage.

RESULTS

Forty-two patients were included. Cox regression analysis adjusted for age and sex did not identify risk factors for a third haemorrhage. 37% of patients experienced neurological deterioration after the third haemorrhage (p = 0.019). The cumulative 5-year risk of a third bleeding was 66.7% (95% confidence interval [CI] 50.4%-80%) for the whole cohort, 65.9% (95% CI 49.3%-79.5%) for patients with bleeding at initial diagnosis, 72.7% (95% CI 39.3%-92.7%) for patients with a developmental venous anomaly, 76.9% (95% CI 55.9%-90.3%) for patients with CM localization to the brainstem and 75% (95% CI 50.6%-90.4%) for patients suffering from familial CM disease.

CONCLUSIONS

During an untreated 5-year follow-up after a second haemorrhage, a significantly increased risk of a third haemorrhage compared to the known risk of a first and second bleeding event was identified. The third bleeding was significantly associated with neurological deterioration. These findings may justify a surgical treatment after a second bleeding event.

Active expectancy as alternative to treatment for cervical intraepithelial neoplasia grade 2 in women aged 25 to 30 years: ExCIN2-a prospective clinical multicenter cohort study

BACKGROUND

The management of cervical intraepithelial neoplasia grade 2 is a clinical dilemma. Cervical intraepithelial neoplasia grade 3 is considered a cancer precursor and is always treated with excision. Most of the cervical intraepithelial neoplasia grade 1 cases regress spontaneously, and it is internationally mostly monitored with expectant management. Surgical treatment of cervical intraepithelial neoplasia entails increased risk of preterm birth in future pregnancies. Cervical intraepithelial neoplasia grade 2 in women aged under 25 years is quite well-studied; the regression rate is high and the cervical cancer risk is low. Cervical intraepithelial neoplasia grade 2 in women aged 25 years and above, in whom the risk of occult cancer is higher, has been less studied.

OBJECTIVE

This study aimed to evaluate the natural course, over 2 years, of untreated cervical intraepithelial neoplasia grade 2 in women aged 25 to 30 years and its association with human papillomavirus 16.

STUDY DESIGN

The study was conducted as a prospective longitudinal multicenter clinical study during February 2017 to June 2021 at 5 colposcopy clinics managing referrals after abnormal cervical screening in Region Västra Götaland, Sweden. The per protocol group comprised 127 women, aged 25 to 30 years, with fully visible squamocolumnar junction and histologically verified cervical intraepithelial neoplasia grade 2. The patients were followed up for 2 years with colposcopy, cytology, human papillomavirus tests, and at least 2 cervical biopsies every 6 months until progression or regression. The main outcome measures were the rates of regression of cervical intraepithelial neoplasia grade 2 at 6, 12, 18, and 24 months in cases with human papillomavirus 16 and those without human papillomavirus 16. The secondary outcomes were persistence and progression.

RESULTS

In the per protocol analysis, partial or total regression during the 2-year period was found in 72% of patients (95% confidence interval, 63-79). In patients with human papillomavirus 16, the regression rate was 51% (95% confidence interval, 36-66) and the progression rate was 47% (95% confidence interval, 32-62). In the human papillomavirus-non-16 group, 83% (95% confidence interval, 73-90) regressed and 16% (95% confidence interval, 9-26) progressed. Most of the regression and progression in both the groups occurred within 15 months. The difference in regression between human papillomavirus 16 and human papillomavirus-non-16 cases was statistically significant (P value=.0001), as was the difference in progression (P=.0002).

CONCLUSION

The regression rate of cervical intraepithelial neoplasia grade 2 is high, and human papillomavirus 16 is a strong determinant of the natural course. Patients aged 25 to 30 years with a fully visible squamocolumnar junction and without human papillomavirus 16 should generally be recommended active surveillance for 15 months, whereas immediate treatment should be considered in cases with human papillomavirus 16.

Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations

OBJECTIVE

The objective of this study was to analyze the impact of medication intake on hemorrhage risk in patients with familial cerebral cavernous malformation (FCCM).

METHODS

The authors' institutional database was screened for patients with FCCM who had been admitted to their department between 2003 and 2020. Patients with a complete magnetic resonance imaging (MRI) data set, evidence of multiple CCMs, clinical baseline characteristics, and follow-up (FU) examination were included in the study. The authors assessed the influence of medication intake on first or recurrent intracerebral hemorrhage (ICH) using univariate and multivariate logistic regression adjusted for age and sex. The longitudinal cumulative 5-year risk of hemorrhage was calculated by applying Kaplan-Meier and Cox regression analyses adjusted for age and sex.

RESULTS

Two hundred five patients with FCCMs were included in the study. Multivariate Cox regression analysis revealed ICH as a predictor for recurrent hemorrhage during the 5-year FU. The authors also noted a tendency toward a decreased association with ICH during FU in patients on statin medication (HR 0.22, 95% CI 0.03-1.68, p = 0.143), although the relationship was not statistically significant. No bleeding events were observed in patients on antithrombotic therapy. Kaplan-Meier analysis and log-rank test showed a tendency toward a low risk of ICH during FU in patients on antithrombotic therapy (p = 0.085), as well as those on statin therapy (p = 0.193). The cumulative 5-year risk of bleeding was 22.82% (95% CI 17.33%-29.38%) for the entire cohort, 31.41% (95% CI 23.26%-40.83%) for patients with a history of ICH, 26.54% (95% CI 11.13%-49.7%) for individuals on beta-blocker medication, 6.25% (95% CI 0.33%-32.29%) for patients on statin medication, and 0% (95% CI 0%-30.13%) for patients on antithrombotic medication.

CONCLUSIONS

ICH at diagnosis was identified as a risk factor for recurrent hemorrhage. Although the relationships were not statistically significant, statin and antithrombotic medication tended to be associated with decreased bleeding events.

Natural course of Rathke's cleft cysts and risk factors for progression

OBJECTIVE

Rathke's cleft cysts (RCCs) are relatively common and often detected incidentally. They are usually asymptomatic and managed conservatively. However, little is known about their natural history. Thus, the authors aimed to examine the natural course of RCCs and identify the risk factors for their progression.

METHODS

This retrospective study examined 229 patients (median age 43.0 years) diagnosed with RCCs by MRI and followed up without surgery (median period 36.6 months). The median cyst height on the initial MRI was 10 mm. Progression or regression of RCC was defined as cyst height changes of ≥ 1 mm.

RESULTS

In total, 23 (10.0%) RCCs progressed, whereas 73 (31.9%) RCCs spontaneously regressed. The remaining 133 were noted to be stable throughout the follow-up period. Patients with progressed RCCs were significantly older than those with stable RCCs. In patients with acute headache as an initial symptom, RCCs were significantly more likely to spontaneously regress. New symptoms occurred in 6 patients, 5 of whom underwent surgery for RCC progression. Of these 6 patients, 1 patient had persistent adrenocorticotropic hormone deficiency and 1 patient developed diabetes insipidus. Kaplan-Meier analysis results showed RCC progression and new symptom development rates to be 12.0% and 4.1% at 5 years and 13.7% and 5.7% at 10 years, respectively.

