An algorithmic approach for clinical management of low back pain.

BACKGROUND: Low back pain is caused by a variety of conditions. When conventional imaging failed, single-photon emission computed tomography (SPECT) was superior to scintigraphy in identifying the pathology. Injection therapies are often helpful in treating the pathology. AIM: To determine the cause of chronic low backache in individuals with normal conventional imaging (radiographs, computed tomography and magnetic resonance imaging), to determine the specific pathology using scintigraphic studies and diagnostic blocks; and, to treat the individuals with various spinal injection techniques and determine their efficacy. MATERIAL AND METHODS: All the patients having chronic back pain on presentation in the outpatient clinic from April 2013 to October 2014 were prospectively evaluated. RESULTS: The 40 patients included in the study were followed up pre- and post operatively with various pain scales (visual analogue scale [VAS], Oswestry disability index [ODI] and short form health survery 36 [SF36]). The mean age at presentation was 41.3 years. Female patients formed the predominant subgroup in the study (57.5% female and 42.5% male patients). Pain indices like VAS and ODI were helpful in assessing the efficacy of spinal injections. Preoperative and postoperative pain scale assessment, supplemented by a SPECT evaluation of the sacroiliac and facet joints, showed a statistically significant difference, which correlated with clinically significant pain relief. CONCLUSIONS: SPECT imaging is helpful in diagnosing sacroiliac joint syndrome and facetal syndrome. Epidural injections were a better choice in cases of low backache, where clinically, the patient had no signs of sacroiliac joint syndrome and facetal syndrome. Spinal injections with steroid and local anaesthetic had better relief. Radiotracer uptake at the pain generating area is a good predictor of outcome. Image guided spinal injection improves the accuracy of the injection.

Markers of Oxidative Stress, Inflammation, and Endothelial Dysfunction in Diabetic and Nondiabetic Patients with Chronic Kidney Disease on Peritoneal Dialysis.

Chronic kidney disease (CKD) is a low-grade inflammatory state which is accom-panied by elevated markers of oxidative stress, inflammatory, and endothelial dysfunction in patients on peritoneal dialysis (PD). These represent a key triad for the development and progression of atherosclerosis. The present study assessed the markers of oxidative stress, inflammatory and endothelial dysfunction in diabetic and non-diabetic CKD patients on PD. A cross-sectional study was undertaken on 100 CKD patients on PD, of whom 52 patients were nondiabetic and 48 were diabetic patients. Blood samples were estimated for malondialdehyde (MDA) and ferric reducing ability of plasma (FRAP) as markers of oxidative stress; interleukin (IL)-6, high-sensitivity C-reactive protein (hs-CRP), and fibrinogen as inflammatory markers; and markers of endothelial dysfunction such as nitric oxide (NO), carotid wall intimal medial thickness (CIMT), and number of plaques, among others. The MDA levels increased and FRAP levels decreased in both diabetic and nondiabetic CKD patients on PD. The levels of IL-6, hs-CRP, fibrinogen, NO, CIMT, and the number of plaques were significantly higher in diabetic patients than in nondiabetic CKD patients on PD. The lipid profile was significantly atherogenic in diabetic patients compared with nondiabetics CKD patients. The results showed increased oxidative stress, inflammation, and endothelial dysfunction in diabetic patients compared with nondiabetics CKD patients on PD.

Gall stone ileus with acute kidney injury--a case report.

Gall stone ileus is a rare serious complication of cholelithiasis. We report a case of cholecystoduodenal fistula presenting as gall stone ileus with acute kidney injury which was managed successfully.

Utility of Short-Acting Intravenous Insulin Therapy in Preparation of F-18 Fluorodeoxyglucose Positron Emission Tomography Computed Tomography Scan in Cancer Patients Incidentally Detected with High Blood Glucose Levels on the Day of Test.

