Paraneoplastic necrotizing myopathy and dermatomyositis in a patient with rectosigmoid carcinoma.

An 81-year-old woman with adenocarcinoma of the rectosigmoid presented with progressive muscle weakness and difficulty swallowing, with symptoms worsening following successful resection of the tumor. On examination, she had weakness primarily of lower limb proximal muscles, with no other abnormal findings. Laboratory tests showed significant elevation of creatine kinase, and EMG findings indicated myositis of the proximal muscles. While MRI showed increased signal intensity on T2-weighted images of the leg muscles, indicating inflammation, muscle biopsy found widespread necrosis with only weak and focal lymphocytic infiltration. A diagnosis of paraneoplastic necrotizing myopathy (PNM) was made, and immunomodulatory treatment initiated, with little response. Four months later she returned with exacerbation of symptoms, this time with skin changes pathognomonic of dermatomyositis (DM). A repeat MRI showed progression of inflammation, as well as necrotic foci. It is important to distinguish between paraneoplastic myopathies such as DM and PNM, with implications regarding treatment and prognosis.

A Deep-Learning Approach to Spleen Volume Estimation in Patients with Gaucher Disease.

The enlargement of the liver and spleen (hepatosplenomegaly) is a common manifestation of Gaucher disease (GD). An accurate estimation of the liver and spleen volumes in patients with GD, using imaging tools such as magnetic resonance imaging (MRI), is crucial for the baseline assessment and monitoring of the response to treatment. A commonly used method in clinical practice to estimate the spleen volume is the employment of a formula that uses the measurements of the craniocaudal length, diameter, and thickness of the spleen in MRI. However, the inaccuracy of this formula is significant, which, in turn, emphasizes the need for a more precise and reliable alternative. To this end, we employed deep-learning techniques, to achieve a more accurate spleen segmentation and, subsequently, calculate the resulting spleen volume with higher accuracy on a testing set cohort of 20 patients with GD. Our results indicate that the mean error obtained using the deep-learning approach to spleen volume estimation is 3.6 ± 2.7%, which is significantly lower than the common formula approach, which resulted in a mean error of 13.9 ± 9.6%. These findings suggest that the integration of deep-learning methods into the clinical routine practice for spleen volume calculation could lead to improved diagnostic and monitoring outcomes.

CT-guided radiofrequency ablation of pediatric osteoid osteoma utilizing a water-cooled tip.

BACKGROUND: Radiofrequency ablation (RFA) has a success rate of 70% to 90% in the treatment of osteoid osteoma (OO). Failures are due to malpositioning of probes or incomplete ablation, possibly related to conventional probes' small heating diameter (range, .5-.8 cm). Cooled-tip probes have a larger heating distance, ablating up to 3 cm, affecting a larger volume, and improving success rate in adults. Concerns regarding damage to surrounding structures and unknown effects on bony growth potential have delayed the widespread use of cooled tips in children. Our goal was to examine whether this technique, when added to conventional RFA, improves the clinical results and whether it carries any additional risks to children. METHODS: A total of 22 patients with OO, 15 boys and 7 girls aged 3.5 to 18 years, were treated with the Cool-tip Tyco probe (Valleylab, Boulder, CO). Fifteen lesions were located in the femur, two in the tibia, and the remainder in the humerus, talus, calcaneus, second metatarsus, and sacrum. The OO was intra-articular in five patients: three in the femur, and one each in the calcaneus and talus. Average postoperative follow-up was 38.5 (range, 16-66) months. RESULTS: The symptoms of all but one patient resolved immediately after a single RFA treatment. One patient experienced partial relief and underwent a second successful ablation. One patient experienced recurrence of disease after 18 months, and one superficial infection occurred. No fractures, neurovascular complications, or growth disturbances were found. CONCLUSIONS: The cooled-tip probe is highly effective and safe for the treatment of pediatric osteoid osteoma, with no adverse events in this age group.

Posttraumatic painful hip: sonography as a screening test for occult hip fractures.

