Reproducibility of Lesion Count in Various Subregions on MRI Scans in Multiple Sclerosis.

Purpose: Lesion number and burden can predict the long-term outcome of multiple sclerosis, while the localization of the lesions is also a good predictive marker of disease progression. These biomarkers are used in studies and in clinical practice, but the reproducibility of lesion count is not well-known. Methods: In total, five raters evaluated T2 hyperintense lesions in 140 patients with multiple sclerosis in six localizations: periventricular, juxtacortical, deep white matter, infratentorial, spinal cord, and optic nerve. Black holes on T1-weighted images and brain atrophy were subjectively measured on a binary scale. Reproducibility was measured using the intraclass correlation coefficient (ICC). ICCs were also calculated for the four most accurate raters to see how one outlier can influence the results. Results: Overall, moderate reproducibility (ICC 0.5-0.75) was shown, which did not improve considerably when the most divergent rater was excluded. The areas that produced the worst results were the optic nerve region (ICC: 0.118) and atrophy judgment (ICC: 0.364). Comparing high- and low-lesion burdens in each region revealed that the ICC is higher when the lesion count is in the mid-range. In the periventricular and deep white matter area, where lesions are common, higher ICC was found in patients who had a lower lesion count. On the other hand, juxtacortical lesions and black holes that are less common showed higher ICC when the subjects had more lesions. This difference was significant in the juxtacortical region when the most accurate raters compared patients with low (ICC: 0.406 CI: 0.273-0.546) and high (0.702 CI: 0.603-0.785) lesion loads. Conclusion: Lesion classification showed high variability by location and overall moderate reproducibility. The excellent range was not achieved, owing to the fact that some areas showed poor performance. Hence, putting effort toward the development of artificial intelligence for the evaluation of lesion burden should be considered.

Differences between proximal bone remodeling in femoral revisions for aseptic loosening and periprosthetic fractures using the Wagner SL stem.

BACKGROUND: Monoblock taper fluted stems have been reliably used to treat proximal femoral periprosthetic fractures (PFF) and femoral aseptic loosening (AL). Although proximal femoral remodeling has been observed around the Wagner Self-Locking (SL) stem, the exact characteristics of this process are yet to be established. Our aim was to compare the remodeling that takes place after femoral revisions for PFF and AL. METHODS: Consecutive patients between January 2015 and December 2017 undergoing femoral revision using the Wagner SL stem for PFF or AL without an extended trochanteric osteotomy (ETO) or bone grafting were selected from our database. Radiological follow-up was performed using plain antero-posterior hip radiographs taken postoperatively and at 3, 6, 12 months and at 24 months. The Global Radiological Score (GRxS) was utilized by four blinded observers. Intra and interobserver variability was calculated. Secondary outcome measures included the Oxford Hip Score and the Visual Analog Scale for pain. RESULTS: We identified 20 patients from our database, 10 PFF and 10 AL cases. The severity of AL was Paprosky 2 in 2 cases, Paprosky 3A in 2 cases and Paprosky 3B in 6. PFF were classified as Vancouver B2 in 7 cases and Vancouver B3 in 3 cases. Patients undergoing femoral revision for PFF regained 89% (GRxS: 17.7/20) of their bone stock by 6 months, whilst patients with AL, required almost 2 years to achieve similar reconstitution of proximal femoral bony architecture 86% (GRxS: 17.1/20). Inter-observer reproducibility for numerical GRxS values showed a "good" correlation with 0.68, whilst the intra-observer agreement was "very good" with 0.89. Except immediate after the revision, we found a significant difference between the GRxS results of the two groups at each timepoint with pair-wise comparisons. Functional results were similar in the two groups. We were not able to show a correlation between GRxS and functional results. CONCLUSIONS: Proximal femoral bone stock reconstitutes much quicker around PFF, than in the cases of AL, where revision is performed without an ETO. The accuracy of GRxS measurements on plain radiographs showed good reproducibility, making it suitable for everyday use in a revision arthroplasty practice.

Ultrasonography of sciatic nerve endometriosis.

INTRODUCTION: We describe the ultrasonographic findings of sciatic nerve endometriosis. METHODS: Two premenopausal women with catamenial sciatica symptoms were examined, the first without a history of endometriosis, the second with previously confirmed endometriosis of the ovary. Ultrasonography, extending from the sciatic notch to the level of the ischial tuberosity showed that the sciatic nerve was "engulfed" in a large, perineural, hypoechogenic, inhomogeneous lesion with an irregular contour corresponding to an endometrioma. The nerve was enlarged, but it was discernible within the lesion, except at its most cranial part. MRI of the pelvis showed intrapelvic extension in both patients. RESULTS: The first patient was treated with a gonadotropin-releasing hormone agonist, leading to complete morphological regression and normalization of nerve structure, parallel with symptomatic resolution. CONCLUSIONS: These cases illustrate that ultrasound is a feasible imaging modality for sciatic nerve endometriosis that may even be used to monitor morphological regression of endometrial tissue during treatment. Muscle Nerve 54: 500-505, 2016.

"Ulcerative crepitus" -- a case with subcutaneous emphysema and pneumomediastinum without colonic perforation or toxic megacolon in ulcerative colitis successfully treated conservatively.

A 19-year-old man with a 1-year history of ulcerative colitis presented with fever, bloody diarrhea and severe dehidration. He was on po.48 mg methylprednisolon and 3 g mesalazine daily, and has recently finished taking chlarythromycin for Campylobacter jejuni infection. On physical examination, no abdominal tenderness was found, but surprisingly, extensive bilateral subcutaneous emphysema was detected in the supraclavicular regions. Laboratory tests proved anaemia, elevated white blood cell count, thrombocyte count and CRP levels. Stool culture was negative. Chest X-ray and CT scan revealed pneumomediastinum and subcutaneous air on the neck spreading to the scapular regions. Besides blood transfusion, iv. cyclosporin therapy was initiated (200 mg/day) along with iv. methylprednisolon (1mg/kg/day) and iv. ceftriaxon (2 g/day). Stool frequency and bloody stools decreased remarkably within one week, and subcutaneous emphysema has resolved. Colonoscopy one week later revealed deep, extensive ulcerations in the transverse and descending colon without any sign of previous perforation. Cyclosporin and methylprednisolon was continued orally. Pneumomediastinum and subcutaneous emphysema in ulcerative colitis are unusual complications, typically linked to retroperitoneal colonic perforation or toxic megacolon, and are extremely rare without preceding endoscopic procedures. Except from two cases in the literature, conservative treatment with iv. antibiotics and steroids failed to save from urgent surgical procedure, resulting in a partial or total colectomy. In our case we were able to avoid urgent surgery by the immediate use of iv. cyclosporin in combination with iv. steroids and antibiotics, while the outcome of the bowel remains questionable in the next few months.