The value of palpation, varicoscreen contact thermography and colour Doppler ultrasound in the diagnosis of varicocele.

Three non-invasive methods for the detection of a varicocele were evaluated in 63 men presenting with infertility. Physical examination, varicoscreen contact thermography and colour Doppler ultrasound were compared with spermatic venography as reference strategy. Physical examination had a sensitivity of 71%. Whether the non-palpable varicoceles are all subclinical is questionable since the specificity of physical examination was 69%. Varicoscreen proved be quick, easy and cheap but of no clinical value (sensitivity 97%, specificity 9%). Colour Doppler ultrasound using strict criteria was a good diagnostic tool (sensitivity 97%, specificity 94%). No imaging difference was seen with colour Doppler ultrasound among clinical and subclinical varicoceles. Since the debate on treating all degrees of varicocoeles is ongoing, we suggest that Doppler sonography should be a routine examination in infertile men.

Comparison of cystic rheumatoid arthritis and erosive rheumatoid arthritis.

OBJECTIVE: To test the hypothesis that cystic rheumatoid arthritis (RA), characterized as subchondral cysts as the only radiographic abnormality in hands and feet for 2 years after first abnormal radiograph, is a mild subset of RA. METHODS: Fifty-four patients with cystic RA were compared with 144 RA controls matched for age, sex, disease duration, and year of first visit. All patients were randomly selected from a database of 1580 patients with RA attending the clinic 1982-88. In 1994, data of 90% of the patients were collected by one investigator, blinded to the study groups. All available radiographs were scored for erosions and cysts by one radiologist. RESULTS: During 17 years of followup (range 2-48 yrs), the cystic RA group had less severe disease. There were fewer disease modifying antirheumatic drug prescriptions and fewer orthopedic operations in the group with cystic RA. The proportion of Rose-Waaler seropositives and the proportion of patients with extraarticular manifestations were the same for both groups. At final assessment, the median Health Assessment Questionnaire score was significantly lower for the group with cystic RA (0,88 vs 1,56; p <0.01). The final radiographic score was significantly lower for the cystic RA group (0,22 vs 0,58; p <0.01). The outcome differences remained after correcting for early radiographic score, rheumatoid factor, early erythrocyte sedimentation rate (ESR), and presence of comorbidity in a multiple regression model. Mortality was the same for both groups. CONCLUSION: Cystic RA is a relatively mild subset of RA.

Defaecation disorders in children, colonic transit time versus the Barr-score.

It is still unclear how to evaluate the existence of faecal retention or impaction in children with defaecation disorders. To objectivate the presence and degree of constipation we measured segmental and total colonic transit times (CTT) using radio-opaque markers in 211 constipated children. On clinical grounds, patients (median age 8 years (5-14 years)) could be divided into three groups; constipation, isolated encopresis/soiling and recurrent abdominal pain. Barr-scores, a method for assessment of stool retention using plain abdominal radiographs, were obtained in the first 101 patients, for comparison with CTT measurements as to the clinical outcome. Of the children with constipation, 48% showed significantly prolonged total and segmental CTT. Surprisingly, 91% and 91%, respectively, of the encopresis/soiling and recurrent abdominal pain children had a total CTT within normal limits, suggesting that no motility disorder was present. Prolonged CTT through all segments, known as colonic inertia, was found in the constipation group only. Based on significant differences in clinical presentation, CTT and colonic transit patterns, encopresis/soiling children formed a separate entity among children with defaecation disorders, compared to children with constipation. Recurrent abdominal pain in children was in the great majority, not related to constipation. Barr-scores were poorly reproducible, with low inter- and intra-observer reliability. This is the first study which shows that clinical differences in constipated children are associated with different colonic transit patterns. The usefulness of CTT measurements lies in the objectivation of complaints and the discrimination of certain transit patterns. Conclusion. Abdominal radiographs, even when assessed with the Barr-score proved unreliable in diagnosing constipation.(ABSTRACT TRUNCATED AT 250 WORDS)

Gadolinium-DTPA enhanced magnetic resonance imaging of bone cysts in patients with rheumatoid arthritis.

