Comparison and Correlation of Magnetic Resonance Imaging and Clinical Severity in Nonhuman Immunodeficiency Virus Patients with Cryptococcal Infection of Central Nervous System.

BACKGROUND: The incidence of cryptococcal meningitis among immunocompetent patients increases, especially in China and imaging plays an important role. The current study was to find the correlation between magnetic resonance imaging (MRI) manifestation and clinical severity in nonhuman immunodeficiency virus patients with cryptococcal infection of central nervous system (CNS). METHODS: A total of 65 patients with CNS cryptococcal infection from August 2014 to October 2016 were retrospectively included in this study. All the patients had MRI data and clinical data. The patients were divided into two groups according to whether the patients were confirmed with identifiable underlying disease. Comparison and correlation of MRI and clinical data in both groups were investigated using independent sample t- test, Chi-square test, Mann-Whitney test and Spearman rank correlation analysis. RESULTS: In all 65 patients, 41 cases (41/65, 63.1%; Group 1) had normal immunity and 24 cases (24/65, 36.9%; Group 2) had at least one identifiable underlying disease. Fever, higher percentage of neutrophil (NEUT) in white blood cell (WBC), and increased cell number of cerebral spinal fluid (CSF) were much common in patients with underlying disease (Group 1 vs. Group 2: Fever: 21/41 vs. 21/24, χ2 = 8.715, P = 0.003; NEUT in WBC: 73.15% vs. 79.60%, Z = -2.370, P = 0.018; cell number of CSF: 19 vs. 200, Z = -4.298, P < 0.001; respectively). Compared to the patients with normal immunity, the lesions are more common in the basal ganglia among patients with identifiable underlying disease (Group 1 vs. Group 2: 20/41 vs. 20/24, χ2 = 7.636, P = 0.006). The number of the involved brain areas in patients with identifiable underlying disease were well correlated with the number of cells and pressure of CSF (r = -0.472, P = 0.031; r = 0.779, P = 0.039; respectively). CONCLUSIONS: With the increased number of the involved brain areas in patients with identifiable underlying disease, the body has lower immunity against the organism which might result in higher intracranial pressure and more severe clinical status.

Evaluation of "top-down" treatment of early Crohn's disease by double balloon enteroscopy.

AIM: To assess "top-down" treatment for deep remission of early moderate to severe Crohn's disease (CD) by double balloon enteroscopy. METHODS: Patients with early active moderate to severe ileocolonic CD received either infusion of infliximab 5 mg/kg at weeks 0, 2, 6, 14, 22 and 30 with azathioprine from week 6 onwards (Group I), or prednisone from week 0 as induction therapy with azathioprine from week 6 onwards (Group II). Endoscopic evaluation was performed at weeks 0, 30, 54 and 102 by double balloon enteroscopy. The primary endpoints were deep remission rates at weeks 30, 54 and 102. Secondary endpoints included the time to achieve clinical remission, clinical remission rates at weeks 2, 6, 14, 22, 30, 54 and 102, and improvement of Crohn's Disease Endoscopic Index of Severity scores at weeks 30 and 54 relative to baseline. Intention-to-treat analyses of the endpoints were performed. RESULTS: Seventy-seven patients were enrolled, with 38 in Group I and 39 in Group II. By week 30, deep remission rates were 44.7% and 17.9% in Groups I and II, respectively (P = 0.011). The median time to clinical remission was longer for patients in Group II (14.2 wk) than for patients in Group I (6.8 wk, P = 0.009). More patients in Group I were in clinical remission than in Group II at weeks 2, 6, 22 and 30 (2 wk: 26.3% vs 2.6%; 6 wk: 65.8% vs 28.2%; 22 wk: 71.1% vs 46.2%; 30 wk: 68.4% vs 43.6%, P < 0.05). The rates of clinical remission and deep remission were greater at weeks 54 and 102 in Group I, but the differences were insignificant. CONCLUSION: Top-down treatment with infliximab and azathioprine, as compared with corticosteroid and azathioprine, results in higher rates of earlier deep remission in early CD.

Low-dose azathioprine effectively improves mucosal healing in Chinese patients with small bowel Crohn's disease.

