Brown tumor of the iliac crest initially misdiagnosed as a giant cell tumor of the bone.

SUMMARY: Brown tumors (BTs) are expansile osteolytic lesions complicating severe primary hyperparathyroidism (PHPT). Clinical, radiological and histological features of BTs share many similarities with other giant cell-containing lesions of the bone, which can make their diagnosis challenging. We report the case of a 32-year-old man in whom an aggressive osteolytic lesion of the iliac crest was initially diagnosed as a giant cell tumor by biopsy. The patient was scheduled for surgical curettage, with a course of neoadjuvant denosumab. Routine biochemical workup prior to denosumab administration incidentally revealed high serum calcium levels. The patient was diagnosed with PHPT and a parathyroid adenoma was identified. In light of these findings, histological slices of the iliac lesion were reviewed and diagnosis of a BT was confirmed. Follow-up CT-scans performed 2 and 7 months after parathyroidectomy showed regression and re-ossification of the bone lesion. The aim of this case report is to underline the importance of distinguishing BTs from other giant cell-containing lesions of the bone and to highlight the relevance of measuring serum calcium as part of the initial evaluation of osteolytic bone lesions. This can have a major impact on patients' management and can prevent unnecessary invasive surgical interventions. LEARNING POINTS: Although rare, brown tumors should always be considered in the differential diagnosis of osteolytic giant cell-containing bone lesions. Among giant cell-containing lesions of the bone, the main differential diagnoses of brown tumors are giant cell tumors and aneurysmal bone cysts. Clinical, radiological and histological characteristics can be non-discriminating between brown tumors and giant cell tumors. One of the best ways to distinguish these two diagnoses appears to be through biochemical workup. Differentiating brown tumors from giant cell tumors and aneurysmal bone cysts is crucial in order to ensure better patient care and prevent unnecessary morbid surgical interventions.

Energy expenditure during the group exercise course Bodypump in young healthy individuals.

AIM: The purpose of the present study was to examine the energy expenditure during the group resistance training exercise course Bodypump in young healthy individuals. METHODS: The study population consisted of 40 men and women (age: 31.7±5.8 years, body mass index [BMI]: 24±2.6 kg/m2) that performed three 60-min sessions of the group resistance training exercise course Bodypump. Free living energy expenditure during the course was measured using the portable SenseWear armband. Perceived energy expenditure, perception of effort, fatigue and pleasure were also measured after the course. RESULTS: Mean energy expenditure and intensity during the Bodypump course for all participants were 250.3±67.8 kcal or 4.2 kcal/min and 3.5±0.7 METS, respectively. Interestingly, perceived energy expenditure for all participants was significantly higher by ~67% compared to measured energy expenditure (394.1±116 vs. 250.3±67.8 kcal, respectively; P<0.05). Moreover, 85% of all individuals reported that the Bodypump course was highly enjoyable. CONCLUSION: Energy expenditure during a 60-min Bodypump course appears to be approximately 250 kcal and seems to be performed at a moderate intensity (3.5 METS) in young healthy men and women. These results could have an impact on the amount of physical activity an individual performs as well as the preparation of physical activity programs by kinesiologists.

Additive action of 11beta-HSD1 inhibition and PPAR-gamma agonism on hepatic steatosis and triglyceridemia in diet-induced obese rats.

Both 11beta-hydroxysteroid dehydrogenase (11beta-HSD1) inhibition and peroxisome proliferator-activated receptor-gamma (PPAR-gamma) agonism reduce liver and plasma lipids in rodents through partly distinct mechanisms. This study aimed to assess their additivity of action on liver and plasma lipids in a model of diet-induced steatosis. Rats were fed an obesogenic diet and were treated either with an 11beta-HSD1 inhibitor (Compound A, 3 mg kg(-1) day(-1)) or rosiglitazone (RSG, 5 mg kg(-1) day(-1)) or both for 6 weeks. Compound A and RSG reduced liver steatosis and triglyceridemia, and did so additively when given in combination. The 11beta-HSD1 inhibitor had no effect on serum adiponectin, but increased liver adiponectin receptor type 2 (Adipo-R2) mRNA levels. Conversely, RSG increased serum adiponectin, a likely mediator of its antisteatotic action, but had no effect per se on the Adipo-R2 expression. mRNA levels of representative genes of fatty acid oxidation tended to be increased by both compounds. The study shows that combined 11beta-HSD1 inhibition and PPAR-gamma agonism additively reduce liver steatosis and triglyceridemia, which may eventually prove therapeutically useful.