OBJECTIVE: Nondisplaced hip fractures may be radiographically occult and require magnetic resonance imaging (MRI) or bone scintigraphy for diagnosis. Both examinations are expensive and are not readily available in many hospitals. Our objective was to evaluate sonography as a screening tool for occult hip fractures in posttraumatic painful hips in elderly patients. METHODS: We prospectively evaluated 30 patients (mean age, 73 years), who were admitted for painful hips after having low-energy trauma with nondiagnostic hip radiographs. After inclusion, patients underwent sonography of both hips for signs of injury. After completion of the sonographic examination and analysis of the results, patients underwent MRI of both hips. The sonographic findings were compared with the MRI findings, which served as the reference standard for accurate detection of a hip fracture. RESULTS: Ten hip fractures were diagnosed by MRI. Sonography showed trauma-related changes in all of those patients and in 7 additional patients, 3 of whom had pubic fractures. Sonography correctly identified 13 patients without hip fractures. The sensitivity of sonography was found to be 100%, whereas the specificity for hip fractures was 65%. CONCLUSIONS: Sonography for posttraumatic hip pain with negative radiographic findings did not result in a single missed hip fracture. Therefore, sonography may serve as an effective screening tool, mandating MRI only for cases with positive findings, whereas patients with negative sonographic findings need no further investigation. Sonography may therefore be very useful in hospitals around the world, where MRI may not be readily affordable or available.

Magnetic resonance imaging showed no signs of overuse or permanent injury to the lumbar sacral spine during a Special Forces training course.

BACKGROUND CONTEXT: Special Forces training is even more demanding than that of elite athletes. The training includes grueling physical activity and periods of sleep deprivation. The soldiers routinely carry heavy loads up to 40% of their body weight on their backs while running and marching for distances up to 90 km. PURPOSE: Our purpose was to find out if Special Forces recruits are able to complete the preparatory Navy Seals training program without sustaining magnetic resonance imaging (MRI) signs of overuse or irreversible injury to their backs. STUDY DESIGN/SETTING: Prospective cohort study. We performed MRI scans before and after 14 weeks of Navy Seals preparatory training course. PATIENT SAMPLE: Ten soldiers underwent MRI of their lumbar sacral spines and right knees before and after the completion of Navy Seals preparatory training. OUTCOME MEASURES: Physiologic measures. Lumbar sacral spine and knee MRI tests were performed before and after the training to identify changes in the spinal discs, facet joints, pars interarticularis, vertebral bodies, knee articular cartilage, ligaments, knee menisci, and the presence or absence of soft tissue and/or bone edema. METHODS: We investigated the difference in spine and knee pathology before and after a 14-week Navy Seals preparatory training course by using MRI criteria. The recruits participating in the study were monitored for acute and overuse injuries every 3 to 4 weeks. RESULTS: Before the training, seven out of ten spine MRI scans were normal. Two showed small L5-S1 disc bulges, one of them with concomitant Scheuermann's disease. Another soldier's MRI showed L1-L4 mild Scheuermann's disease. Follow-up MRI showed no spinal changes. Before the training, one knee had a small lateral femoral condyle cartilage lesion. Nine of ten knees had prepatellar swelling, five had increased joint fluid, and two bone edema. Follow-up magnetic resonance imaging showed improvement in the prepatellar swelling in eight soldiers, no change in one soldier, and increased knee effusion and a new medial femoral condyle bone edema in another. The lateral femoral condyle lesion remained unchanged. CONCLUSIONS: According to MRI criteria, the soldiers in this study completed the 14-week training, which involved loading of their spines far beyond the levels recommended by the US National Institute for Occupational Safety and Health without sustaining irreversible damage to their spines or knees. Although the subjects' knees showed signs of overuse injury, their backs did not.

Chondromyxoid fibroma of the distal fibula treated by percutaneous radiofrequency ablation.

BACKGROUND: Percutaneous radiofrequency ablation (RFA) has been shown to be an effective treatment for soft tissue lesions and also benign bone tumors, especially osteoid osteoma. There are limited data regarding this technique in other bone tumors, specifically larger and more aggressive ones. PURPOSES: To describe the use of RFA as a definitive treatment and an alternative to traditional open surgery for the treatment of chondromyxoid fibroma (CMF), a benign but locally aggressive bone tumor. CASE PRESENTATION: An 11.5-year-old girl was diagnosed with a 4-cm lytic bone lesion of the distal fibula. Evaluation, including biopsy, revealed CMF. It was managed by fluoroscopy-guided RFA only. Six-year follow-up demonstrated complete healing without damage to the adjacent distal fibular growth plate. DISCUSSION AND CONCLUSIONS: RFA induces local heat in the ablation field and causes tissue necrosis. The depth of heat penetration and the size of heated sphere are accurately controlled by modern types of ablation probes and accurate positioning. The current report demonstrates the ability to use this percutaneous technique for larger and more aggressive bone tumors than has been indicated previously.

