Osteochondroma or exostosis is a bony developmental anomaly, which arises from exophytic outgrowth on bone surfaces in a characteristic manner. Osteochondroma is asymptomatic and grows away from the nearby joint. This paper reports an unusual presentation of osteochondroma in which the patient was surprisingly completely symptomatic. The lesion grew toward the nearby joint and the radiographic findings were not compatible with surgical findings
Knee joint; osteochondroma; radiography
Proper placement of central venous catheter (CVC) tip could reduce early and late catheter-related complications. Although the live fluoroscopy is standard of care for placement of the catheter, it is not available in many centers. Therefore, the present study evaluated the sensitivity and specificity of bedside chest X-ray (CXR) for proper positioning of the catheter tip.
Materials and Methods:
A total of 82 adult patients undergoing elective placement of tunneled CVC were enrolled in this study during 2010-2012. The catheter tip position was evaluated by postoperative bedside chest radiographs as well as trans-thoracic echocardiogram as definite diagnostic tool. The catheter position was considered correct if the tip was positioned in the right atrium both in CXR or echocardiography. Finally, CXRs interpreted by expert radiologist. Thus findings were compared by echocardiography. Sensitivity, specificity, accuracy, positive, and negative predictive values were calculated. Data were analyzed using SPSS version 16 (SPSS Inc., Chicago, IL), and P < 0.05 considered as significant.
The patients were 57.37 ± 18.91 years of age, weighed 65.79 ± 15.58 kg and were 166.36 ± 9.91 cm tall. Sensitivity and specificity of CXR for proper catheter tip position were 74.3% and 58.3%, respectively. Positive and negative predictive values were 91.2% and 28%. In addition accuracy, positive likelihood ratio, and negative likelihood ratio were 71.9%, 1.78, and 2.27 respectively.
Bedside CXR alone does not reliably predict malpositioning after CVC placement.
Chest X-ray; hemodialysis; tunneled central catheter
Magnetic resonance cholangiography (MRC) has gained popularity for diagnosing primary sclerosing cholangitis (PSC). We determined the accuracy of MRC compared with endoscopic retrograde cholangiography (ERC) for diagnosing PSC.
Materials and Methods:
This retrospective case-control study was conducted on patients referred to an outpatient gastroenterology clinic from 2001 to 2013. Patients with established diagnosis of PSC who had undergone MRC and ERC within a 6-month interval were included. Controls were selected from patients who had undergone imaging for reasons other than PSC evaluation. Disease outcome at the study time and liver biochemistry data at diagnosis and 1-year thereafter were retrieved. Diagnostic accuracy of MRC in comparison with ERC was evaluated.
A total of 46 definite PSC patients (age at diagnosis = 36.8 ± 11.6 years, 33 male) were found. Diagnostic imaging for PSC was ERC alone in 12, MRC alone in 23, and ERC plus MRC in 11 patients. Controls were 89 patients mostly with bile stones. The sensitivity, specificity, and positive and negative likelihood ratios of MRC was 90.9%, 95.5%, 20.23, and 0.10, respectively. Early PSC was found more frequently by MRC compared with ERC (30.4% vs. 8.3%, P = 0.146). No significant difference was found between imaging modalities with regards to patients’ outcome (P = 0.786) or liver biochemistry at diagnosis or 1-year thereafter (P >0.05).
Starting diagnostic imaging for PSC with MRC seems better and may provide diagnosis of PSC at its earlier phase. Further studies with larger sample of patients and longer follow-ups are warranted.
Cholangiography; diagnosis; magnetic resonance imaging; sclerosing cholangitis; sensitivity; specificity
Neurofibromas are rare, benign, nerve sheath tumors in the peripheral nervous system. The solitary type is found in those who do not have neurofibromatosis. Solitary neurofibromas are too rare in the giant type. We report a rare case of a solitary giant neurofibroma of the anterior right thigh. The diagnostic criteria, characteristics of imaging studies, and operative approach are represented.
Giant; lower extremity; neurofibroma; solitary; thigh
Alzheimer's disease (AD) is a neurodegenerative disease with atrophic changes in the temporal lobe. Enlargement of cerebrospinal fluid (CSF) spaces, hippocampal sulcus (HS) enlargement, or an increase in the number or size of hippocampal cavities (HCs) could be associated with medial temporal lobe atrophy (MTA). In this study, we assessed the relation of these CSF spaces with AD.