CONCLUSIONS

RCCs rarely progress or cause new symptoms in the long term. Patients with asymptomatic RCC should be followed up for at least 5 years to ensure RCC inactivity. RCCs in older adults may require greater surveillance.

Natural Course of Fetal Hyaloid Artery: SlowflowHD Longitudinal Study

OBJECTIVE

To assess the natural course of the fetal hyaloid artery (FHA) using SlowflowHD during pregnancy.

METHODS

One-hundred and eighteen normal fetuses were studied longitudinally using SlowflowHD to assess the natural course of FHA at 18-21 + 6, 28-31 + 6, and after 35 weeks of gestation. Blood flow of FHA with/without its branches (BF) was evaluated using SlowflowHD, and the band of FHA without blood flow (Band) was identified in each gestational period. The natural course of FHA was classified into six types: Type A, not detected (ND) in each gestational period; Type B, Band at 18-21 + 6 weeks; Type C, Band at 18-21 + 6 and 28-31 + 6 weeks; Type D, BF at 18-21 + 6 weeks; Type E, BF at 18-21 + 6 weeks and Band at 28-31 + 6 weeks; Type F, BF at 18-21 + 6 and 28-31 + 6 weeks.

RESULTS

BF, Band, and ND were 83.5, 15.5, and 1.0% at 18-21 + 6 weeks, 8.8, 15.5, and 75.7% at 28-31 + 6 weeks, and 0, 0, and 100% after 35 weeks, respectively. Type A was 1.0%, Type B was 13.6%, Type C was 1.9%, Type D was 61.2%, Type E was 13.6%, and Type F was 8.7%.

CONCLUSIONS

The presence of FHA blood flow before 30 weeks of gestation should be regarded as a physiologic phenomenon in normal fetuses.

Pediatric brainstem cavernous malformations: 2-center experience in 40 children

OBJECTIVE

Brainstem cavernous malformations (BSCMs) are relatively uncommon, low-flow vascular lesions in children. Given the paucity of data, guidelines regarding the clinical management of BSCMs in children are lacking and the surgical indication is most commonly based on an individual surgeon's judgment and experience. The goal in this study was to evaluate the clinical behavior of BSCMs in childhood and the long-term outcome in children managed conservatively and surgically.

METHODS

This was an observational, retrospective study including all children with BSCMs who were followed at 2 institutions between 2008 and 2020.

RESULTS

The study population consisted of 40 children (27 boys, 67.5%) with a mean age of 11.4 years. Twenty-three children (57.5%) were managed conservatively, whereas 17 children (42.5%) underwent resection of BSCMs. An aggressive clinical course was observed in 13 children (32.5%), who experienced multiple hemorrhages with a progressive pattern of neurological decline. Multiple BSCMs were observed in 8 patients, of whom 3 patients presented with a complex of multiple tightly attached BSCMs and posed a significant therapeutic challenge. The overall long-term outcome was favorable (modified Rankin Scale [mRS] scores 0-2) in 36 patients (90%), whereas an unfavorable outcome (mRS scores 3 and 4) was seen in 4 children (10%). An mRS score of 5 or 6 was not observed. The mean (± SD) follow-up was 88.0 (± 92.6) months.

CONCLUSIONS

The clinical course of BSCMs in children is highly variable, with benign lesions on the one hand and highly aggressive lesions with repetitive hemorrhages on the other. Given the greater life expectancy and the known higher functional recovery in children, surgical treatment should be considered early in young patients presenting with surgically accessible lesions and an aggressive clinical course, and it should be performed in a high-volume center.

Comparison of the Malignant Predictors in Intrahepatic and Extrahepatic Intraductal Papillary Neoplasm of the Bile Duct

Background: Intraductal papillary neoplasm of the bile duct (IPNB) is a precancerous lesion of cholangiocarcinoma, for which surgical resection is the most effective treatment. We evaluated the predictors of malignancy in IPNB according to anatomical location and the prognosis without surgery. Methods: A total of 196 IPNB patients who underwent pathologic confirmation by surgical resection or endoscopic retrograde cholangiography or percutaneous transhepatic cholangioscopic biopsy were included. Clinicopathological findings of IPNB with invasive carcinoma or mucosal dysplasia were analyzed according to anatomical location. Results: Of the 116 patients with intrahepatic IPNB (I-IPNB) and 80 patients with extrahepatic IPNB (E-IPNB), 62 (53.4%) and 61 (76.3%) were diagnosed with invasive carcinoma, respectively. Multivariate analysis revealed that mural nodule > 12 mm (p = 0.043) in I-IPNB and enhancement of mural nodule (p = 0.044) in E-IPNB were predictive factors for malignancy. For pathologic discrepancy before and after surgery, IPNB has a 71.2% sensitivity and 82.3% specificity. In the non-surgical IPNB group, composed of nine I-IPNB and seven E-IPNB patients, 43.7% progressed to IPNB with invasive carcinoma within 876 days. Conclusions: E-IPNB has a higher rate of malignancy than I-IPNB. The predictive factor for malignancy is mural nodule > 12 mm in I-IPNB and mural nodule enhancement in E-IPNB.

The Role of the Natural Course in Causal Analysis

The average causal effect compares counterfactual outcomes if everyone had been exposed versus if everyone had been unexposed, which can be an unrealistic contrast. Alternatively, we can target effects that compare counterfactual outcomes against the factual outcomes observed in the sample (i.e., we can compare against the natural course). Here, we demonstrate how the natural course can be estimated and used in causal analyses for model validation and effect estimation. Our example is an analysis assessing the impact of taking aspirin on pregnancy, 26 weeks after randomization, in the Effects of Aspirin in Gestation and Reproduction trial (United States, 2006-2012). To validate our models, we estimated the natural course using g-computation and then compared that against the observed incidence of pregnancy. We observed good agreement between the observed and model-based natural courses. We then estimated an effect that compared the natural course against the scenario in which participants assigned to aspirin always complied. If participants had always complied, there would have been 5.0 (95% confidence interval: 2.2, 7.8) more pregnancies per 100 women than was observed. It is good practice to estimate the natural course for model validation when using parametric models, but whether one should estimate a natural course contrast depends on the underlying research questions.

Natural course of untreated spinal cord cavernous malformations: a follow-up study within the initial 5 years after diagnosis

OBJECTIVE

Cavernous spinal cord malformations (SCMs) are believed to have a high rate of bleeding. The risk of intramedullary hemorrhage (IMH) or recurrent IMH and the neurological impact of bleeding events are important for clinical decision-making and could impact current treatment strategies.

