The effect of etanercept on osteoclast precursor frequency and enhancing bone marrow oedema in patients with psoriatic arthritis.

OBJECTIVE: The frequency of osteoclast precursors (OCPF) and the presence of bone marrow oedema (BMO) are potential response biomarkers in psoriatic arthritis (PsA). Previous studies suggest a central role for tumour necrosis factor (TNF) in the formation of osteoclast precursors. To better understand this association, the effect of etanercept on OCPF and BMO was analysed in PsA patients with erosive arthritis. METHODS: A total of 20 PsA patients with active erosive PsA were enrolled. Etanercept was administered twice weekly for 24 weeks. OCPF was measured and clinical assessments were performed at baseline, 2, 12 and 24 weeks. Gadolinium enhanced MR images were obtained at baseline and 24 weeks. RESULTS: Significant improvements in joint score (p<0.001), HAQ scores (p<0.001) and SF-36 parameters were observed after 6 months of therapy with etanercept compared to baseline. The median OCPF decreased from 24.5 to 9 (p = 0.04) and to 7 (p = 0.006) after 3 months and 6 months of treatment, respectively. MR images were available for 13 patients. The BMO volume decreased in 47 and increased in 31 sites at 6 months. No correlation was noted between OCPF, BMO and clinical parameters. CONCLUSION: The rapid decline in OCPF and overall improvement in BMO after anti-TNFalpha therapy provides one mechanism to explain the anti-erosive effects of TNF blockade in PsA. Persistence of BMO after etanercept treatment, despite a marked clinical response, was unexpected, and suggests ongoing subchondral inflammation or altered remodelling in PsA bone.

Dermatomyositis with normal muscle enzyme concentrations. A single-blind study of the diagnostic value of magnetic resonance imaging and ultrasound.

BACKGROUND AND METHODS: It is well documented that the cutaneous lesions of dermatomyositis may precede clinical myositis or may occur in the absence of any muscle disease detectable by current diagnostic criteria. In this single-blind study, we used magnetic resonance imaging (MRI) and ultrasound to evaluate five patients who presented with classical clinicopathologic dermatomyositis, but with normal levels of serum muscle enzymes. This patients group has not been previously studied with these techniques. Patients who served as positive and negative control subjects were also examined. RESULTS: Ultrasonography revealed hyperechogenicity, and MRI revealed high signals on T2-weighted images in several muscle groups of the patient with active myositis (positive control). Increased echogenicity was also noted in the deltoid region of one patient who had previously had a normal muscle biopsy finding. In the same patient, MRI revealed inflammatory changes in the lumbar paraspinal muscles. Another patient, with all previous study results being normal, had MRI evidence of T2 high signals in the gluteus minimus. CONCLUSIONS: Noninvasive examinations such as MRI and ultrasound are beneficial as adjunctive means of examination in the evaluation of patients with dermatomyositis sine myositis or dermatomyositis. Future studies may suggest additional uses for these tests, including serial evaluation of patients, noninvasive confirmation of diagnosis in pediatric patients, or in directing muscle biopsy, thus increasing sensitivity. Ultrasound appears to be the more cost-effective and simple test; but MRI, although more expensive, may be more sensitive and specific.

Synovial osteochondromatosis.

Primary or idiopathic synovial osteochondromatosis is an uncommon condition probably caused by synovial metaplasia and typically resulting in multiple calcified periarticular bodies. Synovial osteochondromatosis also may occur secondary to other joint disorders. This article reviews the pathogenesis, pathologic features, clinical features, and radiologic imaging of synovial osteochondromatosis. The differentiation of synovial osteochondromatosis from other conditions associated with periarticular calcified bodies is discussed.

Some upper cervical spine norms.

Lateral cervical spine films from 175 normal examinations of adults performed in the emergency room of North Carolina Baptist Hospital were analyzed to establish some norms and relationships in the upper cervical spine. The predens angle was found to be between 0 degree-13 degrees (mean 5.57 degrees) in neutral position and 0-18 degrees (mean 9.27 degrees) in flexion in most persons. Ninety-two percent of persons have angles greater than 3 degrees in flexion. A V-shaped predens space is not indicative of injury to the cruciate ligament. Virtually every person has posterior slanting or tilting of the dens and the range of values is up to 35 degrees (mean 17.43 degrees). Ninety-eight percent of persons have an angle greater than 6 degrees. A tilted dens does not indicate acute or remote trauma. No relationship was identified between the predens angle and the dens tilt angle. The posterior arch of the atlas can be found at any position between the occiput and spinous process of C2 in all positions of the head and neck. Hence, fanning or widening of the C1-C2 interspinous distance is not a reliable index of ligamentous injury in the upper cervical spine.

The superior mesenteric artery syndrome in pregnancy: a case resulting in recurrent pregnancy loss.

The Superior Mesenteric Artery (SMA) syndrome was the underlying cause of severe gastrointestinal symptoms in a patient with recurrent pregnancy loss. Following a surgical transposition of the duodenum, two normal pregnancies were carried to term. This is the first report of the SMA syndrome in pregnancy, to our knowledge.

Pattern of urolithiasis in Benin City, Nigeria.