Correlation between bone lesion changes and cartilage volume loss in patients with osteoarthritis of the knee as assessed by quantitative magnetic resonance imaging over a 24-month period.

OBJECTIVE: To evaluate in patients with knee osteoarthritis (OA) the size changes in bone oedema and cysts over 24 months, and to contrast these changes with cartilage volume loss using quantitative magnetic resonance imaging. METHODS: 107 patients with knee OA, selected from a large trial evaluating the effect of a bisphosphonate, were analysed by magnetic resonance imaging at baseline and 24 months. Assessments of subchondral bone oedema and cysts, and cartilage volume were done. RESULTS: At baseline, 86 patients showed the presence of at least one type of bone lesion: 71 oedema, 61 cysts and 51 both. At 24 months, although not statistically significant, the oedema total size change increased by 2.09 (SD 15.03) mm, and the cyst by 1.09 (8.13) mm; mean size change for the oedema was +0.38 (2.18) mm and -0.10 (4.36) mm for the cyst. When analysed according to subregions, an increase was found for the cyst size in the trochlea (+0.67 (2.74) mm, p = 0.02) and in the lateral tibial plateau (+0.15 (0.83) mm, p = 0.09), and for the oedema size in the medial tibial plateau (+1.73 (8.11) mm, p = 0.05). At 24 months, significant correlations were seen between the loss of cartilage volume and oedema size change in the medial condyle (-0.40, p = 0.0001) and the medial tibial plateau (-0.23, p = 0.03), and the changes in cyst size in the medial condyle (-0.29, p = 0.01). A multivariate analysis showed that the oedema size change was strongly and independently associated with medial cartilage volume loss (-0.31, p = 0.0004). CONCLUSION: These data demonstrate that bone lesions are prevalent in knee OA. The correlation of the oedema and cyst size increase in the medial compartment over time with a greater loss of cartilage volume in this area underlines the importance of subchondral bone lesions in OA pathophysiology.

Metabolic action of peroxisome proliferator-activated receptor gamma agonism in rats with exogenous hypercorticosteronemia.

OBJECTIVE: The beneficial metabolic actions of peroxisome proliferator-activated receptor gamma (PPARgamma) agonism are associated with modifications in adipose tissue metabolism that include a reduction in local glucocorticoid (GC) production by 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1). This study aimed to assess the contribution of GC attenuation to PPARgamma agonism action on gene expression in visceral adipose tissue and global metabolic profile. DESIGN: Rats were treated (2 weeks) with the PPARgamma agonist rosiglitazone (RSG, 10 mg/kg/day) with concomitant infusion of vehicle (cholesterol implant) or corticosterone (HiCORT, 75 mg/implant/week) to defeat PPARgamma-mediated GC attenuation. MEASUREMENTS: mRNA levels of enzymes involved in lipid uptake (and lipoprotein lipase activity), storage, lipolysis, recycling, and oxidation in retroperitoneal white adipose tissue (RWAT). Serum glucose, insulin and lipids, and lipid content of oxidative tissues. RESULTS: Whereas HiCORT did not alter RWAT mass, RSG increased the latter (+33%) independently of the corticosterone status. Both HiCORT and RSG increased lipoprotein lipase activity, the mRNA levels of the de novo lipogenesis enzyme fatty acid synthase, and that of the fatty acid retention-promoting enzyme acyl-CoA synthase 1, albeit in a nonadditive fashion. Expression level of the lipolysis enzyme adipose triglyceride lipase was increased additively by HiCORT and RSG. PPARgamma agonism increased mRNA of the fatty acid recycling enzymes glycerol kinase and cytosolic phosphoenolpyruvate carboxykinase and those of the fatty acid oxidation enzymes muscle-type carnitine palmitoyltransferase 1 and acyl-CoA oxidase, whereas HiCORT remained without effect. HiCORT resulted in liver steatosis and hyperinsulinemia, which were abrogated by RSG, whereas the HiCORT-induced elevation in serum nonesterified fatty acid levels was only partially prevented. The hypotriglyceridemic action of RSG was maintained in HiCORT rats. CONCLUSION: The GC and PPARgamma pathways exert both congruent and opposite actions on specific aspects of adipose tissue metabolism. Both the modulation of adipose gene expression and the beneficial global metabolic actions of PPARgamma agonism are retained under imposed high ambient GC, and are therefore independent from PPARgamma effects on 11beta-HSD1-mediated GC production.

PPARgamma agonism increases rat adipose tissue lipolysis, expression of glyceride lipases, and the response of lipolysis to hormonal control.