OBJECTIVE: To evaluate mucosal healing after 24-month low-dose azathioprine (AZA) treatment in Chinese patients with moderate small bowel Crohn's disease (CD). METHODS: Patients with lesions mainly located at the ileum were screened by baseline multislice computed tomography enterography and anal-route double-balloon enteroscopy (DBE). They were naive to any immunomodulators and biological agents before the enrollment. Lesions from 150 cm of the terminal ileum proximal to ileocecal valve were assessed by DBE with the simple endoscopic score for CD (SES-CD) after 12 and 24 months of low-dose AZA treatment, respectively. RESULTS: The average maximal tolerance dose of AZA was 61.8 ± 17.2 mg/day. The total rates of complete, near-complete, partial and no mucosal healing in 36 patients were 19.4%, 5.6%, 27.8% and 47.2% at month 12 and 30.6%, 25.0%, 33.3% and 11.1% at month 24, respectively. The baseline SES-CD (odds ratio [OR] 2.71, 95% confidence interval [CI] 1.11-6.63, P = 0.029) and duration of disease (OR 1.27, 95% CI 1.10-1.47, P = 0.001) were two relevant factors associated with the mucosal healing of patients with small bowel CD. CONCLUSION: A 24-month low-dose AZA regimen as maintenance treatment in moderate small bowel CD could achieve a higher mucosal healing rate than that of 12-month treatment in Chinese patients, especially in those with duration of disease less than 12 months and a baseline SES-CD of 5 or 6.

Quantitative measures of comb sign in Crohn's disease: correlation with disease activity and laboratory indications.

To determine retrospectively if quantitative measures of the comb sign at CT enterography correlated with laboratory indications in Crohn's disease. We retrospectively included 72 known CD patients (47 male and 25 female patients) and 41 normal controls who had undergone CT enterography (CTE) from 2008 to 2010 and had high-sensitive C reaction protein (Hs-CRP) and erythrocyte sedimentation rate (ESR) results. We divided the 72 CD patients into two groups based on disease activity which was determined by Rutgeerts' score. 41 patients were characterized as active disease while 31 patients were as inactive disease. For each individual, one reformatted coronal CTE image in which the comb sign (vasa recta) was most obviously displayed was selected by two experienced radiologists in a double blind manner. For each image, 20 regions of interest (ROI) with area of 1 cm(2) were drawn and placed over the site where the comb sign exists; the comb sign amount was counted in each ROI and recorded. Total amount of the comb sign were assessed from 20 ROI data. Quantitative comb sign results were compared with Hs-CRP and ESR level. Quantitative comb sign score is significantly higher in the CD group than in the control group at both the arterial stage and venous stage (P < 0.001). Quantitative comb sign score is obviously higher in active CD patients than in inactive CD patients both at arterial stage and venous stage (3.63 vs. 2.86 at arterial stage; 3.53 vs. 2.90 at venous stage). ESR level was well correlated with quantitative comb sign score both at arterial and venous stage whereas Hs-CRP has no significant correlation at either stage. Quantitative comb sign results did well in predicting CD activity with the accuracy rate of 78.4% at arterial stage and 80% at venous stage when using 3.33 as the cutoff of quantitative comb sign score. Quantitative comb sign score is a promising CTE parameter in predicting CD activity and be well correlates with the ESR level.

Crohn's disease: CT enterography manifestations before and after treatment.

