Ethical issues in decision making by hospital health committee members in Turkey.

Hospital health committees (HHC) in Turkey review medical reports from clinical practitioners and decide whether or not they are justified. As a rule, each HHC member is expected to observe and examine each patient and then evaluate the report. If the report from the patient's doctor is approved, then the Social Security Administration, a state organisation, will meet all of the patient's expenses covering treatment, medication and operations. Justification of health expenditure is crucial for the state because health resources have to be carefully allocated. Conflicts of obligation also generate ethical issues which have to be resolved as well. However, HHCs are not designed to make ethical decisions. An overall concept of organisational ethics needs to be developed.

The relationship between clinical parameters and ultrasonographic enthesitis assessment in patients with spondyloarthritis.

Objectives: The study aimed to evaluate the role of ultrasonographic assessment of enthesitis in patients with spondyloarthritis (SpA) in terms of disease activity, functionality, and quality of life. Patients and methods: Ninety SpA patients (57 males, 33 females; mean age: 37.5±9.7 years; range, 18 to 60 years) were included in cross-sectional study between November 2016 and January 2017. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Functional Index (BASFI), Short Form-12 (SF-12), and Ankylosing Spondylitis Quality of Life (ASQoL) were utilized for clinical evaluation. The clinical evaluation of enthesitis was performed with the Spondyloarthritis Research Consortium of Canada (SPARCC) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) via an algometer calibrated to 4 kg/cm2 of pressure. Ultrasound evaluation was performed according to Madrid Sonographic Enthesitis Index (MASEI). A total of 2,610 entheseal sites were examined clinically, and 1,080 were assessed ultrasonographically. Results: A significant proportion of enthesitis (463/1,080) was detected on ultrasonographic evaluation but not with clinical enthesitis score (MASES and SPARCC). Although ultrasonographic entheseal evaluation detected enthesitis in at least one enthesis of all patients, 35 of the patients had no enthesitis with clinical examination. The sites most frequently involved in the entheses were the proximal patellar tendon and Achilles tendon. The MASEI score did not correlate with the MASES, SPARCC, BASDAI, SF-12, and ASQoL but moderately correlated with the C-reactive protein (CRP) level (r=0.348), ASDAS-CRP (r=0.294), and BASFI score (r=0.244). Conclusion: The association of ultrasonography scores with CRP levels and ASDAS-CRP indicates that ultrasonography is effective in detecting inflammation. The MASEI score weakly correlates with functionality but not with quality of life. Ultrasonographic evaluation is invaluable and merits to be incorporated into SpA disease scoring system.

Clinical and ultrasonographic enthesitis assessment before and after anti-tumor necrosis factor treatment in patients with spondyloarthritis.

Objectives: This study aimed to clinically and ultrasonographically evaluate enthesitis in patients with spondyloarthritis (SpA) and to determine enthesitis response to anti-tumor necrosis factor (TNF) treatment. Patients and methods: Thirty-one SpA patients (22 males, 9 females; mean age: 39.4±10.9 years; range, 22 to 60 years) who started anti-TNF treatment due to their high disease activity were included in the cross-sectional prospective study between May 2017 and January 2018. Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Quality of Life Questionnaire, Bath Ankylosing Spondylitis Functional Index, and Bath Ankylosing Spondylitis Metrology Index were recorded. Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and Spondyloarthritis Research Consortium of Canada (SPARCC) Enthesitis Score were utilized for clinical enthesitis evaluation. Patients were ultrasonographically evaluated in accordance with the Madrid Sonographic Enthesitis Index (MASEI) by a blinded sonographer. Patients were clinically and ultrasonographically assessed at baseline and in the third month after the treatment. Results: In the initial evaluation, 24 (77.42%) of the patients had clinical enthesitis, and 30 (96.77%) of the patients had ultrasonographic enthesitis. After anti-TNF treatment, MASES, SPARCC, MASEI-structure, MASEI-thickness, MASEI-bursitis, MASEI-Doppler, MASEI-inflammatory, and MASEI-total scores significantly decreased (p<0.05). There was no significant change in MASEI-damage, MASEI-erosion, and MASEI-calcification scores following the therapy (p>0.05). Conclusion: Anti-TNF treatment may improve clinical and ultrasonographic enthesitis, particularly inflammatory changes. Erosions and calcifications may not ameliorate after three months of anti-TNF treatment.

De Quervain's syndrome associated with osteopoikilosis: a case report and review of the literature.

Osteopoikilosis is a rare, usually asymptomatic, autosomal-dominant bone disorder, which is generally diagnosed incidentally on X-ray. De Quervain's syndrome is a disorder characterized by pain on the radial (thumb) side of the wrist, impairment of thumb function and thickening of the ligamentous structure covering the tendons in the first dorsal compartment of the wrist. In this case report, we present a young woman with De Quervain's syndrome associated with osteopoikilosis.