METHODS

The authors screened their institutional database for patients with cavernous SCM treated between 2003 and 2020. Patients with complete MRI data sets and clinical baseline characteristics were included. Surgically treated patients were censored after cavernous SCM removal. Neurological functional status was obtained using the modified McCormick (MMcC) scale at diagnosis, first IMH, and second IMH. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for hemorrhage or rehemorrhage.

RESULTS

Seventy-one patients with cavernous SCM were analyzed. Cox regression analysis identified previous IMH (hazard ratio 7.86, 95% confidence interval 1.01-61.47, p = 0.049) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of bleeding or rebleeding was 41.3% for cavernous SCM. The MMcC score significantly deteriorated in 75% of patients after recurrent hemorrhage (p = 0.012).

CONCLUSIONS

During untreated 5-year follow-up, a considerably increased risk for hemorrhage or rehemorrhage was found in cavernous malformations of the spinal cord compared to cerebral cavernous malformations. Neurological function significantly deteriorates after the second bleeding. The probability of recurrent IMH increased significantly after initial presentation with hemorrhage.

Frequency and natural course of congenital cytomegalovirus-associated hearing loss in children

BACKGROUND

Congenital cytomegalovirus-associated hearing loss (cCMV-associated HL) is a common cause of congenital or early-onset deafness. Although cCMV infection has been reported to lead to various types of HL, the natural course of cCMV-associated HL over a long period is not yet known.

OBJECTIVES

To investigate the clinical phenotype of cCMV-associated HL in the largest study to date.

METHODS

Thirty-one CMV-positive children, diagnosed by examining CMV DNA extracted from their dried umbilical cords retrospectively, were divided into unilateral and bilateral HL groups, and their hearing ability was evaluated using pure-tone audiometry and auditory steady-state response over time.

RESULTS

Thirteen patients (41.9%) had unilateral HL and 18 (58.1%) had bilateral HL. In most cases of unilateral cCMV-associated HL, the ear with better hearing maintained a normal hearing threshold. Notably, in most cases of both unilateral and bilateral HL, the ear with worse hearing ultimately showed severe to profound HL.

CONCLUSION

Our findings revealed that the natural course of cCMV-associated HL was different between the cases of unilateral and bilateral HL, as well as between the ears with better or worse hearing in all cases. These findings indicate that accurate diagnosis could enable proper follow-up and management of cCMV-associated HL in children.

Controversials of Microscopic Colitis

Microscopic colitis (MC) has become a disease with increased awareness due to the availability of new data about the pathogenesis, diagnosis and therapy of this disease. The incidence of MC is increasing, reaching the incidence of the inflammatory bowel disease (IBD) in some populations. However, some aspects of MC are still controversial. It is unknown whether the changes of microbiome play a role in the pathogenesis and what is in the background of the different subtypes of disease that can transform into each other. Is there a connection between MC and IBD or why the histological changes do not follow the clinical activity? We do not know what the etiology of the incomplete MC is, and what its natural course is. The association of MC with celiac disease is well-known- is there a common pathogenesis? The MC treatment is budesonide. Its effectiveness is high, but the relapse rate is high, as well. Why would biologics be effective in these cases when budesonide is not? This mini-review makes an attempt to summarize the data about MC and highlight that there are still unanswered questions in the pathogenesis, diagnosis and therapy of the disease, which can initiate further investigations in the future.

The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale

BACKGROUND

A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership.

RESULTS

A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores.

CONCLUSION

Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.

The Natural Course of Serum D-Dimer, C-Reactive Protein, and Erythrocyte Sedimentation Rate Levels After Uneventful Primary Total Joint Arthroplasty

BACKGROUND

This study aimed to assess the baseline levels of D-dimer, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) and monitor the natural course of these serum markers after uneventful primary total joint arthroplasty.

METHODS

This prospective study enrolled 81 patients undergoing primary total knee arthroplasty or total hip arthroplasty. The level of serum D-dimer, CRP, and ESR was measured preoperatively and on postoperative days 1, 3, 5, 15, and 45. Mean peak values, peak times, and distribution were compared between D-Dimer, CRP, and ESR.

RESULTS

The mean preoperative serum D-dimer, CRP, and ESR level was 412 ± 260 (range 200-980) ng/mL, 2.93 ± 2.1 (range 1-18) mg/L, and 22.88 ± 17.5 (range 3-102) mm/h, respectively. The highest mean peak for D-dimer, CRP, and ESR was at postoperative day 1, 3, and 5, respectively.

CONCLUSION

D-dimer levels reached peak levels on postoperative day 1 and then declined rapidly to a plateau level by postoperative day 3. A second, albeit small, peak in the level of D-dimer occurred on postoperative day 15. The level of CRP and ESR remained elevated for much longer with CRP returning to baseline on postoperative day 45 and the level of ESR had not returned back to normal on postoperative day 45.

Natural-Course Evaluation of Infants with Positional Severe Plagiocephaly Using a Three-Dimensional Scanner in Japan: Comparison with Those Who Received Cranial Helmet Therapy

This study aimed to clarify the natural course of positional plagiocephaly using a three-dimensional (3D) scanner and investigate the effectiveness of cranial helmet therapy (CHT). One hundred infants with severe plagiocephaly who visited our institutions between April 2020 and March 2021 were included. Cranial shape was measured using an Artec Eva 3D scanner. A cranial asymmetry (CA) >12 mm was diagnosed as severe plagiocephaly. An infant whose CA subsided to <12 mm was considered to have improved naturally or by CHT. The difference in CA between the second and initial scans was defined as the improvement value (median scan interval was two months). In the natural-course group comprising 56 infants with severe plagiocephaly, 37 (66%) with a median CA of 15.6 mm exhibited no improvement after two months. In the scan age- and evaluation interval-matched case-control study, the CA value in the CHT group improved by three times that in the natural-course group (−4.6 mm [n = 33] vs. −1.55 mm [n = 24], p < 0.001). Severe plagiocephaly did not improve naturally in 66% of the cases. Therefore, CHT should be considered if the CA is >12 mm on the initial evaluation.

Symptomatic osteonecrosis of the hip and knee in patients with systemic lupus erythematosus: Prevalence, pattern, and comparison of natural course

OBJECTIVE

Osteonecrosis (ON), also known as avascular necrosis, is characterized by the collapse of the architectural bone structure secondary to the death of the bone marrow and trabecular bone. Osteonecrosis may accompany many conditions, especially rheumatic diseases. Among rheumatic diseases, osteonecrosis is most commonly associated with systemic lupus erythematosus (SLE). We assessed prevalence and distribution pattern of symptomatic ON in patients with SLE and compare the natural courses of hip and knee ON.

METHODS

912 SLE patients admitted between 1981 and 2012 were reviewed. SLE patients with symptomatic ON were retrospectively identified both from the existing SLE/APS database. The prevalence of symptomatic ON was calculated; with ON, the joint involvement pattern was determined by examining the distribution of the joints involved, and then the data about the hip and knee joints were entered in the Kaplan-Meier analysis. Kaplan-Meier methods were used to calculate 5- and 10-year rates of ON-related hip (the hip group) and knee survival (the knee group).

RESULTS

Symptomatic ON developed in various joints in 97 of 912 patients with SLE, and the overall prevalence of ON was detected as 10.6%. The mean age at the time of SLE and ON diagnoses were 27.9 ± 9.9 (14-53) and 34.2 ± 11.3 (16-62) years, respectively. The mean duration from diagnosis of SLE to the first development of ON was 70.7± 60.2 (range = 0-216) months. The most common site for symptomatic ON was the hips (68%, n=66), followed by the knees (38%, n = 37). According to Kaplan-Meier analysis, hip and knee joint survival rates associated with 5-year ON were 51% and 88%, and 10-year survival rates were 43% and 84%, respectively.

CONCLUSION

We observed that the prevalence of symptomatic ON in patients with SLE was 10.6%. With the estimated 10-year survival rates of 40% versus 84% for the hip and knee joints, respectively, hip involvement may demonstrate a more aggressive course to end-stage osteoarthritis than the knee involvement.

A Comprehensive Review of Tic Disorders in Children

Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.

Patterns of acute decompensation in hospitalized patients with cirrhosis and course of acute-on-chronic liver failure

INTRODUCTION

Recently, based on data from the PREDICT study, the European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium proposed pathophysiological/prognostic groups in hospitalized patients with cirrhosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-acute-on-chronic liver failure (pre-ACLF), and ACLF. We evaluated the outcomes of these subgroups in a real-life cohort of hospitalized patients with cirrhosis.

METHODS

Patients with cirrhosis developing first AD between 09/2010 and 12/2017 at the Vienna General Hospital were evaluated for this retrospective analysis.

RESULTS

Two hundred and ten patients with cirrhosis (aged 57.6 ± 11.8 years) including n = 45 (21.4%) SDC, n = 100 (47.6%) UDC, n = 28 (13.3%) pre-ACLF, and n = 37 (17.6%) with ACLF were considered. The proposed AD subgroups discriminated between patients with favorable (1-year mortality: SDC: 6.7% and UDC: 19.6%) and dismal prognosis (90-day mortality: pre-ACLF: 42.9%). Interestingly, systemic inflammation gradually increased (e.g., C-reactive protein, SDC: 0.9 mg/dl, vs. UDC: 2.0 mg/dl vs. pre-ACLF: 3.2 mg/dl, p < 0.001) while renal function was progressively deteriorating (creatinine levels, SDC: 0.8 mg/dl vs. UDC: 0.9 mg/dl vs. pre-ACLF: 1.2 mg/dl, p < 0.001) across prognostic subgroups in patients with cirrhosis.

DISCUSSION

The recently proposed pathophysiological/prognostic EF-CLIF subgroups are also reproduceable in a real-life cohort of cirrhotic patients. As ACLF is a common and important complication, patients at risk of pre-ACLF at index AD should be evaluated and if disease proceeds, been treated early and aggressively to avoid excessive mortality.

The natural course of COVID-19 patients without clinical intervention

The natural course of coronavirus disease 2019 (COVID‐19) patients without clinical intervention has not yet been documented. One hundred and fifty‐eight patients from two hospitals were enrolled to identify the indicators of severe COVID‐19 and observe the natural course of COVID‐19 patients without clinical intervention. The total computed tomography (CT) score, a quantitative score based on assessment of the number, quadrant, and area of the lesions in CT, tended to perform better than assessment based only on the number or area of the lesions (p = 0.0004 and p = 0.0887, respectively). Multivariate logistic regression showed that the total CT score, chest tightness, lymphocyte, and lactate dehydrogenase (LDH) were independent factors for severe COVID‐19. For patients admitted in 2 weeks from onset to hospitalization, the frequency of severe COVID‐19 was gradually increased with the delayed hospitalization. The symptoms of fatigue, dry cough, sputum production, chest tightness, and polypnea were gradually more frequent. The levels of C‐reactive protein, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, γ‐glutamyl transpeptidase, LDH, and d‐dimer were also gradually increased, as well as the scores based on CT. Conversely, the lymphocyte count and the albumin level were gradually decreased with the delayed hospitalization. Detail turning points of the above alterations were observed after 10–14 days from onset to hospitalization. Total CT score was a simple and feasible score for identifying severe COVID‐19. COVID‐19 patients without clinical intervention deteriorated gradually during the initial 10–14 days but gradually improved thereafter.

Present study developed a simple and feasible score based on CT to identify severe COVID‐19.

Present study was the first to investigate the natural course of COVID‐19 patients without clinical intervention.

COVID‐19 patients without clinical intervention deteriorated gradually during the initial 10‐14 days but gradually improved thereafter.

Prenatal ventriculomegaly: natural course, survival, and neurodevelopmental status

OBJECTIVE

Prenatal ventriculomegaly is classified as mild, moderate, or severe based on the atrium diameter. The natural course and intrauterine progression of mild and moderate ventriculomegaly associated with the neurodevelopmental status of these children has been widely reported.

METHODS

One hundred twenty-two pregnancies with mild and moderate ventriculomegaly referred to the pediatric neurosurgery clinic of Children's Medical Center between 2010 and 2018 were retrospectively studied. The authors collected demographic and first and sequential ultrasonographic information, associated abnormalities, information about pregnancy outcomes, and the latest developmental status of these children according to Centers for Disease Control and Prevention criteria by calling parents at least 1 year after birth.

RESULTS

The mean gestational age at the time of diagnosis was 29.1 weeks, and 53% of fetuses were female. The width of the atrium was registered precisely in 106 cases, in which 61% had mild and 39% had moderate ventriculomegaly. Information on serial ultrasound scans was collected in 84 cases in which ventriculomegaly regressed in 5, remained stable in 67, and progressed in 12 patients. Fourteen cases (29.7%) in the mild ventriculomegaly group and 6 cases (16.2%) in the moderate group had associated abnormalities, with corpus callosum agenesis as the most frequent abnormality. The survival rate was 80% in mild and 89.4% in moderate ventriculomegaly. Considering survival to live birth and progression of the ventriculomegaly, the survival rate was 100% in regressed, 97% in stable, and 41.6% in progressed ventricular width groups (p < 0.001). Neurodevelopmental status was evaluated in 73 cases and found to be normal in 69.8% of the cases; 16.4% of children had mild delay, and 5.4% and 8.2% of cases were diagnosed with moderate and severe delays, respectively.

CONCLUSIONS

In spite of a high rate of missed data in our retrospective study, most patients with mild or moderate ventriculomegaly had a stable or regressed course. Most cases had near-normal developmental status. Prospective studies with a larger sample size and detailed developmental evaluation tests are needed to answer the questions related to the natural course, survival, and prognosis of prenatal ventriculomegaly.