PURPOSE: The purpose of this study was to determine whether CT enterography (CTE) changes of Crohn's disease (CD) after treatment correlated with clinical remission. MATERIALS AND METHODS: We retrospectively studied 50 known CD patients (male: 35; female: 15) with clinical remission in a period of 3 years (2005-2008). CD was diagnosed by clinical, enteroscopic and pathologic manifestations. Clinical remission was identified by experienced gastroenterologists using the combing criteria of clinical, endoscopy and laboratory tests. First CTE and endoscopy exams were performed during their first hospitalization in our hospital meanwhile CD diagnosis was made during that time. Repeated CTE and endoscopy exams were done after treatment. CTE findings were determined by two experienced radiologists with double-blind approach. Each patient was analyzed for the CTE parameters including bowel wall attenuation, bowel wall thickening (>3mm), bowel wall thickening types (type A: multilayered mural stratification; type B: two layers with strong mucosal enhancement and prominent low-density submucosa; type C: two layers without strong mucosal enhancement; type D: homogeneous enhancement) comb sign, luminal stenosis (mild: luminal diameter 2-3 cm; moderate: luminal diameter 1-2 cm; severe: luminal diameter<1cm) and the presence of extraenteric complications (such as fistulas and abscess). All the quantitative parameters were measured three times by each review. RESULTS: After treatment, bowel wall thickening was attenuated in 88% of CD patients. Thickness of bowel wall was decreased from 8.8 ± 2.8mm to 6.4 ± 1.9 mm (P<0.001). CT value of bowel wall in portal stage was also declined from 90.0 ± 15.4 (HU) to 73.4 ± 14.2 (HU (P<0.001). The percentage of patients with type A or B bowel wall thickening was decreased from 78.7% to 35.4%, while those with type C or D thickening was increased from 21.2% to 64.6% (P<0.001). The percentage of patients with comb sign was decreased from 88% to 60% (P=0.001). The percentage of patients with moderate or severe luminal stenosis was reduced from 74% to 32% (P<0.001). The ROC (receiver operating characteristic) analysis showed bowel wall attenuation (A(z)=0.89) and bowel wall thickness (A(z)=0.81) were the two best parameters to predict disease activity, and combining of these two values was better than using them solely (κ=0.71, P<0.001). The bowel wall attenuation (OR=9.56, P<0.001) and bowel wall thickness (OR=3.32, P=0.001) were significantly correlated with the disease activity in the following logistic regression analysis. CONCLUSION: Therapeutic effect of CD and disease activity can be properly evaluated by CTE.

Special diaphragm-like strictures of small bowel unrelated to non-steroidal anti-inflammatory drugs.

AIM: To summarize clinical, endoscopic, radiologic and pathologic features of special diaphragm-like strictures found in small bowel, with no patient use of non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: From January 2000 to December 2009, 5 cases (2 men and 3 women, with a mean age of 41.6 years) were diagnosed as having diaphragm-like strictures of small bowel on imaging, operation and pathology. All the patients denied the use of NSAIDs. The clinical, endoscopic, radiologic and pathologic findings in these 5 patients were retrospectively reviewed from the hospital database. Images of capsule endoscopy (CE) and small bowel follow-through (SBFT) obtained in 3 and 3 patients, respectively, and images of double-balloon enteroscopy and computed tomography enterography (CTE) obtained in all 5 patients were available for review. RESULTS: All patients presented with long-term (2-16 years) symptoms of gastrointestinal bleeding and varying degrees of anemia. There was only one stricture in four cases and three lesions in one case, and all the lesions were located in the middle or distal segment of ileum. Circumferential stricture was shown in the small bowel in three cases in the CE image, but the capsule was retained in the small bowel of 2 patients. Routine abdomen computed tomography scan showed no other abnormal results except gallstones in one patient. The lesions were shown as circumferential strictures accompanied by dilated small bowel loops in the small bowel on the images of CTE (in all 5 cases), SBFT (in 2 cases) and double-balloon enteroscopy (in all cases). On microscopy, a chronic inflammatory infiltrate and circumferential diaphragm were found in all lesions. CONCLUSION: Diaphragm-like strictures of small bowel might be a special consequence of unclear damaging insults to the intestine, having similar clinical, endoscopic, radiologic and pathologic features.

[Direct repair of adolescent lumbar spondylolysis using a pedicle screw-laminar hook system by paramedian approach].

OBJECTIVE: To discuss the indication and clinical effect of direct repair of adolescent lumbar spondylolysis by screw-laminar hook system. METHODS: From August 2003 to December 2008, 28 patients (13 males and 15 females,ranging in age from 15 and 26 years, averaged 21.6 years) with lumbar spondylolysis were treated with isthmic bone grafting and internal fixation with a pedicle screw-laminar hook system. Three patients had spondylolysis at L3, L4; 5 patients had spondylolysis at L4, L5; 8 patients had spondylolysis at L4; and 12 patients had spondylolysis at L5. All the patients had low back pain and lasted over 6 months. According to preoperative and postoperative plain radiograph, CT scan and Macnab criteria, the fusion rate and clinical effect of this technique were evaluated. RESULTS: All the patients were followed up with a mean period of 14.9 months, ranging from 9 to 24 months. All the patients had bony union according to the X-rays and CT scan. According to the calculation results of Macnab criteria, 22 patients got an excellent result, 5 good and 1 fair. CONCLUSION: The direct repair of adolescent lumbar spondylolysis with pedicle screw-laminar hook system can shorten length of operation,decrease blood loss, preserve more posterior structures of spine and avoid iatrogenic instability of spine. The postoperative immediate stability of vertebral segment is acquired and the mobility of adjacent intervertebral discs is reserved. The screw-laminar hook system for the treatment of adolescent spondylolisthesis can get satisfactory clinical results.