The clinical importance of the thyroid nodules during anti-tumor necrosis factor therapy in patients with axial spondyloarthritis.

The clinical importance of the thyroid nodules in patients with axial spondyloarthritis (ax-SpA) rests with the need to exclude thyroid malignancy. The aim of this study is to assess the risk of thyroid malignancy in ax-SpA patients receiving anti-TNF therapy. From September 2015 until December 2015, 70 patients diagnosed with ax-SpA were included in the research. Forty of the patients had received anti-TNF therapy, and 30 of the patients were anti-TNF naive. All cases were screened for the presence of nodules in the thyroid gland with ultrasound. Of the patients that received anti-TNF therapy, 15 (37.5%); and of the anti-TNF naive patients, 11 (36.7%) had thyroid nodule(s). Four patients from the anti-TNF group underwent fine needle aspiration biopsy of the nodules, and two of them were diagnosed with papillary thyroid carcinoma. None of the nodules in anti-TNF naive patients required biopsy. When compared to the normal population, the standardized incidence ratio (SIR) was found to be increased in both male (SIR 2.03, 95% CI 1.9 to 18) and female (SIR 2.7, 95% CI 2.6 to 24) cases. It is not yet established whether the development of cancer during the treatment process is the effect of the treatment or if it is a part of the natural course of the disease or if it is coincidental. We saw a mild increase in thyroid malignancies in ax-SpA patients who received anti-TNF therapy. Therefore, we believe that the thyroid gland should also be taken into consideration while screening for malignancy before anti-TNF therapy.

Regression of a symptomatic thoracic disc herniation with a calcified intervertebral disc component.

There were only a few cases describing spontaneous regression of calcified thoracic disc herniation in the literature. We present a 38-year-old male office worker who had left paramedian-foraminal extruded disc at T7-T8 with calcifications of the T7-T8 and T8-T9 intervertebral discs. This case was unique in that the non-calcified extruded disc material regressed almost completely in 5 months while the calcified intervertebral discs remained the same during the process of regression. This report stresses that regression of the herniated material of the thoracic discs with subsidence of the symptoms is still possible even if the disc material is calcified.

Computed tomographic evaluation of lumbar spinal structures during traction.

In the previous studies, it is reported that traction diminishes the compressive load on intervertebral discs, reduces herniation, stretches lumbar spinal muscle and ligaments, decreases muscle spasm, and widens intervertebral foramina. The aim of this study was to evaluate the effects of horizontal motorized static traction on spinal anatomic structures (herniated area, spinal canal area, intervertebral disc heights, neural foraminal diameter, and m.psoas diameter) by quantitative measures in patients with lumbar disc herniation (LDH). At the same time the effect of traction in different localizations (median and posterolateral herniation) and at different levels (L4-L5 and L5-S1) was assessed. Thirty two patients with acute LDH participated in the study. A special traction system was used to apply horizontally-motorized static lumbar traction. Before and during traction a CT- scan was made to observe the changes in the area of spinal canal and herniated disc material, in the width of neural foramina, intervertebral disc heights, and in the thickness of psoas muscle. During traction, the area of protruded disc area, and the thickness of psoas muscle decreased 24.5% (p = 0.0001), and 5.7% (p = 0.0001), respectively. The area of the spinal canal and the width of the neural foramen increased 21.6% (p = 0.0001) and 26.7% (p = 0.0001), respectively. The anterior intervertebral disc height remained unchanged with traction however the posterior intervertebral disc height was significantly expanded. This study is the first to evaluated in detail and quantitatively the effect of motorized horizontal lumbar spinal traction on spinal structures and herniated area. According to detailed measures it was concluded that during traction of individuals with acute LDH there was a reduction of the size of the herniation, increased space within the spinal canal, widening of the neural foramina, and decreased thickness of the psoas muscle.

Aggressive vertebral hemangioma as a rare cause of myelopathy.

Vertebral hemangiomas (VHs) are common lesions in the adult population. They are usually asymptomatic and found incidentally on radiological imaging. New-onset back pain followed by subacute progression of thoracal myelopathy is the most common presentation in patients with neurological deficit. Differential diagnoses would include metastasis, multiple myeloma, lymphoma, Paget disease, osseous tumors such as Ewing sarcoma or hemangioblastoma and blood dyscrasia. We present a 41 year-old-male patient with thoracal VH causing myelopathy that completely improved after rehabilitation program with embolization and vertebroplasty procedures.

Osteopoikilosis associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles.

Osteopoikilosis is a sclerosing bone dysplasia, characterized by multiple oval spots of radiodensities within the trabecular bone. It occurs equally common among men and women. Prevalence is estimated to be as high as 1:50,000. Most reported cases have been found incidentally on roentgenograms taken for other purposes. We present a 58-year-old woman with OPK associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles.