An allele of COL9A2 associated with intervertebral disc disease.

Intervertebral disc disease is one of the most common musculoskeletal disorders. A number of environmental and anthropometric risk factors may contribute to it, and recent reports have suggested the importance of genetic factors as well. The COL9A2 gene, which codes for one of the polypeptide chains of collagen IX that is expressed in the intervertebral disc, was screened for sequence variations in individuals with intervertebral disc disease. The analysis identified a putative disease-causing sequence variation that converted a codon for glutamine to one for tryptophan in six out of the 157 individuals but in none of 174 controls. The tryptophan allele cosegregated with the disease phenotype in the four families studied, giving a lod score (logarithm of odds ratio) for linkage of 4.5, and subsequent linkage disequilibrium analysis conditional on linkage gave an additional lod score of 7.1.

Roentgenographic findings of pneumonia caused by Chlamydia pneumoniae. A comparison with streptococcus pneumonia.

BACKGROUND: Pneumonia caused by Chlamydia pneumoniae or Streptococcus pneumoniae cannot be reliably differentiated by clinical signs or symptoms. OBJECTIVE: To find differences in the roentgenographic patterns of community-acquired pneumonia caused by C pneumoniae, S pneumoniae, or both in hospitalized patients during a C pneumoniae epidemic in Finland. METHODS: The patients were divided into 3 groups: 24 patients with serologic evidence of C pneumoniae only; 8 patients with combined C pneumoniae and S pneumoniae infection; and 13 patients with infection caused by S pneumoniae only. The chest roentgenograms obtained on admission to the hospital, during the hospital stay, and at follow-up visits were reevaluated by one of us (S.L.) who was unaware of the causative organism. In the final study groups, other causes of community-acquired pneumonia were excluded by a large pattern of microbiological methods. RESULTS: Bronchopneumonia was observed in 21 (88%) of the group with C pneumoniae and 10 (77%) of the group with S pneumoniae (P = .67). Lobar or sublobar (air space) pneumonia was seen in 7 (29%) of the patients with C pneumoniae compared with 7 (54%) with pneumonia caused by S pneumoniae. In the combined group, bronchopneumonia was seen as frequently as in the group with C pneumoniae, and air-space involvement was seen as frequently as in the group with S pneumoniae. The pneumonic shadowing was usually unilateral and in the lower lobes in all groups. Of the patients in the C pneumoniae group, 17% had residual abnormalities at follow-up visits. CONCLUSIONS: Roentgenographic changes cannot be used to differentiate pneumonia caused by C pneumoniae from that caused by S pneumoniae. Thus, initial antibiotic treatment should be directed at the pathogens that commonly cause community-acquired pneumonia.

Computed tomographic evaluation of retrosternal adhesions after pericardial substitution.

BACKGROUND: Reoperative median sternotomy can result in cardiac injury and serious bleeding, with the rate ranging from 2% to 6%. Closure of the native pericardium can maintain a preventing plane of cleavage. In patients in whom primary pericardial closure is not possible, several substitutes have been tried with variable results. We conducted a prospective study to evaluate the clinical feasibility of polytetrafluoroethylene and polyglycolic acid patches as pericardial substitutes, using computed tomography for imaging the postoperative state of the retrosternal space. METHODS: The basic population comprised 540 patients who were scheduled for coronary artery bypass grafting, and 52 of them who met the research criteria were chosen for computed tomographic evaluation after 5 years after the primary operation. RESULTS: As a substitute, polytetrafluoroethylene seemed to be less adhesive to the posterior surface of the sternum. Total adhesion scores were also statistically significant (p < 0.001) to the advantage of polytetrafluoroethylene over polyglycolic acid as a pericardial substitute. CONCLUSIONS: Polytetrafluoroethylene membrane seems to be capable of minimizing retrosternal adhesion formation and thus it may protect the heart during subsequent reoperative sternotomy.

A low-dose CT-pelvimetry.

The suitability of CT for pelvimetry was studied. For accurate measurement of the true conjugate and interspinous diameter, a lateral topogram and an axial CT slice were taken. The radiation dose was reduced from 1 mGy (in conventional system) to 0.1-0.2 mGy.