Materials and Methods:
A total 36 demented patients with diagnosis of Alzheimer (Mini-Mental State Examination (MMSE) ≤25) and 36 non-demented elderly individuals were referred for basic magnetic resonance imaging (MRI) before initiating anti-dementia therapy in the demented group. Two observers assessed the maximal HS width, as well as the occurrence, number, and size of HCs, and the visual rating score of MTA on magnified coronal high-resolution T1-weighted MR images.
The findings of our study indicate that the presence of hippocampal cavity (HC) (especially in the left side) and medial temporal lobe atrophy in demented patients was significantly higher in comparison with non-demented elderly subjects (P ≤ 0.05). There was a significant relationship between MTA and HS width (P = 0.003, r = 0.00323), and it also had a trend to be significant with size of HCs (P = 0.08, r = 0.00314). A correlation between MTA and number of HCs was not detected.
HS width is associated with MTA in patients with AD. It may serve as a measure to evaluate MTA for identifying individuals at particularly high risk for Alzheimer progression, and could be employed for selecting subjects for clinical trials or for treatment decisions.
Alzheimer's disease; hippocampal cavities; hippocampal sulcus; magnetic resonance imaging
Azygos vein aneurysm is a rare cause of a posterior or paratracheal mediastinal mass. Trauma or conditions causing elevated ﬂow or pressure in the azygos system, such as cardiac failure or cirrhosis of the liver are secondary causes of aneurysm of the azygos vein. We report a case of asymptomatic saccular aneurysm of the azygos vein in a 45-year-old man with blunt minor chest trauma. The azygos vein aneurysm was managed by conservative treatment.
Azygos Vein; Aneurysm; Mediastinum; Tomography, X-Ray Computed; Magnetic Resonance Angiography
Tracheal chondrosarcoma is a rare malignant mesenchymal tumor and there are less than 15 reports in the literature. We report a rare case of laryngotracheal chondrosarcoma in a 74-year-old man. He gave a history of radioiodine therapy for thyroid papillary carcinoma about 24 years ago. Diagnostic steps, histological presentation, and therapy are described in detail.
Radioiodine therapy; thyroid cancer; tracheal chondrosarcoma
To evaluate the association of apolipoprotein B (apoB), apolipoprotein A (apoA), and apoB/apoA ratio with the body fat indicators in patients with stable angina pectoris (SA).
Materials and Methods:
One hundred and twenty two participants aged 40-60 years old, with a mean age of 52.1 ± 7.2 years and SA, were recruited for the present study. Body weight, height, and waist circumference (WC) were measured, and waist to height ratio (WHtR) was calculated. After 12 hours of fasting, a blood sample was obtained and serum levels of apoB and apoA were measured and the apoB/apoA ratio was calculated. These patients underwent an abdominal computerized tomography scan (CTS) to assess visceral and subcutaneous adipose tissue (VAT, SAT). Linear regressions were computed to assess the relation of apoB, apoA, and their ratio with various measurements of adiposity (VAT, SAT, WC, and WHtR), with adjustment for age, sex, and BMI ≥ 25, WC ≥ 80 in women and WC ≥ 90 in men and WHtR ≥ 0.59.
From totally 123 patients with SA with a mean age of 52.1 ± 7.2 years, 44.7% male and 55.3% women were entered. Significant positive associations were found between visceral fat area and the apoB/apoA ratio (P = 0.02, β = 0.2), and significant negative correlations were observed between visceral fat area and apoA concentrations (P = 0.04, β = −0.2).
As abdominal fat accumulation is associated with other risk factors such as apolipoproteins in ischemic patients, then we most focus on control of these factors.
Apolipoprotein A; apolipoprotein B; apolipoprotein B/apolipoprotein A; cardiovascular disease; intra-abdominal fat
The aim of the present study is to evaluate the accuracy of 64-multidetector-row computed tomography angiography (CTA) in comparison to conventional invasive angiography (CIA) in the diagnosis of significant stenosis (≥ 50%) of coronary artery tree.