BACKGROUND: In diabetic (DM) patients, hyperglycemia degrades image quality in F-18 FDG PET CT by altering bio-distribution of FDG in the body and augmenting soft tissue and muscular uptake. We intend to evaluate the use of short acting I.V insulin in minimising the rescheduling of patients detected with FBG>160 mg/dL on the day of scan. AIM AND OBJECTIVES: To show the utility of short acting IV insulin therapy in preparation of cancer patients incidentally detected with high blood glucose levels for F-18 FDG PET CT scan, (>160mg/dL) and to compare the obtained image quality with patients detected with fasting blood glucose level (FBG) <100mg/dL and <160 mg/dL, using visual and semi quantitative methods. MATERIAL AND METHODS: 613 cancer patients referred for PET CT were divided into 3 groups, Group I (n=30): known diabetics (DM) or incidentally diagnosed with FBG >160 mg/dL, Group II (n=349): DM patients with FBG <160 mg/dL (100-160mg/dL), Group III (n=234): Non DM patients FBG <100mg/dL. In Group I short acting insulin was given intravenously using a sliding scale, post insulin after 90 minutes F-18 FDG (radiotracer) injection was given and PETCT scan was obtained 60 mins post radiotracer injection. Qualitative image analysis was done using biodistribution score and quantitative analysis was done by chi square test, ANOVA (analysis of variance) and paired t-test. RESULTS: In group I patients post insulin there was significant decrease in FBG levels (216±22.2 to 136±13.4mg/dL) and acceptable image quality. Comparison of quantitative parameters (mean and maximum SUV calculated by drawing ROI around brain, heart, liver, muscle, subcutaneous fat) among the 3 groups showed significant intergroup difference with p value <0.05. CONCLUSION: This short acting I.V insulin protocol is safe and can be used to obtain optimal quality F-18 FDG PET CT scan images by alleviating the need for rescheduling patients though they present with high glucose levels.

Proptosis in a post-renal transplant patient with disseminated tuberculosis.

A 55-year-old male patient 13 years post living-related renal transplant on immunosuppressives presented with prolonged fever and a recent protrusion of the right eyeball. Evaluation revealed disseminated tuberculosis with a tuberculoma in the right orbit.

Oxidative stress in relation to obesity in breast cancer.

PURPOSE: Breast carcinoma is one of the most common neoplasms in women and is a leading cause of cancer-related deaths worldwide. Obesity-induced chronic inflammation promoted by adipose tissue dysfunction is a key feature, which is thought to be an important link between obesity and cancer. Oxidative stress (OS) has been suggested to play an important role in carcinogenesis. Obese women have been shown to have higher levels of OS markers. The study was performed to know the influence of obesity on OS to be replaced with OS markers in patients with breast cancer. MATERIALS AND METHODS: Thirty women attending the outpatient Department of Surgical Oncology and Surgery at Sri Venkateswara Institute of Medical Science, Tirupati, who were clinically diagnosed and histologically confirmed with breast cancer were considered as the patients and 30 healthy women were included as controls. Malondialdehyde (MDA), protein carbonyls (PCC), and advanced oxidation protein products (AOPP) as oxidative markers along with protein thiols and ferric-reducing ability of plasma (FRAP) were studied as markers of antioxidant status. RESULTS: Patients with breast cancer had significantly higher levels of MDA (P = 0.005), PCC, and AOPP compared to controls (P = 0.001) and significantly lower levels of thiols and FRAP compared to controls (P = 0.001). No significant correlation was found between OS markers and indices of obesity. A significant association was found between OS markers (P = 0.005), PCC (P = 0.002), AOPP (P = 0.002), and breast cancer. CONCLUSIONS: Patients with breast cancer have increased OS as evidenced by an increase in oxidant markers and a decrease in antioxidant markers. OS is not related to their adiposity but is related to the presence of breast cancer.

Nerve and vein preserving neck dissections for oral cancers: a prospective evaluation of spinal accessory nerve function and internal jugular vein patency following treatment.

Nerve and vein preserving modification of the radical neck dissection is commonly used in the management of oral squamous cell cancers. There is limited literature addressing nerve function and vein patency following treatment. We prospectively analysed 65 patients with nerve conduction study using surface electromyography at baseline, 1 month and 6 months post-surgery and colour Doppler of the internal jugular vein at baseline and 1 month post-surgery. We also studied functional outcomes of nerve sparing with arm abduction test and Neck Dissection Quality of Life questionnaire. There was a statistically significant increase in mean latency of motor action potential and decrease in the mean amplitude of the motor action potential following surgery, suggesting nerve dysfunction. Following surgery, there was a significant decrease in the diameter of the vein as well as an increase in the velocity of blood flow; there was partial thrombus in 5% of individuals. In conclusion, even though nerve dysfunction compromised shoulder abduction, vein dysfunction rarely resulted in any significant clinical impact.