Disk-space hypodensity in CT: the first radiological sign of postoperative diskitis.

Five patients with recent postoperative diskitis were examined with plain lumbar films and/or multidirectional tomography and CT. Three patients with normal recovery after lumbar disk herniation operation served as controls of the CT findings. Plain films and tomography showed intervertebral disk space narrowing and end plate erosions two and one-half to four weeks after the onset of symptoms. CT detected significant hypodensity of the affected disk spaces as compared to the controls. This was the first recognizable sign of diskitis in three patients and appeared as early as ten days after the onset of symptoms.

CT features of recurrent lumbar disc herniation.

The CT findings of 29 patients with recurrent lumbar disc herniation, confirmed at reoperation, were analyzed. The shape of the recurrent herniation varied from a shallow bulge to round or triangular mass. Every lesion presented density numbers compatible with disc material. An enhancement study was made in six cases, and the lesions remained non-enhanced. Density measurement on CT proved reliable in the differential diagnosis between recurrent disc herniation and postoperative scar.

Comparison of the radiation doses in lumbar CT and myelography.

The radiation doses of the vertebral bodies and ovaries in lumbar CT and myelography were compared using a phantom. The CT examinations were performed with two different scanners using four different programs. At CT the radiation maximum doses of the vertebral bodies were higher than at myelography but the ovarian doses were lower. The radiation exposure does not prevent the use of CT instead of myelography, but the area of examination and the number of pictures should be limited to the minimum based on the clinical enquiry.

Examination of the sprained ankle: anterior drawer test or arthrography?

The accuracy of the anterior drawer test for the diagnosis of recent lateral ligament tears in the ankle was evaluated in a series of 192 patients using surgical or arthrographic findings for reference. Considerable overlapping of results was obtained in ankles with and without ligament tear. Twenty-eight per cent of the anterior talofibular ligament tears, and 38% of the combined anterior talofibular and calcaneofibular tears were not detected, and single and combined tears could not be differentiated. It is concluded that the anterior drawer test is too unreliable as a basis for any decision regarding surgical treatment of a recent sprain. Therefore, arthrography is recommended as the method of choice in such cases of recent ankle sprain, where the need of surgery has to be supported by X-ray analysis.

Late CT-findings in non-surgically treated lumbar disc herniations.

Eighteen patients with non-surgically treated lumbar disc herniation underwent follow-up CT examination at an average of 5.2 years (range 4.3-6.1 years) after their initial examination. In 12 of the patients disc herniation had resolved, although only five of these patients had complete relief of symptoms. Although disc herniation has a tendency to heal spontaneously, there is poor correlation between the morphological changes and the relief of pain.

Assessing resectability of lung cancer: the role of computed tomography of the mediastinum, upper abdomen and head.

In order to assess the value of computed tomography (CT) of the mediastinum, upper abdomen and head in the assessment of resectability of lung cancer, the CT findings of 262 patients, of whom 198 underwent thoracotomy, were analyzed retrospectively and the stagings obtained at CT and thoracotomy were compared. Mediastinal CT reliably predicted resectability when there was no evidence of mediastinal involvement. However, it was often impossible to determine whether tumour with apparent mediastinal infiltration on CT was resectable or not. The sole finding of lymph node enlargement did not permit differentiation of benign from malignant lymphadenopathy when the lymph node diameter was less than 25 mm and the lymphadenopathy was confined to one lymph node station. Upper abdominal metastases were found in 6.1% and brain metastases in 4.6% of patients and neither the histological type nor other features of the tumour were found to be useful predictors of their presence. The large number of non-specific findings decreased the utility of abdominal CT. The appropriate strategy for the pre-operative evaluation of patients with lung cancer is discussed.

Radiological findings in cases of gallbladder carcinoma.