Assessment of CTA in the detection of coronary artery disease (CAD) was performed in patients referred because of symptoms or stress studies suggestive of ischemia. For this purpose, among more than 1000 cases of coronary CTA in a 20 months period a study population of 54 patients suspected to have significant stenosis of the coronary artery tree was investigated. The CIA procedure was performed in these patients one month after CTA. The accuracy of CTA in detecting significant stenosis was compared to CIA.
For vessel based analysis of 179 coronary vessels, CTA had a sensitivity of 96%, specificity of 87.5%, positive predictive value of 90.5%, and negative predictive value of 94.6%. For patient-base analysis, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CTA were 97.9%, 28.6%, 66.6%, and 90.2%, respectively.
The findings of this study reveal that CT angiography with 64-slice scanner could be considered as a suitable technique for rapid triage of patients presenting to hospitals with chest pain. High values of sensitivity and PPV reveal the good performance of CTA in detecting CAD.
Coronary Artery Disease (CAD); Computed Tomography Angiography (CTA); Conventional Invasive Angiography (CIA)
The purpose of the present study is to determine the accuracy of magnetic resonance voiding cystourethrography (MRVCUG) for diagnosis of vesicoureteral reflux (VUR) in children and adolescents with recurrent urinary tract infection (UTI).
Materials and Methods:
During the cross-sectional study from May 2009 to June 2011, 30 patients’ (60 kidney-ureter units) MRVCUG findings by 1.5 T magnetic resonance imaging (MRI) were compared with voiding cystourethrography (VCUG) findings in patients with urinary tract infection. The sensitivity, specificity, positive and negative predictive values for MRVCUG were calculated.
The sensitivity, specificity, positive and negative predictive values and accuracy for MRVCUG for detecting VUR were respectively 92.68% (95% CI: 80.57-97.48%), 68.42% (95% CI: 46.01-84.64%), 86.36% (95% CI: 71.95-94.33%), 81.25% (95% CI: 53.69-95.02%), and 85% (95% CI: 80.40-89.60%. The level of agreement between MRVCUG and VCUG findings for diagnosis VUR was very good (P < 0.001, according to Cohen's kappa value = 0.638). Studying correlation of low grade VUR (grade I and II) and high grade VUR (grade III-V) showed a very good agreement between MRVCUG and VCUG findings (P < 0.001, Cohen's kappa value = 0.754).
MRVCUG could accurately reveal the presence and severity of VUR, especially in cases with high-grade (grade III-V) VUR in both children and adolescents.
Accuracy; diagnosis; magnetic resonance; vesicoureteral reflux; voiding cystourethrography
Diabetic muscle infarction (DMI) is an unusual complication of diabetes mellitus. It is usually seen in long-standing diabetes mellitus. This article presents a case of DMI in the left forearm of a 58-year-old woman. She had a swollen forearm. The level of creatine kinase was 5930 U/L. Her condition was initially suspected for either cellulitis or venous thrombosis. A magnetic resonance imaging (MRI) study of the forearm showed diffuse edema and abnormal signals of the left forearm. The diagnosis of DMI was made. She was treated conservatively and her symptoms resolved within a short period of time. DMI should be considered as a differential diagnosis of any painful and swollen limb in diabetic patients.
Diabetes mellitus; infarction; muscle
Chondrosarcoma; Cervical Vertebrae
Previous studies reported that the distribution of body fat is an important risk factor for coronary artery diseases (CAD) and abdominal adipose tissue is associated with severe CAD. This study was conducted to evaluate the relationship between body fat distributions, plasma lipids and the severity of CAD in patients with stable angina.
Ninety seven patients who underwent coronary angiography for stable angina were allocated into two groups: patients with mild or sever coronary artery involvement. Lipid profile (total cholesterol, LDL, HDL) and triglyceride (TG) and apolipoprotein A and B, were measured for all of the participants and a demographic data questionnaire was filled by the subjects. Participants underwent abdominal computed tomography (CT-Scan) for measurement of adipose tissues that was classified to visceral and superficial and deep subcutaneous fat tissue compartment.
Patients with severe coronary artery involvement had higher level of apo B (P=0.02). Significant correlation was seen between visceral fat index and TG (P=0.01), HDL-C (P<0.01) in patients with mild coronary involvement and with total cholesterol (P=0.02), LDL-C (P=0.01) and apoB (P<0.01) in patients with severe coronary involvement.No significant relationship was seen among deep cutaneous fat index and lipid profile in both groups.