Cephalic Arch Stenosis: Location of Stenosis in Indian Hemodialysis Patients.

The cephalic vein is formed over the "anatomical snuff box" and joins the axillary vein just below the clavicular level. The definition of cephalic arch is varied. In the radiology literature, it is defined as the central perpendicular portion of the cephalic vein as it traverses the deltopectoral groove and joins the axillary vein. The possible etiologies of cephalic arch stenosis are numerous. This study aimed to identify patients with cephalic arch stenosis and to discern the domain site of stenosis. This is a retrospective case series of patients who had an arteriovenous fistula with dysfunction of access and ipsilateral upper-limb edema. The clinical features of the access dysfunction were strong pulse due to increased pressure, weak thrill due to poor proximal flow, high static pressure, or decreased dialysis efficiency. All these 25 patients underwent computed tomography (CT) angiogram. The CT angiographic findings revealed cephalic arch stenosis and stenosis in 13 patients (52%). domain IV was slightly more affected than other domains of cephalic arch.

Gastric cancer with isolated leptomeningeal metastases: a case report.

Leptomeningeal carcinomatosis due to gastric cancer is rare. Gadolinium enhanced MRI and CSF analysis for malignant cells are necessary to confirm the diagnosis.

Comparison of PESI, echocardiogram, CTPA, and NT-proBNP as risk stratification tools in patients with acute pulmonary embolism.

OBJECTIVE: The aim of this study is to prospectively assess the diagnostic accuracy of pulmonary embolism severity index, echocardiogram, computed tomography pulmonary angiogram (CTPA), and N-terminal pro b-type natriuretic peptide (NT-proBNP) for predicting adverse events in acute pulmonary embolism patients. METHODS: Thirty consecutive acute pulmonary embolism patients were included in this study. Combined adverse events consisted of in-hospital death or use of escalation of care including cardiopulmonary resuscitation, mechanical ventilation, vasopressor therapy, or secondary thrombolysis during hospital stay. RESULTS: The outcomes were met in 30% of patients. Qanadli index (a measure of clot burden on CTPA) and NT-proBNP were significantly higher in patients with adverse events than those without (p=0.005 and p=0.009, respectively). PESI had moderate positive correlation with right ventricular dysfunction (RVD) (r=0.449, p=0.013) but there was no significant difference in PESI between patients with and without adverse events (p=0.7). Receiver operating characteristic analysis indicated that Qanadli index was the best predictor of adverse events with area under the curve (AUC) of 0.807 (95% CI: 0.651-0.963) with a negative predictive value (NPV) of 100% and positive predictive value (PPV) of 47.4% at cut-off value of 19. Right ventricle to left ventricle ratio on CTPA was found to predict RVD with AUC of 0.94 (95% CI: 0.842-1.000), NPV (77.8%), and PPV (95.2%) at cut-off value at 1.15. CONCLUSION: Qanadli index is more accurate predictor of adverse events than pulmonary embolism severity index, NT-proBNP, and RVD on echocardiogram and CTPA.

Biomarker response to contrast administration in diabetic and nondiabetic patients following coronary angiography.

Neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C represent early renal injury markers for contrast-induced nephropathy (CIN). Baseline parameters such as type and quantity of contrast, patient preparation, renal function status, and diabetes mellitus (DM) are known to affect the response of the kidney to contrast-induced injury. This study was taken up to know the biomarker response to contrast administration in 58 diabetic and 59 nondiabetic male patients with same baseline parameters and baseline serum creatinine <1.2 mg/dl undergoing coronary angiography and their role in predicting the development of CIN. Serum creatinine, serum cystatin C, and urinary-NGAL (u-NGAL) were analyzed at baseline (0 h), 4 h, and 24 h after the administration of contrast medium. CIN was defined as a 25% increase in serum creatinine concentration from the baseline value or an absolute increase of at least 0.5 mg/dl within 48 h after the administration of contrast media. Serum creatinine rose 24 h after contrast administration in the diabetic group compared to 48 h in the nondiabetic group. Serum cystatin C levels rose 24 h after contrast administration in both the groups. The earliest marker to rise in both the groups was u-NGAL at 4 h. Diabetic patients had significantly higher u-NGAL (P = 0.005), and serum creatinine levels (P = 0.008) 4 h, and 24 h after contrast administration, respectively. Serum creatinine and u-NGAL/creatinine at 4 h were found to be the best predictors of CIN in the DM and non-DM patients, respectively. Biomarker response to contrast administration is different in diabetic and nondiabetic patients following contrast administration. Diabetic patients exhibit early and greater degree of renal impairment compared to the nondiabetic patients irrespective of the outcome. We propose the use of serum creatinine in patients with DM and u-NGAL/creatinine in non-DM patients to identify CIN as early as 4 h after contrast administration.