OBJECTIVES: To examine the contents of intraosseous cysts in patients with rheumatoid arthritis (RA) through the signal intensity characteristics on gadolinium-DTPA (Gd-DTPA) enhanced magnetic resonance imaging. METHODS: The hand or foot joints of nine patients with the cystic form of RA (where the initial radiological abnormality consisted of intraosseous cysts without erosions) were imaged before and after intravenous administration of Gd-DTPA. A 0.6 unit, T1 weighted spin echo and T2* weighted gradient echo were used to obtain images in at least two perpendicular planes. RESULTS: Most cysts showed a low signal intensity on the non-enhanced T1 weighted (spin echo) images and a high signal intensity on the T2* weighted (gradient echo) images, consistent with a fluid content. No cyst showed an enhancement of signal intensity on the T1 weighted images after intravenous administration of Gd-DTPA, whereas synovium hyperplasia at the site of bony erosions did show an increased signal intensity after Gd-DTPA. Magnetic resonance imaging detected more cysts (as small as 2 mm) than plain films, and the cysts were located truly intraosseously. In six patients no other joint abnormalities were identified by magnetic resonance imaging; the three other patients also showed, after Gd-DTPA administration, an enhanced synovium at the site of bony erosions. CONCLUSIONS: It is suggested that intraosseous bone cysts in patients with RA do not contain hyperaemic synovial proliferation. The bone cysts in patients with the cystic form of RA may be the only joint abnormality.

The value of radiographs and bone scintigraphy in suspected scaphoid fracture. A statistical analysis.

The role of radiography and bone scintigraphy in the diagnostic management of suspected scaphoid fracture is controversial. Two strategies were compared for patients with initial negative radiographs: repeated radiography versus selective bone scintigraphy. Using the known positive predictive value of scintigraphy, the sensitivity and specificity of both diagnostic strategies were evaluated in a series of 78 consecutive patients. The kappa value for initial radiographs was 0.76 but decreased to 0.5 for follow-up radiographs. Similarly, sensitivity decreased from 64% to 30% in follow-up radiographs. Specificity of the bone scan was 98%. The best diagnostic strategy in the management of clinically suspected scaphoid fractures consists of initial radiography followed by bone scintigraphy in patients with negative radiographs.

Cystic rheumatoid arthritis: description of a nonerosive form.

In a study of patients with rheumatoid arthritis (RA), 9% (n = 70) were found to have a cystic form. At radiologic examination of these patients with cystic RA, the first abnormality seen consisted of periarticular intraosseous cysts without erosions. The cysts were distributed symmetrically, most often located at the proximal side of the joints and predominantly around the proximal interphalangeal, metacarpophalangeal, and wrist joints of the hands and the first interphalangeal and metatarsophalangeal joints of the feet. Computed tomographic scans showed the peripheral intraosseous location of the cysts. Magnetic resonance images showed that the cysts may contain fluid, inflamed synovia, or both. Cysts can be an important feature in the diagnosis of RA and a supplement to the criteria of the American Rheumatism Association. Osteoporosis, joint-space narrowing, and joint destruction occurred less frequently in patients with cystic RA than in patients with classic RA. Of the patients with cystic RA, 54% were male, and 50% were seronegative. This study is a supplement to and an enlargement on earlier descriptions of cyst predominance in RA.

The cystic form of rheumatoid arthritis.

A non-erosive form of rheumatoid arthritis (R.A.) was found in 62 patients out of 660 patients with R.A. These 62 patients exhibit slowly progressive cystic changes in about the same joints in which usually erosions develop in classic R.A. The E.S.R. is often low, half of the patients remained seronegative and there are 35 males and 27 females in the group. A smaller group of 15 out of these patients could be followed from a stage wherein the radiographs were normal to a stage of extensive cystic changes, over a period of at least 6 years. An attempt is made to delineate this group within the Rheumatoid arthritis disease entity.