What is the best referral strategy for axial spondyloarthritis? A prospective multicenter study in patients with suspicious chronic low back pain.

OBJECTIVE: To assess the value of referral strategies for axial spondyloarthritis (axSpA) in patients with suspicious chronic inflammatory low back pain (LBP), to estimate the value of inflammatory back pain (IBP) for referral, and to identify the predictive factors of the final diagnosis of axSpA in Middle Eastern Arab countries. METHODS: The study was multicentric, prospective, and conducted in LBP first-line clinics (rheumatology, internal, family medicine, orthopedic surgery, neurosurgery, and neurology). Consecutive adult patients aged under 45years were included in case of LBP suspicious of inflammatory nature according to the first-line physician. The rheumatologist's final diagnosis was the gold standard. The diagnostic properties of ten referral strategies (Brandt I, II, III, Hermann, RADAR, RADAR 2/3, MASTER, Braun, CAFASPA, and ASAS) and of IBP were calculated. A multivariable logistic regression identified the clinical predictive factors of axSpA. RESULTS: In 515 referred patients, axSpA was confirmed in 48%, refuted in 43%, and diagnosis remained inconclusive in 9%. The optimal referral strategy was the MASTER (PLR 3.3), which comprises IBP, good response to NSAIDs, positive HLA-B27, and SpA family history. Considering strategies without HLA-B27, the RADAR 2/3 had a PLR of 2.9 (IBP, good response to NSAIDs, any extra-musculoskeletal manifestation). The predictive factors for axSpA were MRI sacroiliitis, positive HLA-B27, high CRP, psoriasis, IBP, and longer symptom duration. Of all patients, 35% were self-referred, 16% were referred by primary care physicians, and 15% by neuro/orthopedic surgeons. CONCLUSION: Optimizing physicians' awareness of these clinical features may enhance referral in axSpA.

Osteitis fibrosa cystica mimicking bone tumor, a case report.

BACKGROUND: We report a case of osteitis fibrosa cystica, a rare benign resorptive bone lesion caused by hyperparathyroidism, that presented on imaging as an aggressive bone tumor. CASE PRESENTATION: The patient is a 51-year-old male complaining of severe sustained pain of the right hip region. Imaging studies were suspicious for a malignant tumor of the right iliac bone. Biopsy under CT guidance was performed and showed remodeled bone trabeculae with numerous osteoclasts, excluding bone tumor and raising the possibility of osteitis fibrosa cystica. Complementary tests disclosed elevated blood level of parathyroid hormone and a partially cystic enlarged left inferior parathyroid gland consistent with adenoma. After parathyroidectomy, the clinical symptoms were relieved and the radiological findings were significantly improved, which confirmed the diagnosis. CONCLUSIONS: Metabolic diseases-associated bone lesions should always be considered in the differential diagnosis of bone tumors, to avoid unnecessary surgeries and treatments.

Clinical effect of computed guided pudendal nerve block for patients with premature ejaculation: a pilot study.

Background: Premature ejaculation has a complex etiology, and its pathophysiology is still unclear, with penile hypersensitivity being the most accepted hypothesis. The aim was to investigate the efficacy and safety of a computed tomography-guided pudendal nerve block at the level of the sacrospinous ligament and the Alcock's canal in patients with premature ejaculation refractory to conventional pharmacological treatment.Methods: This is a prospective pilot study involving five patients suffering from premature ejaculation refractory to standard treatment and clinical features of pudendal nerve entrapment. A CT-guided infiltration of ropivacaine and methylprednisone was done at the levels of sacrospinous ligament and Alcock's canal. Intra-vaginal ejaculatory latency time (IELT) was recorded several times for each patient before and after infiltration. International Index of Erectile Function (IIEF-5), Premature Ejaculation Diagnostic Tool (PEDT) and Sexual Quality of Life-Male version (SQoL-M) questionnaire were also evaluated before and after infiltration.Results: Overall IELT differed significantly before and after treatment (21.94 vs 215.42 s; p = 0.039). IIEF-5, PEDT and SQoL-M also differed significantly before and after treatment. No complications for the CT-guided infiltration were recorded.Conclusion: CT-guided pudendal nerve block at the sacrospinous ligament and the Alcock's canal was effective in improving premature ejaculation. Therefore, pudendal nerve entrapment may be a curable cause of sensory premature ejaculation.

A Large Rice Body-Containing Cyst Mimicking Infection following Total Hip Arthroplasty: A Case Report.

INTRODUCTION: Soft tissue mass following total hip arthroplasty raises several differential diagnoses not limited to infection, hematoma, wear debris, malignancy, and bursitis. Rice body formation in the hip region is an uncommon process denoting a chronic inflammation. We report here the second case of its kind in the medical literature of a wide symptomatic rice-like body cyst complicating a total hip arthroplasty. CASE PRESENTATION: This is the case of an 82-year-old white female, presenting with a warm, red, and inflated groin five years after revision of right total hip arthroplasty. Surgical intervention reveals a large well circumscribed cyst containing well-organized rice-like bodies. This eventuality was never reported in differential diagnosis of hip periprosthetic soft tissue masses before. CONCLUSION: This case report helps widening the array of the differential diagnosis in patients presenting with a slow growing soft tissue mass following total hip arthroplasty, making rice-like bodies cyst a valid one to consider.

Long-term results of percutaneous resection and interstitial laser ablation of osteoid osteomas.

To evaluate the efficiency and complication rate of two percutaneous treatments of osteoid osteomas, percutaneous trephine resection (PR) and interstitial laser ablation (ILA). Ethical review board was obtained for the retrospective study. One hundred and 26 patients were treated by PR (n = 26) or ILA (n = 100) under CT, with a median follow-up of 113 months for the PR group and 47 months for the ILA group. In the group treated by PR, the clinical success rate was 96% at 6-month and 95% at 24-month follow-up, with 12% (3/26) transient complications (one meralgia, two skin burns). One patient experienced immediate failure, and none had delayed failure. In the group treated by ILA, the clinical success rate was 96% at 6-month and 94% at 24-month follow-up, with 4% (4/100) transient complications (one common fibular nerve contusion, one hematoma, one infection and one tendinitis). Four ILA procedures were repeated, one because of initial failure and three because of recurrence (at 6.5, 15 and 32 months). Two were successful and two failed again. Failure was more frequent (p = 0.0094) in patients less than 18 years old, and in lesions with a nidus size of 12 mm or larger (p = 0.0022).