Long-term disease course of two patients with multiple sulfatase deficiency differs from metachromatic leukodystrophy in a broad cohort

Multiple sulfatase deficiency (MSD) is a lysosomal storage disease caused by a deficiency of formylglycine-generating enzyme due to SUMF1 defects. MSD may be misdiagnosed as metachromatic leukodystrophy (MLD), as neurological and neuroimaging findings are similar, and arylsulfatase A (ARSA) deficiency and enhanced urinary sulfatide excretion may also occur. While ARSA deficiency seems a cause for neurological symptoms and later neurodegenerative disease course, deficiency of other sulfatases results in clinical features such as dysmorphism, dysostosis, or ichthyosis. We report on a girl and a boy of the same origin presenting with severe ARSA deficiency and neurological and neuroimaging features compatible with MLD. However, exome sequencing revealed not yet described homozygosity of the missense variant c.529G > C, p.Ala177Pro in SUMF1. We asked whether dynamics of disease course differs between MSD and MLD. Comparison to a cohort of 59 MLD patients revealed different disease course concerning onset and disease progression in both MSD patients. The MSD patients showed first gross motor symptoms earlier than most patients with juvenile MLD (<10th percentile of Gross-Motor-Function in MLD [GMFC-MLD] 1). However, subsequent motor decline was more protracted (75th and 90th percentile of GMFC-MLD 2 (loss of independent walking) and 75th percentile of GMFC-MLD 5 (loss of any locomotion)). Language decline started clearly after 50th percentile of juvenile MLD and progressed rapidly. Thus, dynamics of disease course may be a further clue for the characterization of MSD. These data may contribute to knowledge of natural course of ultra-rare MSD and be relevant for counseling and therapy.

Serum vitamin D level is related to disease progression in primary biliary cholangitis

BACKGROUND AND AIM

A nonskeletal role of vitamin D in primary biliary cholangitis (PBC) patients is not yet clear. The purpose of this study is to investigate the serum vitamin D level in patients with PBC and to explore whether serum vitamin D level is related to disease progression.

METHODS

The serum levels of 25(OH)D₃ were measured in 185 PBC patients and 141 healthy controls. The association with vitamin D levels and disease progression, particularly natural course, was assessed.

RESULTS

Serum vitamin D levels were measured in 185 patients with PBC. The mean level of vitamin D in advanced stage patients was lower than that in early stage patients (9.15 ± 5.33 ng/ml vs. 13.68 ± 6.33 ng/ml, p = .000). In the follow-up patients, the vitamin D level in the taken calcitriol patients showed an upward trend, while the un-taken calcitriol patients was opposite. Besides, vitamin D levels were correlated with the changes of bilirubin, albumin (ALB) and APRI (p<.05). PBC patients with vitamin D deficiency had higher bilirubin levels and lower ALB levels (p<.05). Moreover, there were differences in serum vitamin D levels between taken calcitriol patients and un-taken calcitriol patients (p = .027).

CONCLUSIONS

Vitamin D deficiency is highly prevalent in PBC patients. The decrease of vitamin D levels may indicate disease progression in PBC. PBC patients need to be regularly measured for serum vitamin D level and take appropriate vitamin D supplementation.

Radiographic Follow-Up of Fibrous Dysplasia in 138 Patients

OBJECTIVE. The purpose of this study was to explore the temporal changes in fibrous dysplasia (FD) at radiographic follow-up. MATERIALS AND METHODS. A total of 138 patients with FD who had undergone extremity radiography at least twice with a minimum 12-month interval between examinations were enrolled in this study. FD was monostotic in 99 patients and polyostotic in 39 patients. Patients were also classified according to skeletal maturity as follows: Patients 16 years old or younger were classified in the skeletally immature group (n = 34), and patients 17 years old or older were classified in the skeletally mature group (n = 104). We compared the initial and follow-up radiographs for the following findings: lesion size, opacity, sclerotic rim, calcification, and trabeculation. RESULTS. Of the 138 patients, radiographic follow-up showed no change in lesion size in 101 patients (73.2%), progression in 31 (22.5%), and regression in six (4.3%). FD in immature bones progressed more often than FD in mature bones (23/34 [67.6%] vs 8/104 [7.7%], respectively; p = 0.000), and polyostotic FD had a greater chance of regressing than monostotic FD (4/39 [10.3%] vs 2/99 [2.0%]; p = 0.032). A temporal change in FD lesion opacity was noticed in a minority of patients (19/138, 13.8%). Variable changes were observed in the sclerotic rim, calcification, and trabeculation. CONCLUSION. The radiographic follow-up of FD showed that approximately a quarter of lesions changed in size over time. Regardless of the change in lesion size, opacity and several morphologic features of FD changed during the follow-up period, which might reflect the histopathologic evolution of FD.

Glenohumeral Osteoarthritis: An Overview of Etiology and Diagnostics

BACKGROUND AND AIMS

Osteoarthritis (OA) is the world's most common joint disease and there is currently no cure. Glenohumeral osteoarthritis (GHOA) accounts for an estimated 5% -17% of patients with shoulder complaints. The etiology of GHOA is multifactorial, and we review the various non-specific and specific risk factors and further sub-classify them into local and systemic factors.

MATERIALS AND METHODS

Data for this review article were identified by searches of MEDLINE, PubMed, and references from relevant articles using search terms such as "glenohumeral," "osteoarthritis," "epidemiology," "etiology," "imaging," and "pathophysiology." Only articles published in English, German, and Finnish between 1957 and 2017 were included.

RESULTS

The prevalence of radiological shoulder OA has been estimated to be as high as 16% -20% in the middle-aged and elderly population, but the concordance between structural findings and symptoms seems to be weak, as many of these individuals are asymptomatic. The vast majority of GHOA is related to non-specific factors, namely advancing age, while specific risk factors are commonly found in young patients. Diagnosis of GHOA is made when typical clinical features and defined radiological findings overlap in an individual.

CONCLUSION

Ultimately the determinants of shoulder pain in GHOA remain incompletely understood. Improved understanding of the etiology and diagnosis of GHOA will enable clinicians to better determine which patients will benefit from different treatment modalities, as well as provide new avenues to potential treatments.

The natural course of and risk factors for tear progression in conservatively treated full-thickness rotator cuff tears

BACKGROUND

The natural course of and risk factors for tear progression in full-thickness rotator cuff tears (FTRCTs) have not been clarified yet. The study's purpose was to retrospectively evaluate tear progression in FTRCTs by using magnetic resonance imaging (MRI) and to identify risk factors that are relevant to such tear progression.

METHODS

Between June 2010 and September 2019, a total of 345 patients with FTRCTs who had been diagnosed via MRI were treated conservatively. Of these, 48 patients who underwent post-treatment follow-up MRI were retrospectively enrolled. Tear progression was defined as significant when the tear size increased by >5 mm.