Our findings showed that visceral adipose tissue is significantly associated with severe CAD and has a significant correlation with lipid profile as well as Apo B.
Visceral Abdominal Adipose Tissue; Superficial Subcutaneous Adipose Tissue; Deep Subcutaneous Adipose Tissue; Coronary Involvement; Lipid Profile.
The aim of this study was to compare the usefulness of ultrasonography and scintigraphy in diagnosing the etiology of primary congenital hypothyroidism (CH).
The newborns that were examined by both thyroid scintigraphy and ultrasonography during CH screening program in Isfahan were included in this study. The ultrasonographic findings were compared with the scintigraphic findings and the sensitivity and specificity of the ultrasonography was determined.
During this study, 102 CH newborns were studied. According to the ultrasonographic results, 61.8%, 26.5%, 2.9% and 8.8% of them had normal thyroid gland, agenesia, ectopia and hypoplasia, respectively, and according to scintigraphic results, 55.9%, 35.3% and 8.8% of them had normal thyroid gland, agenesia and ectopia, respectively. Ultrasound detected sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 77%, 92%, 89%, 84%, 9.6 and 0.25, respectively. The sensitivity and specificity of ultrasonography compared with thyroid scintigraphy in diagnosis of thyroid gland ectopia was 33% and 100%, respectively.
Though thyroid ultrasonography failed to diagnose 67% of ectopic cases and nonfunctioning thyroid gland, it had the ability to determine the anatomy of thyroid gland. So, considering some limitations of scintigraphy, we concluded that ultrasonography is a relatively appropriate imaging tool for diagnosing CH etiologies, especially in the initial phase of CH screening.
Congenital Hypothyroidism; Etiology; Iran; Radioisotope Scanning; Ultrasonography
McCune-Albright syndrome (MAS) is a rare non-inherited disorder characterized by the clinical triad of precocious puberty, cafe-au-lait skin lesions, and fibrous dysplasia of bone.
We report a girl with MAS, presenting initially with vaginal bleeding at the age of 17 months. Ultrasonography revealed unilateral ovarian cysts and ureteral and ovarian enlargement. Considering the clinical and paraclinical findings, the patient diagnosed as a case of gonadotropin-independent precocious puberty was treated with medroxy-progestrone acetate (MPA) for three months. During the follow up, recurrent episodes of bleeding, ovarian activation and cyst formation, as well as breast size development were reported. At the age of 5.5 years, fibrous dysplasia was detected, which in coexistence with precocious puberty confirmed the diagnosis of MAS. The patient had no cafe-au-lait skin macles during follow up.
Considering that clinical manifestations of MAS appear later in the course of recurrent periods of ovarian activation and cyst formation, a careful clinical observation and follow up of patients is necessary and the diagnosis of MAS must be kept in mind in cases with gonadotropin-independent precocious puberty.
McCune-Albright Syndrome; Bleeding; Fibrous Dysplasia of Bone; Precocious Puberty
In order to declare the preoperative diagnostic value of brain aneurysms, two radiological modalities, computed tomographic angiography and digital subtraction angiography were compared.
In this descriptive analytic study, diagnostic value of computed tomographic angiography (CTA) was compared with digital subtraction angiography (DSA). Sensitivity, specificity, positive and negative predictive values were calculated and compared between the two modalities. All data were analyzed with SPSS software, version 16.
Mean age of patients was 49.5 ± 9.13 years. 57.9 % of subjects were female. CTA showed 89% sensitivity and 100% specificity whereas DSA demonstrated 74% sensitivity and 100% specificity. Positive predictive value of both methods was 100%, but negative predictive value of CTA and DSA was 85% and 69%, respectively.
Based on our data, CTA is a valuable diagnostic modality for detection of brain aneurysm and subarachnoid hemorrhage.