Radiological findings in 80 cases of gallbladder carcinoma are analysed retrospectively. Seventy-nine of the patients had been examined by US (ultrasonography), 37 by CT (computed tomography), 26 by PTC (percutaneous transhepatic cholangiography), 17 by ERCP (endoscopic retrograde cholangio-pancreaticography), nine by angiography and 27 by US-guided FNB (fine needle biopsy). US showed the primary tumour in 68% and CT in 57%. In 67 cases the tumour had spread outside the gallbladder area, causing bile duct obstruction in 41. US showed the bile duct obstruction in 39 of these cases and CT in 20 out of 22 cases. US showed 73% of the cases that had spread to the liver; the sensitivity being 68% for direct invasion and 88% for peripheral liver metastases. The corresponding percentages for CT were 68, 67 and 75%, respectively. In lymph node enlargement, US showed the nodes in 70% of cases and CT in 52%. PTC showed either stenosis or total obstruction in 25 cases and failed in one case. ERCP showed a tumour in 76% and failed in 24%. Angiography failed to show the primary tumour in two instances out of nine. The results indicate that current imaging methods are insufficient for the accurate staging of gallbladder carcinoma.

Low-cost digital teleradiology.

A teleradiology link based on standard personal computers and a flat-bed CCD scanner was tested. A 64 kbit/s dial-up digital ISDN telephone line was used for transmission. A total of 254 films (174 uncompressed, 80 compressed) were sent. Ninety-six per cent of the uncompressed images and 98% of the compressed images were considered technically acceptable. The total diagnostic agreement between the acceptable transmitted images and the original films was 98%. Image quality was sufficient for diagnosis in CT and conventional chest and bone radiographs. However, a 256-step gray scale of the scanner was not sufficient for demanding situations, such as overexposed images with a high contrast gradient. The average speed of transmission was 60 kbit/s, which was considered adequate. The tested system suggests that a teleradiology link based on standard personal computers and programs works in situations where instant consultation is needed. However, the image digitization time with the prototype system was quite long, and a better user interface is under development.

Ultrasound diagnosis of lumbar disc degeneration. Comparison with computed tomography/discography.

Transabdominal ultrasound (US) imaging was compared with computed tomography (CT)/discography in order to assess whether the former could be used for screening discs to be examined by CT/discography, or could be used to replace CT/discography. A total of 56 discs in 29 patients was examined by both methods. The US findings were classified as local or generalized disc lesions, and the CT/discography findings according to the Dallas Discogram Description. The sensitivity of US for recognizing a discographically painful and deteriorated disc was 0.95, and its specificity was 0.38. Correspondingly, the predictive value of a positive US finding was 1.53, and that of a negative finding was 0.13. US is considered suitable for screening discs prior to CT/discography.

Symptoms and signs of sciatica and their relation to the localization of the lumbar disc herniation.

Neurologic symptoms and signs in patients with sciatica were prospectively studied and compared with myelographic and operative findings in 403 cases with lumbar disc herniation as the cause of sciatica with special reference to accuracy of the clinical level diagnosis. Fifty-six percent of the herniations at L4-5. However, pain projection into the first sacral distribution was most common. Neurologic symptoms and signs of involvement of a single root were present in 239 cases and of two roots in 154 cases in L4-5 and L5S1 herniations. Pain projection into the fifth lumbar distribution was a very important symptom for identification of clinical findings of the fifth lumbar root involvement gave a level diagnostic accuracy comparable with myelography, while pain projection into the first sacral distribution was less reliable especially in cases with signs of two roots. The neurologic picture of high herniations was completely unreliable. Lumbar myelography or computer tomography is recommended as a routine preoperative study.

Assessing non-resectability of lung cancer. The value of thoracic computed tomography.

To investigate whether the assessment of resectability of lung cancer can be reliably made on the basis of computed tomography (CT), the thoracic CT scans of 96 lung cancer patients who were operated on, and in whom the tumour was classified to be of stage III at preoperative CT or at thoracotomy, were analysed. Of the patients, 58 underwent complete resection of the tumour, whereas thoracotomy resulted in non-complete resection or exploration only in 38 cases. Overlapping of the CT findings in the groups of complete and non-successful resection was observed. The majority of tumours with apparent growth to the carina, trachea, oesophagus or great vessels at CT were completely resected. Tumours that only bordered on the pleura could not be distinguished from those with pleural invasion. Mediastinal lymph node enlargement did not always mean metastatic spread. We conclude that there is no definite sign that identifies non-resectability of lung tumours, and a certain proportion of non-curative thoracotomies must be accepted.