RESULTS

The mean MRI follow-up duration was 22 ± 14 months (range, 12-65 months). Among the 48 patients (mean age, 69 years; range, 53-81), 26 (54%) and 20 (41%) showed medial-lateral (M-L) and anterior-posterior (A-P) tear progression on MRI follow-up. Multivariate analysis revealed that MRI follow-up duration (P = .011), diabetes mellitus (P = .017), and infraspinatus muscle atrophy (P = .011) were independent risk factors for tear progression in the A-P plane. A high critical shoulder angle (P = .011) and supraspinatus (P = .024) and infraspinatus (P = .020) muscle atrophy were risk factors associated with M-L tear progression.

CONCLUSION

Among the assessed patients, a considerable number of FTRCTs increased in size during the follow-up period. Severe infraspinatus muscle atrophy was the independent risk factor for exacerbation of A-P and M-L tear progression.

Spontaneous resolution of acute syphilitic posterior placoid chorioretinitis: reappraisal of the literature and pathogenetic insights

Acute syphilitic posterior placoid chorioretinitis (ASPPC) is a rare clinical manifestation of ocular syphilis. Spontaneous resolution of this condition has been reported in a few cases. The aim of this manuscript is to report an additional case and to discuss the possible pathogenesis of this condition by reviewing the current evidence on this subject. A 45-year-old man presented to us with decreased vision in the right eye secondary to a placoid macular lesion. Fourteen days after presentation, there was a dramatic improvement of the vision, and multimodal retinal imaging showed almost complete spontaneous resolution of the placoid lesion. Syphilis serology turned out positive and a diagnosis of ASPPC was made. The pathogenesis of ASPPC is unclear, and there is contrasting evidence about the role of the cellular immune system. Since this condition may resolve spontaneously before systemic antimicrobial treatment, the presence of a placoid macular lesion should raise a high suspicion of ASPPC in order to make a timely diagnosis and to avoid progression of untreated syphilis.

Pathogenesis, clinical course, and recent issues in HIV-1-infected Japanese hemophiliacs: a three-decade follow-up

Nearly 30% of Japanese hemophiliacs were infected with HIV-1 in the early 1980s. They have unique characteristics compared to HIV-1-infected individuals through other routes, including date of infection of 1986 or earlier, mean age of nearly 50 years, and common co-infection with hepatitis C, but rarely with other sexually transmitted diseases. Antiretroviral therapy (ART) was introduced in Japan in 1997. The clinical courses before and after 1997 were quite different. Careful analysis of the pre-1997 clinical data allowed expansion of our knowledge about the natural course and pathogenesis of the disease. Switching to the second receptor agents proved critical in subsequent disease progression. HIV-1 continued to escape immune pressure, pushing disease progression faster. In contrast, ART was effective enough to overcome the natural course. Prognosis improved dramatically and cause of death changed from AIDS-related opportunistic infections and malignancies before 1997, to hepatitis C virus-related cirrhosis and hepatocellular carcinoma (HCC) around 2010, and again to non-AIDS defining malignancies recently. In most cases, hepatitis C was cured with direct acting antiviral therapy. However, HCV progressed to cirrhosis in some cases and risk of HCC is still high among these patients. Together with improvement in anticoagulants and aging of the patients, risk of myocardial infarction has increased recently. In addition, the numbers of patients with life-style related co-morbidities, such as diabetes mellitus, hypertension, and chronic kidney disease have been also increasing. Finally, stigma is still an important barrier to a better life in HIV-1-positive individuals.

Human Case Infected With Babesia venatorum: A 5-Year Follow-Up Study

Background

Human babesiosis is a common zoonosis caused by Babesia and is attracting an increasing concern worldwide. The natural course of babesiosis infection and how the human immune system changes during the course of babesiosis infection are not clear.

Methods

We followed up 1 case infected with Babesia venatorum for 5 years. The patient was immune-intact and received no standard treatment. Clinical data were obtained from medical records. Microbiological tests, ribonucleic acid (RNA) sequence, and serum cytokines and chemokines were detected at different time points.

Results

The patient was confirmed as B venatorum infection based on his tick-bite history, clinical manifestations, and positive results of microbiological tests. The parasitemia of the patient persisted for approximately 2 months. With flu-like symptoms aggravating, most cytokines and chemokines in RNA and protein levels increased progressively and reached the peak when fever occurred; and their concentrations decreased to baseline during the same time as clearance of babesia parasites.

Conclusions

Babesia venatorum infection could take a mild self-limited course in immune-intact individuals. The natural changes of most cytokines and chemokines demonstrated very similar trends, which correlated with blood parasitemia and clinical manifestations. Cytokine profiles involving multiple inflammatory cytokines might be a good indicator of babesia infection.

Incidence and natural course of CT-detected pulmonary ground-glass nodules in Chinese women with breast cancer: a retrospective, single-center, long-term follow-up study in 4682 consecutive patients

Background

Increased use of thin-section computed tomography (CT) scans has revealed that small lung nodules, termed ground-glass nodules, are frequent in primary breast cancer patients and are associated with pre-invasive or invasive pulmonary adenocarcinomas. However, little is known of the incidence and fate of ground-glass nodules.

Purpose

To elucidate the incidence and natural course of CT-detected pulmonary ground-glass nodules in Chinese women with breast cancer.

Material and Methods

We retrospectively reviewed data from female breast cancer patients who underwent lung CT scans and who were followed for ≥3 months after the initial scan to identify the incidence of ground-glass nodules and any changes in them during the follow-up period.

Results

Between January 2008 and April 2018, 693 out of 4682 breast cancer patients (14.8%) had persistent lung ground-glass nodules as detected by CT scan. The median age was 52 years (interquartile range [IQR] = 45–62 years). Median nodule size was 4.9 mm in diameter on initial CT scan. Frequency of growth was 7.5% (52/693 patients). Median volume doubling time was 1092 days (IQR = 719–1808 days) for 39 growing in size nodules. Initial nodule size, nodule type, and follow-up period were independent predictors of nodule growth.

Conclusion

Most pulmonary ground-glass nodules in breast cancer patients were stable during long-term follow-up; most growing nodules had an indolent clinical course, suggesting that nodules should be monitored until growth is detected. This information is clinically relevant for accurate diagnosis of cancer stage and for appropriate treatment plans for patients with lung ground-glass nodules.

Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI

BACKGROUND

Asymptomatic acromioclavicular osteoarthritis (AC-OA) is a frequent finding in shoulder magnetic resonance imaging (MRI). Its natural course is unknown. Therefore, the question arises whether a resection should be performed simultaneously with shoulder surgery for another reason to prevent future pain and reoperation. The purpose of this study was to investigate the mid-term course of asymptomatic AC-OA.

METHODS

Overall, 114 asymptomatic AC-OA diagnosed on MRI were followed for 7 years between 2011 and 2018. At baseline, MRI signal enhancement in the clavicle and acromion, OA grade, physical demand as well as the parameters (1) Constant Score Visual Analogue Scale, (2) pain on AC-joint compression, and (3) cross-body adduction test were measured. All patients were followed up after 7 years by interview, and in case of symptoms by clinical examination. The endpoint "deterioration" was reached if 2 of the 3 parameters turned worse.