CT scan angiography; digital subtraction angiography; cerebral aneurysm; subarachnoid hemorrhage
Craniopharyngioma accounts for 2.5-4 percent of all intracranial tumors. The tumor is more observed in the chiasmatic region in adults and the intraventricular subtype is rare. We report an intraventricular craniopharyngioma in a 22-year-old woman presented with chronic headache. Magnetic Resonance Imaging showed hyperintense large mass on T1-weighted images and hypointense mass on T2-weighted images in third ventricle with pressure effect on both lateral ventricles and foramen of Monro. The diagnosis of craniopharyngioma was confirmed through histopathological examination of the resected tumor after surgery. After a follow-up period of nine months, neither tumor recurrence nor regrowth occurred. The early diagnosis of this relatively frequent tumor would help to prevent related sequelae.
Craniopharyngioma; Headache; Histopathology
Low Back Pain (LBP) and radicular leg pain (RLP) after lumbar disc surgery are great challenges that prevent patients and neurosurgeons in making a surgical decision. By spinal anesthesia, LBP and RLP diminish up to 2 to 3 hours postoperatively. The aim of this study was to determine the effect of impregnated epidural adipose tissue (EAT) with bupivacaine or methylprednisolone acetate on reduction of late postoperative pain after spinal anesthesia.
This study was performed on lumbar disc herniation surgery under spinal anesthesia. Sixty six patients entered our study who were divided into three groups, EAT impregnated with bupivacaine (group 1), methylprednisolone acetate (group2) and normal saline (control group). The LBP and RLP were evaluated during the first 24 hours postoperatively and 14 days later by visual analogue scale (VAS).
Of 66 patients, 53% were female and 47% male. The average (SE) LBP in the first 6 hours after surgery based on VAS were 1.59 ± 0.90 in group one, 2.36 ± 2.38 in group 2 and 3.09 ± 1.41 in control group but the VAS for RLP in this period were 1.95 ± 1.13, 1.31 ± 1.39 and 2.40 ± 1.09, respectively. The average LBP and RLP did not show any differences after 14 days postoperatively.
According to our data bupivacaine was effective on LBP relief and steroid was effective on RLP relief during the first 12 hours after surgery.
Intervertebral Disc Degeneration; Bupivacaine; Prednisolone Acetate; Adipose Tissue
Cemento-ossifying fibroma is a lesion containing both fibrous and osseous components. Such lesions include fibrous dysplasia, ossifying fibroma, cemento-ossifying fibroma and cementifying fibroma. Periodontal membrane is the origin of fibro-osseous lesions other than fibrous dysplasia.
Here a clinical case of a young woman referred for evaluation of a mass in the right side of face between eye and nose is presented. The first time she noticed the mass was 2 years ago and was growing larger inwards. She was treated with surgical resection.
In this case of a cemento-ossifying fibroma, histological interpretation was critical, and was the basis of correct treatment.
Fibroma; Ossifying; Ethmoid Sinus; Tomography; X-Ray Computed; Magnetic Resonance Imaging
The efficacy of Mycophenolate mofetil (MMF) plus interferon beta-1a (IFNB-1a) in treatment of relapsing-remitting multiple sclerosis (RRMS) was evaluated.
This was a pilot study with randomized, double-blinded, placebo-controlled design. Patients with RRMS and Expanded Disability Status Scale score (EDSS) of < 6.0 were included. Those with relapse within the previous two months and prior use of immunomodulatory/immunosuppressive drugs were excluded. Patients were randomized into MMF (n = 13) and placebo (n = 13) groups and received weekly intramuscular IFNB-1a plus either MMF or placebo. MMF started by 500 mg/d for one week and weekly escalated by 500 mg/d, until target divided dose of 2000 mg/d and continued for 12 months. Radiologic and clinical assessments were performed at baseline and then at month 12.
After one year of therapy, difference between the two groups in number of new T2 lesions was not statistically significant (0.54 ± 0.77 in MMF vs. 1.85 ± 3.2 in placebo group, p = 0.169). Two patients in the placebo group had gadoliniumenhanced lesions and one patient had relapse. There were 3 patients in each group with more than one point progression in EDSS. Common side effect in the MMF group included gastrointestinal upset, but no patient discontinued the treatment.
Combination of MMF with IFNB-1a in patients with RRMS is well tolerated, but the efficacy of such combination was not statistically significant in this pilot study and deserves further investigation with a larger sample size and a longer follow-up.
Mycophenolate Mofetil; Interferon Beta-1a; Immunosuppressive; Relapsing-Remitting Multiple Sclerosis