AIMS/HYPOTHESIS: The aim of this study was to investigate the effect and mechanisms of action of in vivo peroxisome proliferator-activated receptor gamma (PPARgamma) activation on white adipose tissue (WAT) lipolysis and NEFA metabolism. MATERIALS AND METHODS: Study rats were treated for 7 days with 15 mg/kg of rosiglitazone per day; control rats were not treated. After a 6-h fast, lipolysis and levels of mRNA for lipases were assessed in explants from various adipose depots. RESULTS: Rosiglitazone markedly increased basal and noradrenaline (norepinephrine)-stimulated glycerol and NEFA release from WAT explants, and amplified their inhibition by insulin. Primary adipocytes isolated from PPARgamma agonist-treated rats were also more responsive to noradrenaline stimulation expressed per cell, ruling out a contribution of an altered number of mature adipocytes in explants. Rosiglitazone concomitantly increased levels of mRNA transcripts for adipose triglyceride lipase (ATGL) and monoglyceride lipase (MGL) in subcutaneous and visceral WAT, and mRNA for hormone-sensitive lipase (HSL) in subcutaneous WAT. Lipase expression increased within 12 h of in vitro exposure of naïve explants to rosiglitazone, suggesting direct transcriptional activation. In parallel, chronic in vivo treatment with rosiglitazone lowered plasma NEFAs and in WAT its expected stimulatory action on glycerol and NEFA recycling, and on the expression of genes involved in NEFA uptake and retention by WAT, such processes counteracting net NEFA export. CONCLUSIONS/INTERPRETATION: These findings demonstrate that, in the face of its plasma NEFA-lowering action, PPARgamma agonism stimulates WAT lipolysis, an effect that is compensated by lipid-retaining pathways. The results further suggest that PPARgamma agonism stimulates lipolysis by increasing the lipolytic potential, including the expression levels of the genes encoding adipose triglyceride lipase and monoglyceride lipase.

Meniscal tear and extrusion are strongly associated with progression of symptomatic knee osteoarthritis as assessed by quantitative magnetic resonance imaging.

BACKGROUND: The relation between knee meniscal structural damage and cartilage degradation is plausible but not yet clearly proven. OBJECTIVES: To quantitate the cartilage volume changes in knee osteoarthritis using magnetic resonance imaging (MRI), and determine whether meniscal alteration predicts cartilage volume loss over time. METHODS: 32 patients meeting ACR criteria for symptomatic knee osteoarthritis were studied. MRI knee acquisitions were done every six months for two years. The cartilage volumes of different knee regions were measured. Three indices of structural change in the medial and lateral menisci were evaluated--degeneration, tear, and extrusion--using a semiquantitative scale. RESULTS: 24 patients (75%) had mild to moderate or severe meniscal damage (tear or extrusion) at baseline. A highly significant difference in global cartilage volume loss was observed between severe medial meniscal tear and absence of tear (mean (SD), -10.1 (2.1)% v -5.1 (2.4)%, p = 0.002). An even greater difference was found between the medial meniscal changes and medial compartment cartilage volume loss (-14.3 (3.0)% in the presence of severe tear v -6.3 (2.7)% in the absence of tear; p<0.0001). Similarly, a major difference was found between the presence of a medial meniscal extrusion and loss of medial compartment cartilage volume (-15.4 (4.1)% in the presence of extrusion v -4.5 (1.7)% with no extrusion; p<0.001). CONCLUSIONS: Meniscal tear and extrusion appear to be associated with progression of symptomatic knee osteoarthritis.

Reliability of a quantification imaging system using magnetic resonance images to measure cartilage thickness and volume in human normal and osteoarthritic knees.

OBJECTIVE: The aim of this study was to evaluate the reliability of a software tool that assesses knee cartilage volumes using magnetic resonance (MR) images. The objectives were to assess measurement reliability by: (1) determining the differences between readings of the same image made by the same reader 2 weeks apart (test-retest reliability), (2) determining the differences between the readings of the same image made by different readers (between-reader agreement), and (3) determining the differences between the cartilage volume readings obtained from two MR images of the same knee image acquired a few hours apart (patient positioning reliability). METHODS: Forty-eight MR examinations of the knee from normal subjects, patients with different stages of symptomatic knee osteoarthritis (OA), and a subset of duplicate images were independently and blindly quantified by three readers using the imaging system. The following cartilage areas were analyzed to compute volumes: global cartilage, medial and lateral compartments, and medial and lateral femoral condyles. RESULTS: Between-reader agreement of measurements was excellent, as shown by intra-class correlation (ICC) coefficients ranging from 0.958 to 0.997 for global cartilage (P<0.0001), 0.974 to 0.998 for the compartments (P<0.0001), and 0.943 to 0.999 for the condyles(P<0.0001). Test-retest reliability of within-reader data was also excellent, with Pearson correlation coefficients ranging from 0.978 to 0.999 (P<0.0001). Patient positioning reliability was also excellent, with Pearson correlation coefficients ranging from 0.978 to 0.999 (P<0.0001). CONCLUSIONS: The results of this study establish the reliability of this MR imaging system. Test-retest reliability, between-reader agreement, and patient positioning reliability were all extremely high. This study represents a first step in the overall validation of an imaging system designed to follow progression of human knee OA.