A retrospective study was performed to determine the frequency and pattern of urinary stone disease in a black African population. Urolithiasis was found to be a rare condition in the black African occurring with a frequency of 6.3 per 100,000 hospital population, with a male:female ratio of 4:1. Urinary stasis and infection are associated or etiologically related factors in a significant number of patients. Idiopathic stone disease is uncommon (28% of patients). A recurrence rate of 10% is similar to that found in other areas of the world where the disease is more prevalent.

Diffuse abdominal wall cellulitis in ascending omphalitis--a lethal association in neonatal necrotizing fasciitis.

Necrotizing fasciitis is a grave complication of ascending omphalitis in the neonate, but because it is rare some of the signs are not well documented. Rapidly progressive anterior abdominal wall edema and cellulitis were noted in 16 patients who were clinically diagnosed with necrotizing fasciitis. Fifteen of these patients died soon after emergence of anterior abdominal wall edema and cellulitis. The appearance of anterior abdominal edema and cellulitis in a patient with ascending omphalitis has serious implications and demands intensive care if the patient is to survive.

Neonatal bone infarction following cord sepsis: case report.

An unusual case of infarction of the tibia in a neonate who presented with sepsis following poor cord management at birth is reported. He was managed as for necrotizing enterocolitis and had limited debridement of infarcted limb because the parents refused amputation of the limb. This patient was a diagnostic problem. Necrotizing fasciitis and in retrospect purpura fulminans are considered as possible diagnoses and are discussed briefly.

Pattern of childhood pleural disease in Benin City, Nigeria.

Pleural disease is a frequent finding in childhood, occurring with a frequency of 12.8% in all childhood radiographs or 1.48% of all pediatric hospital admissions in the University of Benin Teaching Hospital in Nigeria. Pleural disease was found more frequently in males with a male:female ratio of 1.9:1. Pleural disease also occurred twice as commonly in the right hemithorax. Pleural calcification is uncommon in childhood. There was a seasonal variation in the occurrence of pleural disease with the highest numbers being seen in the month of July, which is the wettest month of the year in Benin. Pyogenic pneumonia and measles-related pneumonia remain the more frequent causes of pleural disease in childhood.

Appendiceal abscess--an unusual cause of acute urinary retention: a case report.

Acute urinary retention can result as a complication of gastrointestinal diseases such as diverticulitis and granulomatous enterocolitis. Appendiceal abscess has been reported as a rare cause of acute urinary retention in children but not in adults. A young adult male who had appendiceal abscess and presented in acute urinary retention forms the subject of this report.

Appendiceal abscess--unusual cause of acute urinary retention. Report of a case.

Appendiceal abscess with urinary symptoms may be the cause of acute urinary retention. The authors present the diagnosis and treatment of such a case.

Ultrasonography of the prostate: a preliminary report from Nigeria.

Suprapubic transabdominal prostatic sonography was performed at two Nigerian centers over the past year. All abnormal glands were found enlarged. Capsular, periprostatic and extra-organ features helped to segregate carcinomas from benign diseases. Gland shape and internal texture were less useful criteria. Prostatic sonography has great promise in developing and fragile economies, where other efficacious and contemporary imaging modalities are unaffordable.

Type 4 acromion: a new classification.

The three types of acromial processes previously described in the literature include type 1, in which the undersurface is straight, and types 2 and 3, in which the undersurface is concave. In this report, a fourth type of acromion is described in which the undersurface is convex near its distal end. The frequency of a type 4 acromion in the normal population is discussed based on a retrospective review of the MR examinations of 30 patients that originally were read as normal.

Neonatal necrotizing fasciitis--a complication of poor cord hygiene: report of three cases.

Necrotizing fasciitis is a potentially lethal syndrome which rarely affects Occurrence in the neonatal period is uncommon, although it has been estimated that up to 50% of reported paediatric cases involve the neonate. Two previous reports have associated the syndrome with neonatal omphalitis. Three cases seen in the University of Benin Teaching Hospital are presented, with poor umbilical cord stump hygiene being the immediate predisposing/associated condition. Two of the infants had Fourier's gangrene and the third developed gangrene of the anterior abdominal wall.

Case report 789: Dorsal defect of the left patella.

Dorsal defect of the patella is an uncommon but well known abnormality. It is believed to be an incidental finding that should not merit further intervention. However, the association of patellofemoral symptoms and a dorsal defect of the patella suggests abnormality of the cartilage overlying the defect. Resection of this area of abnormal cartilage has resulted in relief of symptoms in some patients. A patient who had a dorsal defect of the patella and persistent symptoms had MR imaging. The MR scans showed signal inhomogeneity with streaks of high signal in the cartilage overlying the lesion on both T1-weighted and T2-weighted images. Drilling of the defect relieved his pain.

Sonographic evaluation of jaundice in Benin-City, Nigeria. A preliminary report.

We performed sonographic evaluations on 14 jaundiced patients over a six months period. Medical jaundice was correctly diagnosed in three, as confirmed by the subsequent clinical course. Sonographic features of surgical jaundice were identified in the remaining 11 cases, five of which were confirmed through either percutaneous transhepatic cholangiography, surgery and pathology or both. Sonography is efficacious in the work-up of jaundice; since the technique is affordable and versatile, it is particularly relevant in developing economies where available resources are limited.