A positive endomyocardial biopsy result for sarcoid is associated with poor prognosis in patients with initially unexplained cardiomyopathy.

BACKGROUND: Sarcoidosis is a systemic granulomatous disorder of unknown etiology. In patients with cardiomyopathy, the diagnosis of sarcoidosis has important treatment implications. We studied the prognostic implications of a cardiac biopsy diagnosis of sarcoidosis in patients with unexplained cardiomyopathy. METHODS: We evaluated 1235 patients with unexplained cardiomyopathy who underwent endomyocardial biopsy (EMBx) between 1982 and 1997 at the Johns Hopkins Hospital. Twenty-eight patients were referred with a clinical diagnosis of sarcoidosis. RESULTS: Seven of these 28 patients (25%) plus 3 more with other initial diagnoses had sarcoidosis on heart biopsy. Of these 10 patients, 3 (30%) died with a median survival time after biopsy of 0.69 years. Of the remaining 21 patients with a clinical diagnosis of sarcoidosis, 20 had negative biopsy results for sarcoidosis and 7 (35%) died with a median survival time of 2.34 years. The odds of death within 1, 2, and 3 years were higher for those with than for those without an EMBx-proven cardiac sarcoid (crude OR 4.75 [P = .23], 8.1 [P = .09], and 1.28 [P = .78], respectively), but the differences failed to reach significance at the .05 level. However, the difference in the odds of death within 2 years did achieve marginal significance. CONCLUSIONS: Only a quarter of patients with cardiomyopathy and clinical diagnosis of sarcoid have a noncaseating granuloma on EMBx. Of those with a clinical diagnosis of sarcoidosis, heart biopsy results that are positive for sarcoidosis appear to be associated with a shorter median survival time than heart biopsy results that are negative for sarcoidosis. Finally, a noncaseating granuloma on EMBx is a rare finding in patients with cardiomyopathy without a history of sarcoidosis.

Anatomic Evaluation of the Sacroiliac Joint: A Radiographic Study with Implications for Procedures.

BACKGROUND: Sacroiliac joint (SI) pain is increasingly being recognized as a source of low back pain. Injections and percutaneous type procedures are performed to treat symptomatic joints. However, there are limited studies available assessing the anatomy of the SI joint in vivo among patients with pain. OBJECTIVES: The purpose of this study was to provide more precise information on the dimensions and orientation of the SI joint using a new technique for the radiographic evaluation of this joint. STUDY DESIGN: Observational study. SETTING: Emergency department METHODS: Three dimensional computed tomographic (CT) reconstructions of the pelvis were formatted from 100 SI joints in 50 patients who had clinically indicated abdominal/pelvic scans. These images were manipulated to evaluate the SI joint in multiple planes and measure its dimensions, area, and relationship to anatomic landmarks such as the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS). RESULTS: Of the 50 patients, 23 were men and 27 women. Their mean age was 47.6 years (± 18.1). The SI joint consists of a superior limb which measures 39.7 mm (± 4.8) in length, and an inferior limb which measures 54.3 mm (± 5.1), oriented at an angle of 100.1° (± 8.1) to one another. The mean area of the joint was 1276.8 mm2 (± 189.8). The horizontal distance from the ASIS to the front of the superior SI joint is 75.4 mm (± 8.4). The horizontal distance from the PSIS to the back of the superior SI joint is 43.9 mm (± 5.6). The joint stretches 7.5 mm (± 5.9) cephalad and 38.1 mm (± 6.4) caudal to the PSIS, and 35.4 mm (± 8.8) cephalad and 10.2 mm (± 11.4) caudal to the ASIS. LIMITATIONS: CT scans were performed with patients lying supine, while most SI joint procedures are performed with a patient prone. However it is doubtful that the bony anatomic landmarks would change appreciable in this largely immobile joint. These patients were seen in the emergency department for a variety of conditions related to abdominal and pelvic pain, and not exclusively for SI joint pain. CONCLUSIONS: Treatment of the SI joint by surgeons and interventionalists is hampered by the limited number of anatomic studies in the literature. Our study presents the SI joint as a 2-limbed structure, sitting from slightly above the level of the PSIS rostrally to slightly below the level of the ASIS caudally. Palpation of these landmarks may assist in directing physicians to the joint. To begin an interventional pain procedure, with a patient lying prone, this data supports tilting the x-ray image intensifier 10 degrees caudal past the vertical anteroposterior (AP) view for optimal approach of the SI joint's inferior limb. The needle entry should be about 44.1 mm (1.75 inches) caudal to the PSIS. The image intensifier should have a 12 degree left lateral oblique view for injection of the right SI joint, and a 12 degree right lateral oblique view for the left SI joint.

Use of a novel mechanical rinsing and aspiration thrombectomy device for treatment of deep venous and arteriovenous graft thrombosis.

The KPS Rinspirator (Kerberos Proximal Solutions, Cupertino, Calif.) is a new thrombectomy device that operates by manually controlled, simultaneous, intravessel infusion and aspiration of fluid to cause localized clot dissolution. We evaluate the ability of the KPS Rinspirator to treat acute (<3 days) and subacute (3-7 days) deep venous and arteriovenous graft thrombosis in 4 patients and 13 vessels (2 arteriovenous grafts and 11 deep veins). Technical and clinical success was achieved in the two patients with acute arteriovenous graft thromboses. Therefore, in our experience, successful "rinspiration" was achieved in acute thrombosis of arteriovenous grafts.

Postlaminectomy kyphosis in the skeletally immature achondroplast.

STUDY DESIGN: Retrospective review. OBJECTIVES: To determine the risk of postlaminectomy thoracolumbar kyphosis in skeletally immature achondroplasts and evaluate the need for concurrent fusion at multilevel decompression. SUMMARY OF BACKGROUND DATA: Spinal stenosis is a relatively common complication of achondroplasia. Although most achondroplasts do not develop symptomatic spinal stenosis until the third or fourth decades, some patients become symptomatic before skeletal maturity. While postlaminectomy kyphosis typically does not occur in the adult achondroplast, it is not known if it occurs in the skeletally immature achondroplast. METHODS: The charts and radiographs of 10 consecutive skeletally immature achondroplasts that underwent surgical treatment for symptomatic spinal stenosis during a 10-year period were retrospectively reviewed. The average age of the 6 male and 4 female patients at surgery was 9.2 years (range 6-16). All patients had preoperative lateral radiographs. Decompression consisted of multilevel (5-8) thoracolumbar laminectomies. More than 50% of each medial facet was preserved bilaterally to maintain spinal stability. RESULTS: Postlaminectomy thoracolumbar kyphoses developed in all 10 patients (100%). The postlaminectomy kyphoses ranged from 78 degrees to 135 degrees (mean 94 degrees ). All patients underwent spinal fusions with instrumentation, performed from 10 months to 2.6 years after the decompressions, to stabilize the kyphoses. CONCLUSIONS: Skeletally immature achondroplasts are at high risk for developing postlaminectomy thoracolumbar kyphoses. Therefore, concurrent spinal fusion is indicated in skeletally immature achondroplasts who undergo thoracolumbar laminectomies of at least 5 levels.