Soft-tissue venous malformations in adult patients: imaging and therapeutic issues.

Venous malformations are the most common vascular malformations. However, confusion with respect to terminology and imaging guidelines continues to result in improper diagnosis and treatment. An appropriate classification scheme for vascular anomalies is important to avoid the use of false generic terms. Adequate imaging in association with clinical findings is crucial to establishing the correct diagnosis. Doppler ultrasonography should be the initial imaging modality and demonstrates absence of flow or low-velocity venous flow. Computed tomography and magnetic resonance (MR) imaging are used primarily for pretreatment evaluation of lesion extension. These lesions are usually hypointense on T1-weighted MR images and markedly hyperintense on T2-weighted images with variable gadolinium enhancement. Direct phlebography helps confirm the diagnosis and exclude other soft-tissue tumors. Three distinct phlebographic patterns (cavitary, spongy, dysmorphic) have been identified. In most cases, conservative treatment is recommended. Sclerotherapy with or without surgery is useful in cases of functional impairment or significant aesthetic prejudice, even if recurrences are frequent. Direct phlebography is performed when a more detailed assessment of the vascular pattern is needed or as part of sclerotherapy. Use of the appropriate imaging technique is critical in establishing the diagnosis, evaluating extension, and planning appropriate treatment.

Bone metastasis from a granulosa cell tumor of the ovary.

BACKGROUND: Granulosa cell tumors (GCT) of the ovary generally have a good prognosis. Recurrences tend to be late and are usually abdominopelvic. Bone metastases are extremely rare. CASE: A case of recurrent GCT with vertebral metastasis is presented. Radiologic studies were helpful in documenting the presence of an invasive tumor destroying the vertebral body of T7. Bone scintigraphy excluded other metastatic sites. Diagnosis could not be established by CT-scan-directed fine-needle aspiration cytology or trocar biopsies. Since the lesion was isolated and resectable, aggressive surgery with complete tumoral excision was performed followed by local radiation therapy. Megestrol acetate was given as systemic treatment. CONCLUSION: Multiple treatments of GCT may alter the pattern of recurrence. Every symptom should be thoroughly evaluated. Bone metastases may be treated aggressively.

Adaptation of parents in relation to their 6-month-old infant's type of disability.

The adaptation of parents to a disabled infant was studied in relation to the type of disability presented by the baby. Participants were divided according to three types of disability and one control group: patents of infants with (1) Down's syndrome (DS), (2) congenital heart disease (CHD), (3) a cleft lip and/or palate (CLP), and (4) no disability (ND). The data were collected using a self-administered questionnaire given to each parent 6 months after the birth of their baby. The measures included parenting stress, stress appraisal, and psychological distress. Overall, the results indicate that parents of infants with DS and parents of infants with CHD report greater levels of parenting stress and psychological distress than parents of babies with CLP or non-disabled infants. Mothers were found to report greater levels of stress and distress overall, but differences across diagnostic groups were similar for mothers and fathers. The implications of the findings for theory and clinical intervention are discussed.

Preference for sex of first child among women classified as androgynous and nonandrogynous.

This paper examined the relation between gender-role orientation and the preference for sex of firstborn child in 212 pregnant nulliparous women. The Bem Sex-role Inventory was used to assess gender-role orientation of participants. Analysis suggested that gender-role orientation, as measured does not effectively predict the preference for sex of firstborn child.

Correlation between ossification of the stylohyoid ligament and osteophytes of the cervical spine.