Ultrasonography in the diagnosis of abdominal aortic aneurysms.

An abdominal aortic aneurysm was detected in 77 patients among 16 488 abdominal ultrasonographies (US) performed in 1978-1983. In 62 cases the US finding was confirmed by operation, autopsy or other imaging method, and the US finding proved true in 60 cases. The length and diameter were accurately estimated and accompanying thrombosis reliably visualised. An error rate of 24% was observed in assessing the relation of the aneurysm to the renal arteries. US is recommended as the primary imaging mode in suspected abdominal aortic aneurysm. Screening of the abdominal aorta is recommended in elderly patients with abdominal pain and/or referred for abdominal US.

Pancreatitis in patients with chronic inflammatory bowel disease.

We describe six patients with acute pancreatitis associated with chronic inflammatory bowel disease (IBD) and no other etiological factor of pancreatic disease in a series of 513 patients with IBD. Five of the 6 patients had Crohn's disease and one indeterminate colitis; four had simultaneous symptoms of active colitis. The pancreatis was not caused by drugs or duodenal involvement of IBD. Our study suggests that pancreatic disease is one of the extra-intestinal manifestations of IBD, in particular of Crohn's disease.

Relationship of pancreatic function and glucose tolerance to the morphology of the pancreatic ductal system as revealed by ERCP.

A series of 226 patients with suspected pancreatic disease examined with ERCP, included 130 patients with normal ductal morphology (group I), 24 with 1-2 smooth narrowings of the main duct of the pancreas (group II), 20 with ectatic small branches (group III), 22 with an irregular main duct and ectatic small branches (group IV), and 30 patients with other findings in the pancreatogram. Pancreatic exocrine function was measured in 140 patients using the secretin test. The mean value of the maximal bicarbonate concentration was significantly (p less than 0.001) lower in the patients with severe ductal changes than in those with a normal pancreatogram. In addition, the number of patients with impaired exocrine function was significantly higher in group IV than in group I. The other groups did not differ significantly. A two-hour glucose tolerance test was done on 104 patients in addition to which 19 patients had overt diabetes. The number of patients with abnormal glucose tolerance was significantly higher in group IV (60%) than in group I (27.5%). The mean blood sugar value was also higher after one hour in group IV than in group I. The patients in the other groups did not differ significantly with regard to glucose metabolism. An almost significant negative correlation was found between the maximal bicarbonate concentrations and the one-hour blood glucose values (p less than 0.05).

[Ejection as index of left ventricle function]. / Le travail d'éjection comme indicateur de la fonction du ventricule gauche.

Quantative left ventricular cineangiography performed 1 year post operatively in 24 patients with prosthetic aortic valves demonstrated significant reductions in the end diastolic volume and myocardial mass. Cardiac work was only slightly reduced. When cardiac work was compared to the end diastolic volume or myocardial mass results suggestive of myocardial hypercontractility were obtained. However when cardiac work was normalised simultaneously with the end diastolic volume and myocardial mass, the index so obtained was lowered pre operatively but did not differ significantly from normal values after operation. This index with seems to reflect the clinical evolution appears to be of greater value than the other indices used for determining left ventricular function. The reducted function of the hypertrophied myocardium was shown to be reversible during the 1 year post operative period.

Relationship between calf muscle size and strength after achilles rupture repair.

The object was to study the relationships between calf muscle size and strength in 85 patients an average of 3.1 years after repair of achilles tendon rupture. The isokinetic calf muscle strength results were excellent or good for 73% of the patients, whereas calf muscle size was normal in only 30%. The average plantar flexion peak torque per unit muscle cross-sectional area was higher on the injured side than on the uninjured side. The average calf muscle cross-sectional area deficit was 15+/-9% (p<0.001) of that on the unaffected side, while the average plantar flexion peak torque deficit was speed-dependent, being 9+/-18%, 10+/-18 and 2+/-13% of that on the unaffected side at 30, 90, and 240 degrees/sec (p<0.001). The correlation between cross-sectional area and peak torque varied in the range 0.52-0.61 at 30, 90 and 240 degrees/sec (p<0.001).