Talc sclerodhesis of persistent Morel-Lavallée lesions (posttraumatic pseudocysts): case report of 4 patients.

Large posttraumatic pseudocysts are infamous for their tendency to recur despite repeated aspiration. The standard practice has been repeated extensive surgical debridement. To avoid the need for such treatment, talc was used to sclerose the lesion in 4 patients treated between 2000 and 2003. The patients were between the ages of 20 and 73 and had thigh and buttock pseudocysts that persisted for an average of 3 months. Talc was administered under fluoroscopic guidance and suction drainage (wall suction followed by a bulb vacuum drainage system) was applied for an average of 12 days. The patients were followed for an average period of 27 months after talc sclerodhesis. All persistent pseudocysts showed an immediate cessation of fluid accumulation in the treated space without reccurence. One case which was complicated by infection, had to be treated twice with talc to cease the accumulation. In this case, the infection recurred, although fluid accumulation did not recur. Talc sclerodhesis proved to be a simple and rapid method of treatment in posttraumatic cases classically treated by repeated and aggressive surgical methods.

Hypertrophic pulmonary osteoarthropathy: control of pain and symptoms with pamidronate.

This case presents a patient with hypertrophic osteoarthropathy of the lower extremities that developed secondary to congenital cyanotic heart disease. The major clinical manifestation was severe bilateral leg pain. The pain that was debilitating in nature completely resolved following a single administration of 60 mg pamidronate. Hypertrophic osteoarthropathy (HOA) is an acquired, uncommon disorder of obscure etiology. It has been described mainly in association with chronic suppurative pulmonary diseases, bronchogenic carcinoma and lung metastases, cystic fibrosis, and cyanotic congenital malformations of the heart.

The effect of very high versus very low sustained loading on the lower back and knees in middle life.

To evaluate the effect of the extremes of long term high and low physical activities on musculoskeletal heath in middle age, a historical cohort study was performed. The MRI knee and back findings of 25 randomly selected subjects who were inducted into the armed forces in 1983 and served at least 3 years as elite infantry soldiers were compared 25 years later, with 20 randomly selected subjects who were deferred from army service for full time religious studies at the same time. Both cohorts were from the same common genome. The two primary outcome measures were degenerative lumbar disc disease evaluated by the Pfirrmann score and degenerative knee changes evaluated by the WORMS score. At the 25-year follow up, the mean Pfirrmann score (8.6) for the L1 to S1 level of the elite infantry group was significantly higher than that of the sedentary group (6.7), (P = 0.003). There was no statistically significant difference between the WORMS knee scores between the two cohorts (P = 0.7). In spite of the much greater musculoskeletal loading history of the elite infantry cohort, only their lumbar spines but not their knees showed increased degenerative changes at middle age by MRI criteria.

A lipid-and-polymer-based novel local drug delivery system--BonyPid™: from physicochemical aspects to therapy of bacterially infected bones.

Bacterial infection of bone may result in bone destruction and is difficult to cure due to poor accessibility to bone of systemically-administrated antibiotic and poor performance of currently available local antibacterial treatments. We developed a novel local drug delivery system based on self-assembly of specific familiar lipids and polymers that encapsulate the desired drug (exemplified by doxycycline). The entrapped doxycycline present in the anhydrous environment of the formulation is fully protected from long-term water-exposure-related degradation. The fine coating of the tricalcium phosphate bone filler by this doxycycline-containing formulation (BonyPid™) is capable of releasing intact and active drug at a steady, zero-order rate for a predetermined period of up to 30 days and in amount sufficient to achieve therapy potentially capable of eliminating the contaminating bacteria. Therefore a clinical evaluation is proposed for testing the efficacy and toxicity of BonyPid for therapy of bacterial bone infections.