OBJECTIVE: To investigate the correlation between ligamentous ossification or osteophytes of the cervical spine and ossification of the styloid process and stylohyoid ligament, and to determine any relation between diffuse idiopathic skeletal hyperostosis (DISH) of the thoracic spine and ossification of the styloid process and stylohyoid ligament. METHODS: Four patients having cervical spine DISH, an elongated styloid process and/or variable patterns of stylohyoid ligament ossification, and clinical findings compatible with Eagle's syndrome are described. Cervical computed tomography scans of 100 patients who also had lateral radiographs of the thoracic spine were reviewed. Point biserial and Spearman rank correlation analysis, McNemar test, chi-squared test, and Fisher's exact test were used to determine correlation between elongation of the styloid process and/or ossification of the stylohyoid ligament and (1) ligamentous ossification or osteophytes of the cervical spine (the characteristic spinal manifestation of DISH), and/or (2) DISH of the thoracic spine. RESULTS: (1) Elongation of the styloid process and variable patterns of ossification of the proximal, middle, and distal parts of the stylohyoid ligament, and (2) enlargement of this ligament were significantly correlated with transverse and anteroposterior dimensions of ligamentous ossification or osteophytes of the cervical spine at various levels. The prevalence of such abnormalities of this process and ligament was not significantly different between the patients with and without thoracic spine DISH. CONCLUSION: Variable types of styloid process-stylohyoid ligament complex abnormalities have significant correlation with ligamentous ossification and osteophytes of the cervical spine.

Knee joint hyaline cartilage defects: a comparative study of MR and anatomic sections.

The value of routinely used MR sequences in the detection of focal changes of femorotibial articular cartilage was studied. T1-weighted, proton density, and T2-weighted SE as well as gradient echo images were acquired in 20 cadaveric knees (56-88 years old, mean 73.8 years). Three hundred five coronal and sagittal (3 mm) anatomic sections were prepared, and 82 areas of cartilage defects were identified. Initially, in an unblinded fashion, correlation of MR scans and anatomic sections was performed. Fifty-nine lesions (72.0%) were detectable on T1-weighted images, 57 (70.0%) with meniscal windowing, 49 (60.0%) on proton density images, 56 (68.3%) on T2-weighted images, and 54 (65.9%) on gradient echo images. Sixty-eight (83.0%) were visible on at least one type of imaging sequence. Most defects presented as a focus of abnormal signal. Subsequently, images of a subset of 35 pathologic and 35 normal cartilage surfaces were blindly evaluated by two osteoradiology fellows. Sensitivity was 71.4% for the detection of focal cartilage changes, specificity was 68.6%, and accuracy was 70.0%. We conclude that the value of those MR sequences that are routinely used in the analysis of internal derangements of the knee in the detection of focal defects of the hyaline cartilage is limited.

Factors influencing physicians' preventive practices.

We used data on a stratified random sample of 809 Quebec physicians to determine the extent to which the integration of prevention into medical practice was related to physicians' sociodemographic background, area of specialization, medical practice characteristics, and professional attitudes. Among factors positively associated with physicians' preventive practices were favorable attitudes toward prevention, patient education and patient-oriented activities, being in primary care medicine or in a medical specialty such as cardiology, gastroenterology, or pneumology, practicing in a public community health center on a salary basis, working in a group practice, having an office-based practice, devoting time to research activities, being older, and being a woman. Specialization in neurology, hematology, dermatology, nephrology, obstetrics-gynecology, and most notably surgery was negatively associated with preventive practices, as was working in an emergency room. Overall, the study variables explained 33% of the variance in physicians' preventive practices. The study underlines the prevailing role of attitudes in predicting physicians' preventive practices.

Do female general practitioners have a distinctive type of medical practice?

Using data collected in 1983-84 for a representative sample of 736 general practitioners practising in Quebec, we compared the practice characteristics of the 296 female physicians and the 320 male physicians who agreed to participate. The female doctors were more likely than the male doctors to favour salaried practice in local community health centres, to practise in an urban setting and to have an office-based practice. The female physicians had a less diversified type of practice, being less involved in hospital care, emergency care, home care and administrative work. Sex differences were more marked for physicians in fee-for-service practice than for salaried physicians. Given the increasing numbers of women in the medical profession, these findings are of special interest since they indicate distinctive differences in medical practice between women and men.

Generalists trained in family medicine.

Since their creation in the early 1970s, the residency programs in family medicine have attracted an increasing number of medical graduates. In Quebec, over 1000 general practitioners have received their primary-care training in these programs. In order to assess the potential impact of these new training programs, we surveyed the medical practice characteristics of a representative sample of general practitioners, 294 trained in family medicine and 442 trained in the traditional programs. Results showed that trainees in family medicine were more likely to join group practice, to work in rural areas, to deliver hospital care, to work on a salary basis in local community health centres, and to be involved in teaching and research. There were, however, no differences between the two groups of general practitioners in their interventions with patients, particularly with regard to health promotion, patient education, and humanization of care. Implications of these results are discussed.