RESULTS

Asymptomatic AC-OA remained asymptomatic in 83% of cases, 7% turned better, 10% turned worse. Physical demand and osteoarthritis grade increased the risk of deterioration, whereas MRI signal enhancement in the clavicle or acromion had no influence on outcome. During follow-up, the frequency of pain on AC-joint compression increased from 11% to 16% (P = .24), the frequency of a positive cross-body adduction test increased from 6% to 20% (P = .017), and the mean Constant Score Visual Analogue Scale increased from 10 to 13 points (P < .001) indicating less pain.

CONCLUSIONS

Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. A simultaneous resection of an asymptomatic AC-OA during shoulder surgery for another reason is not indicated in every patient.

Natural course of acquired pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation-Is routine follow-up imaging indicated or not?

INTRODUCTION

Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). The aim of the present study was to analyze the natural course of RFA-induced PVS with regard to the grade of stenosis, clinical symptoms, and mortality during long-term follow-up.

METHODS AND RESULTS

All patients with follow-up imaging for radiofrequency-induced untreated PVS were retrospectively assessed. From 2004 to 2017, the total rate of PVS following AF ablation in our center was 0.78% (87 of 11 103). Thirty-eight patients with a total of 54 untreated PVS underwent follow-up including imaging scan. The mean degree of stenosis at the time of diagnosis was 57% ± 27% vs 45% ± 35% (P = .05) after a mean follow-up of 43 ± 31 months. There was a shift in severity of the PVS: 18 of 54 (33%) vs 16 of 54 (30%) severe PVS, 19 of 54 (35%) vs 10 of 54 (18%) moderate PVS, and 17 of 54 (32%) vs 28 of 54 (52%) mild PVS (P = .0001). The mean symptom score decreased significantly during follow-up (1.8 ± 1.0 vs 0.4 ± 0.5, P = .0001). Each of the four patients with progression of PVS underwent another pulmonary vein isolation for AF recurrence following pulmonary vein reconduction during follow-up period.

CONCLUSION

This study showed a spontaneous reduction in stenosis grade and symptoms of PVS over a 3.5-year follow-up. Consequently, routine follow-up imaging of PVS seems not to be necessary. However, additional RF energy delivery to stenotic pulmonary veins should be avoided if possible. In case of conduction recovery, the ablation line should be done wide-antrally and follow-up imaging of PVS is recommended.

Natural course of isolated mild congenital hydronephrosis: A 2-year prospective study at a single center in Japan

OBJECTIVES

To determine a follow-up plan for mild congenital hydronephrosis in Japanese individuals.

METHODS

Neonates at Kansai Medical University Hospital (Hirakata, Osaka, Japan) who were diagnosed with mild congenital hydronephrosis - defined as a Society for Fetal Urology grade 1 or 2 - at 1-month old by abdominal ultrasonography between 2014 and 2016 were enrolled. These patients were encouraged to undergo repeated abdominal ultrasonography for 2 years every 3 months to investigate the course of congenital hydronephrosis.

RESULTS

Among 1009 neonates, congenital hydronephrosis was detected in 118 affected renal units of 100 (9.9%) patients. According to the definition of the Society for Fetal Urology, 118 affected renal units were graded as grade 1 in 87 (74%), grade 2 in 30 (25%), grade 3 in one (1%) and grade 4 in 0 units. Among them, 117 affected renal units of mild congenital hydronephrosis comprising grades 1 and 2 were subjected to ultrasonographic evaluation to monitor the natural course. The rates of resolution at 7, 10, 13, 16, 19, 22 and 25 months after birth in Society for Fetal Urology grades 1 and 2 cases were 60% and 8%, 77% and 19%, 90% and 32%, 92% and 40%, 95% and 52%, 96% and 56%, and 99% and 60%, respectively.

CONCLUSIONS

Grade 1 congenital hydronephrosis does not need to be followed up, because it mostly shows spontaneous resolution by 2 years of follow up without any complications. However, ultrasonographic examinations at 1-year intervals for grade 2 congenital hydronephrosis are recommended to determine the subsequent follow-up plan of patients.

Spontaneous clearance of urogenital, anorectal and oropharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae in women, MSM and heterosexual men visiting the STI clinic: a prospective cohort study

OBJECTIVE

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections can clear without treatment. Despite high prevalence of anorectal infections in men who have sex with men (MSM) and women, studies on anorectal clearance are scarce. Moreover it is unknown whether bacterial load affects urogenital/anorectal CT clearance. In this prospective cohort study, CT and NG clearance is assessed at three anatomical sites of men and women.

METHODS

CT-positive and NG-positive MSM, heterosexual men and women ≥18 years of age visiting our STI clinic between 2011 and 2013 underwent a repeat test when returning for treatment (n=482). The primary outcome was clearance, defined as a positive nucleic acid amplification test (NAAT) at screening-consultation, followed by a negative NAAT at treatment-consultation. Sociodemographics, sexual risk behaviour and CT bacterial load (inhouse quantitative PCR) were tested as determinants for clearance using multivariable logistic regression for CT and Fisher's exact test for NG.

RESULTS

CT clearance was 9.1% (10/110) for urine, 6.8% (20/292) for vaginal swabs, 12.7% (8/63) for anorectal swabs (ie, 4.0% [1/25] in MSM and 18.4% [7/38] in women) and 57.1% (4/7) for oropharyngeal swabs. For NG this was 33.3% (2/6), 28.6% (2/7), 20.0% (2/10) and 27.3% (6/22), respectively. The number of days between tests (median 10, IQR 7-14) was not associated with clearance. Lower bacterial load at screening was the only predictor for CT clearance (urine mean 1.2 vs 2.6 log CT/mL, p=0.001; vaginal swabs mean 2.1 vs 5.2 log CT/mL p<0.0001; anorectal swabs mean 2.0 vs 3.7 log CT/mL, p=0.002). None of the tested determinants were associated with NG clearance.

CONCLUSIONS

This study reports the largest number of anorectal infections tested for CT and NG clearance to date. Clearance in all sample types was substantial: between 7% and 57% for CT, and between 20% and 33% for NG (notwithstanding low absolute numbers). CT clearance was associated with a lower load at screening. However, not all individuals with low bacterial CT load cleared the infection, hampering STI guideline change.