Space occupying lesion (paraganglioma) of the urinary bladder in a young male: A case report and brief review of the literature.

Urinary bladder paragangliomas are rare with a reported incidence of <1% of bladder tumors. In the absence of typical clinical features, histopathology helps in rendering definitive diagnosis. We describe a case of nonfunctional urinary bladder paraganglioma in a 28-year-old male who presented with the chief complaint of abdominal pain. The final diagnosis was made by histopathological and immunohistochemical analysis. It is important to distinguish paraganglioma from urothelial carcinoma as the treatment differs. This is an additional case of nonfunctional urinary bladder paraganglioma in a male patient with a brief review of the literature.

Hepatic metastasis arising from diverse primary pathologies diagnosed on 99mTc-Methylene diphosphonate bone scan.

We are presenting two cases that illustrate nonosseous localization of 99mTc-Methylene diphosphonate (MDP) in hepatic metastases arising from varied primary pathology and review of the literature. This series emphasizes the evidence of MDP localization in hepatic metastases arising from adenocarcinoma of rectum and infiltrating duct cell carcinoma of the breast.

Hemorrhage from lumbar artery following percutaneous renal biopsy.

We present a 58-year-old lady who underwent ultrasound-guided renal biopsy for suspected acute glomerulonephritis. Within minutes, the radiologist noticed an echogenic band around left kidney and in the muscular planes. Computerized tomography revealed focal active contrast extravasation from arcuate or interlobular artery in lower pole of left kidney and lumbar artery at third lumbar vertebra. The bleeding vessel was occluded with gelfoam.

Hepatic cysts in adult polycystic kidney disease.

Of ninety two adult polycystic kidney patients 18.5% had liver cysts. Mostly they were multiple. Liver cysts were more common in men.

Well-differentiated fetal adenocarcinoma of the lung in an adult male: report of an unusual tumor with a brief review of literature.

We report a case of a well-differentiated fetal adenocarcinoma (WDFA) of the lung in a 50-year-old male smoker. The literature regarding this uncommon tumor is limited. This rare variant of adenocarcinoma is more common in females, in the third and fourth decades. Microscopically it is composed of neoplastic glands and tubules that resemble the fetal lung. Well-differentiated fetal adenocarcinoma is a low-grade malignancy and surgery is the preferred mode of therapy. This uncommon case of a well-differentiated fetal adenocarcinoma in an adult male patient is reported, with relevant immunohistochemical findings, along with a discussion of the current literature.

A clinical study of bilateral non-obstructive acute pyelonephritis with acute kidney injury in patients of type 2 diabetes mellitus.

The aim of our study was to study the clinical profile of type 2 diabetes mellitus patients admitted with the diagnosis of acute kidney injury (AKI) due to bilateral acute non-obstructive pyelonephritis. The bilateral involvement was identified on various imaging modalities (ultrasound, computed tomography, nuclear scintigrapy). All the patients had AKI. Those with severe AKI underwent hemodialysis. The factors associated with the severity of illness were identified. Twenty-five patients of type 2 diabetes mellitus admitted with the diagnosis of AKI due to bilateral acute non-obstructive pyelonephritis were identified. On ultrasound, bilateral involvement was found in 12 patients and in 17 patients on computed tomography and eight patients on nuclear scintigraphy. Fourteen of them needed dialysis support. Bilateral acute pyelonephritis needs to be considered while evaluating the AKI in type 2 diabetes mellitus patients.