Imaging features of small intestinal amyloidosis: a case report.

Amyloidosis is a rare disease characterized by forming pathological protein deposits in organs or tissues. The localized form of amyloidosis affecting small intestine is rare. We report a case of small intestine amyloidosis which presented gastrointestinal bleeding and abdominal pain. We also display radiologic features of amyloidosis of the small bowel which will add evidence to accurate diagnosis and management.

Prognostic factors and outcome of resected patients with gastrointestinal stromal tumors of small intestine.

We document the clinical behavior of gastrointestinal stromal tumors (GISTs) of the small intestine and identify predictors for long-term disease-free survival (DFS) for small intestine GIST patients. From December 2001 to 2008, 114 consecutive patients with mesenchymal tumors involving the small intestine were enrolled. There were 54 male and 60 female (50.6%) patients. After a median follow-up period of 36 months (ranging from 12 to 96 months), recurrence was noted in 19 patients (16.7%) with a median time of 20 months (ranging from 7 to 50 months). There were 12 patients (10.5%) who died of GISTs with a median time from recurrence to death of 14 months (ranging from 8 to 22 months). Univariate analysis by log-rank test indicated that tumor size and mitotic activity were statistically significant for DFS (P = 0.001 and 0.036, respectively). Tumor size was the only significant predictive factor for DFS according to multivariate analysis (P = 0.006). Small tumor size, indicating low risk, predicted more favorable DFS of small intestine GIST patients who underwent curative resection.

New progress in CT and MRI examination and diagnosis of small intestinal tumors.

Precise examination and diagnosis of small intestinal tumors is difficult because of the curved course and overlapping canal of the small intestine. Traditional technology for intestinal canal examination and endoscopy cannot exhibit the intestinal wall and extra-luminal structure well. With the development and advancement of multi-slice spiral computed tomography and magnetic resonance imaging (MRI), computed tomography enteroclysis (CTE) and magnetic resonance enteroclysis (MRE) are widely used in the examination and diagnosis of small intestinal tumors. CTE and MRE, with three-dimensional imaging capabilities and excellent soft-tissue contrast, can analyze the abnormalities of peripheral intestinal structure as well as the tunica mucosa. In addition, these two technologies can clearly reveal the localization, appearance, degree of mesenteric infiltration and remote tumor metastasis, which increases our cognition of the imaging diagnosis for intestinal tumors. Here we review recent progress in imaging (CT and MRI) examination and diagnosis of small intestinal tumors.

[Effects of Astragalous Injection on oxidative stress status in maintenance hemodialysis patients].

OBJECTIVE: To analyze the effects of Astragalous Injection on oxidative stress and micro-inflammatory status in patients undergoing maintenance hemodialysis (MHD). METHODS: Sixty MHD patients were included and randomized into treatment group and control group, with another 10 healthy volunteers as normal control. The patients in the treatment group were treated with Astragalous Injection and the patients in the control group were treated with normal saline for 12 weeks. A spectrophotometric method was used for the measurement of plasma concentrations of oxidative parameters including advanced glycation end products (AGEs), advanced oxidation protein product (AOPP), malondialdehyde (MDA) and vitamin E (Vit E). The content of C-reactive protein (CRP) was evaluated by enzyme-linked immunosorbent assay. RESULTS: Compared with the normal control group, the plasma levels of AGEs, AOPP, MDA and CRP were significantly increased, while plasma level of Vit E was significantly decreased in MHD patients ( P<0.01). After Astragalous Injection treatment, the plasma levels of AGEs, AOPP, MDA and CRP were decreased as compared with the control group ( P<0.01), while there was no significant difference in plasma Vit E level between the treatment group and control group. CONCLUSION: There exist oxidative stress and micro-inflammation in MHD patients. Astragalous Injection can ameliorate the accumulation of oxidative products and micro-inflammatory status, but it has no significant effect on plasma Vit E level.