Cyclosporine Therapy in Patients with Transfusion-independent Non-severe Aplastic Anemia: A Retrospective Analysis

Objective The therapeutic approach for transfusion-independent non-severe aplastic anemia (NSAA) is undetermined. This study aimed to investigate the efficacy of immunosuppressive therapy (IST) for NSAA. Methods We retrospectively reviewed 42 consecutive patients with transfusion-independent NSAA. NSAA was further divided into two stages according to the degree of cytopenia. Progression was defined as transition to a transfusion-dependent state. Results Twelve (29%) patients received IST with cyclosporine A (CsA). Eleven (26%) patients became transfusion-dependent. In all patients, a univariate analysis revealed that a low hemoglobin level (p=0.006) and low reticulocyte count (p=0.005) were associated with a high probability of progression. The estimated transfusion-free survival (TFS) was significantly prolonged by IST among patients with advanced-stage NSAA (p=0.002), while IST did not reduce the incidence of progression in the overall cohort (p=0.349). In the non-IST group, an advanced clinical stage was significantly associated with progression (p=0.003). In contrast, the clinical stage was not related to progression in the IST group (p=0.318). None of the patients had to discontinue treatment with CsA due to renal failure. Conclusion IST is expected to be effective in patients with advanced-stage NSAA.

Increasing challenges of inflammatory bowel disease in a Turkish cohort (2006-2016)

BACKGROUND

We aimed to describe the natural course of inflam-matory bowel disease (IBD) in adult Turkish patients during the past decade.

METHODS

We performed a retrospective investigation in total 508 patients with IBD between 2006 and 2016. The severity of IBD was assessed by the need for hospitalization, biological therapy and surgery. The study consisted of 304 (59.8%) patients with UC, 180 (35.4%) with CD and 24 (4.7%) IBD unclassified patients. The ratio of severe disease for both CD and UC was as follows: hospitalization in 71 (39.4%) and 37 (12.2%), biological therapy received in 20 (11.1%) and 3 (1.0%), and surgery in 23 (12.8%) and 2 (0.7%) respectively. Patients were divided into two groups based on the date of disease onset. Earlier group includes the patients followed-up between 2006-2011 and later group, between 2011-2016. Our results revealed that the proportion of patients receiving biological therapies was significantly higher and the rate of surgery was significantly lower in the later group compared to the earlier group (14.5% to 0%, 9.4 to 23.8, respectively). The hospitalization rate was lower in the later group compared to earlier group but did not reach a significant difference (37.7% to 45.2% respectively).

CONCLUSIONS

The course of IBD in Turkish patients appears to be between that of Europe and Asia. In patients with CD, proportion of patients receiving biologic therapy has increased while rate of surgery has decreased.

The natural history of children with joint hypermobility syndrome and Ehlers-Danlos hypermobility type: a longitudinal cohort study

Objectives

The objective of the manuscript was to describe the natural history of complaints and disability in children diagnosed with joint hypermobility syndrome (JHS)/Ehlers-Danlos-hypermobility type (EDS-HT) and to identify the constructs that underlie functional decline.

Methods

One hundred and one JHS/EDS-HT children were observed over 3 years and assessed at three time points on the following: functional impairments, quality of life, connective tissue laxity, muscle function, postural control and musculoskeletal and multi-systemic complaints. Cluster analysis was performed to identify subgroups in severity. Clinical profiles were determined for these subgroups, and differences were assessed by multivariate analysis of covariance. Mixed linear regression models were used to determine the subsequent trajectories. Finally, an exploratory factor analysis was used to uncover the underlying constructs of functional impairment.

Results

Three clusters of children were identified in terms of functional impairment: mild, moderately and severely affected. Functional impairment at baseline was predictive of worsening trajectories in terms of reduced walking distance and decreased quality of life (P ⩽ 0.05) over 3 years. Multiple interactions between the secondary outcomes were observed, with four underlying constructs identified. All four constructs (multi-systemic effects, pain, fatigue and loss of postural control) contributed significantly to disability (P ⩽ 0.046).

Conclusion

Children diagnosed with JHS/EDS-HT who have a high incidence of multi-systemic complaints (particularly, orthostatic intolerance, urinary incontinence and diarrhoea) and poor postural control in addition to high levels of pain and fatigue at baseline are most likely to have a deteriorating trajectory of functional impairment and, accordingly, warrant clinical prioritization.

IgG4-related Hypophysitis with Subtle Hypopituitarism in an Elderly Diabetic Patient: Is Treatment or Observation Preferable?

A 70-year-old man with diabetes mellitus presented with an enlarged pituitary stalk in 2014. IgG4-related parotitis and submandibular sialoadenitis were diagnosed in 2012. He denied any symptoms related to a pituitary mass. His visual field was intact, and his hypopituitarism was subtle. The serum IgG4 level was elevated. A lip biopsy revealed strong fibrosis and hyper-infiltration of IgG4-positive plasma cells. Based on these findings, IgG4-related hypophysitis was diagnosed. The patient was carefully followed without specific intervention. His clinical condition showed no change until December 2016, suggesting a stable, natural course. Care should be taken when considering glucocorticoid therapy, especially for elderly diabetic patients, given possible side effects.

Natural Course of Euthyroidism and Clues for Early Diagnosis of Thyroid Dysfunction: Tehran Thyroid Study

OBJECTIVE

Considering the limited data available on the natural course of euthyroidism, this study was designed to evaluate the progression in time from euthyroidism to subclinical or overt hypo- or hyperthyroidism.

METHODS

This study was conducted within the framework of the Tehran Thyroid Cohort Study, in which 5783 individuals aged 40.4 ± 0.2 years were followed for six years. The overall loss to follow-up rate was 8.3%. After applying exclusion criteria, data of 4204 euthyroid subjects remained for analysis of a six-year natural course analysis. Thyroid function tests, clinical characteristics, and metabolic characteristics were assessed at baseline and every three years.

RESULTS

The annual incidence rates [confidence intervals (CI)] of subclinical and overt hypothyroidism were 7.62 [CI 7.39-7.85) and 2.0 [CI 1.94-2.06] per 1000 persons, respectively. For thyroid hyperfunction, the annual incidence rates of subclinical and overt hyperthyroidism were 0.92 [0.90-0.95) and 0.68 [0.66-0.70) per 1000 persons, respectively. Euthyroid persistency was 93.24% during 6 years. Predictive factors for conversion to thyroid dysfunction were thyrotropin, free thyroxine and thyroid peroxidase antibody levels, sex, and smoking. Criteria for early diagnosis of hypothyroidism (i.e., sensitivity of 94% and specificity of 82%, p < 0.0001) were obtained based on baseline and three-year follow-ups of thyroid function tests and thyroid peroxidase antibody. Early diagnosis of hypothyroidism was significantly associated with impaired glucose tolerance (relative risk with 3.03 [CI 1.36-6.75]; p = 0.007), high cholesterol (relative risk 2.46 [CI 1.45-4.18]; p = 0.001), obesity (relative risk 2.92 [CI 1.64-5.2]; p < 0.001), and hypertension (relative risk 1.68 [CI 1.53-1.84]; p < 0.04).

CONCLUSION

This study shows that after a six-year follow-up in an iodine sufficient area, 6.7% of euthyroid subjects were found to progress to thyroid dysfunction, in particular subclinical hypothyroidism.