Chronic recurrent osteomyelitis: a surgeon's enigma

Abstract

Background

Chronic recurrent forms of osteomyelitis of the mandible with their morbid clinical course have long been considered a challenge to maxillofacial surgeons in terms of both diagnosis and treatment. Various classifications and treatments have been established through the ages to define and manage the inflammatory symptoms occurring in adults and children. This paper discusses two such entities occurring in an adult and a child, highlighting the diagnostic and treatment challenges of recurrent osteomyelitis.

Methods

A thorough work up which included clinical, radiographic, blood investigations was done, followed by administration of antibiotics and anti‐inflammatory with or without surgical debridement / adjuvant therapies. Correlation of our findings and treatment plan was done with evidence based literature and practice.

Results

Complete resolution of symptoms with radiographic evidence were achieved in both the cases. In the recurrence period, long term steroids, NSAIDs, antibiotics resulted in better outcomes.

Conclusion

The evidence based protocol for osteomyelitis stresses on short inpatient stays predicated on efficient literature. Thorough clinical and radiographic evaluation with aggressive medical management and surgical intervention when necessary can result in longer symptom free periods. Thus understanding the disease, recurrence pattern and response to therapy is essential.

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Futile Recanalization With Poor Clinical Outcome Is Associated With Increased Edema Volume After Ischemic Stroke

Purpose Futile recanalization with poor clinical outcome after endovascular treatment of acute ischemic stroke is poorly understood. Recently, vessel recanalization has been associated with reduced ischemic brain edema in patients with good clinical outcome. As edema volume (EV) may be quantified in computed tomography (CT), we hypothesized that higher EV after revascularization predicts futile recanalization with poor outcome. Methods In this observational study, 67 ischemic stroke patients with M1 middle cerebral artery occlusion fulfilled all inclusion criteria and were analyzed. All patients received successful endovascular recanalization (thrombolysis in cerebral infarction scale 2b/3) and subsequent follow-up CT 24 hours later. Edema volume within the infarct lesion was calculated in follow-up CT applying lesion water uptake quantification and was used to predict clinical outcome (Modified Rankin Scale [mRS] after 90 days) compared with infarct volume. Results The median EV after thrombectomy was 1.6 mL (interquartile range, 0.2–4.2 mL) in patients with mRS 0 to 4 and 8.6 mL (interquartile range, 2.0–49.8 mL) in patients with mRS 5 to 6 (P = 0.0008). In regression analysis, an EV increase of 1 mL was associated with an 8.0% increased likelihood of poor outcome (95% confidence interval, 2.8%–15.4%; P = 0.008). Based on univariate receiver operating characteristic curve analysis, absolute EV over 4.2 mL predicted poor outcome (mRS 5–6) with good discriminative power (area under curve, 0.74; 95% confidence interval, 0.62–0.84; specificity, 77%; sensitivity, 68%). In comparison, the area under curve for infarct volume was 0.68. Conclusions Elevated EV after endovascular thrombectomy was associated with poor clinical outcome and may indicate futile recanalization. Received for publication October 25, 2018; and accepted for publication, after revision, November 5, 2018. Conflicts of interest and sources of funding: J.F. is a consultant for Acandis, Boehringer Ingelheim, Codman, Microvention, Sequent, and Stryker; is a speaker for Bayer Healthcare, Bracco, Covidien/ev3, Penumbra, Philips, and Siemens; and received grants from Bundesministeriums für Wirtschaft und Energie, Bundesministerium für Bildung und Forschung, Deutsche Forschungsgemeinschaft, European Union, Covidien, Stryker (THRILL study), Microvention (ERASER study), and Philips. A.K. is part of the research collaboration agreement, Siemens Healthcare. All the other authors have nothing to disclose. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (https://ift.tt/2kq7jVD). Correspondence to: Gabriel Broocks, MD, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. E-mail: g.broocks@uke.de. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Iodinated Contrast Agents and Risk of Hypothyroidism in Young Children in the United States

Background Although it is generally acknowledged that exposure to iodine contrast agents can interfere with thyroid function, little is known about the incidence of iodine-induced hypothyroidism in young children (younger than the age of 4 years). Study Objectives This was a retrospective cohort study to estimate the incidence rate of detected hypothyroidism in a US-based general population of pediatric patients exposed to an iodinated contrast agent. Setting The study was conducted in Kaiser Permanente Northern California, an integrated health care delivery system. Study Population This study included 2320 pediatric patients younger than 4 years of age who had a diagnostic procedure with an iodinated contrast agent during years 2008 to 2016. Results Among 2320 young children who met our study criteria, we identified 34 who met the initial criteria to be a case of hypothyroidism. The incidence density ratio for all hypothyroidism in iodine contrast agent–exposed patients was 1.33 per 1000 person months (95% confidence interval, 0.9–1.8). Most cases appeared to have subclinical hypothyroidism. The rate was higher for the probably iodine-induced cases (0.90 per 1000 person months) compared with cases with a possible alternate etiology (0.43 per 1000 person months), for males compared with females, and among children who had a heart catheterization compared with those with a computed tomography scan. It was also highest among the youngest children (younger than 3 months old), and decreased with increasing age. Discussion Our finding of hypothyroidism in young children exposed to iodine contrast agents (1.33 per 1000 person months [95% confidence interval, 0.9–1.8]) is broadly consistent with the sparse literature on this outcome. Received for publication September 11, 2018; and accepted for publication, after revision, November 15, 2018. Conflicts of interest and sources of funding: This study was funded by Bayer AG Germany. Y.C., P.P., and A.M. are employees of Bayer AG. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (https://ift.tt/2kq7jVD). Correspondence to: Susan S. Jick, DSc, Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, 11 Muzzey St, Lexington, MA 02421. E-mail: sjick@bu.edu. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Automatic Tube Current Modulation and Tube Voltage Selection in Pediatric Computed Tomography: A Phantom Study on Radiation Dose and Image Quality

Objectives The aim of this study was to investigate the effects of a modern automatic tube current modulation (ATCM) and automatic tube voltage selection (ATVS) system on radiation dose and image quality in pediatric head, and torso computed tomography (CT) examinations for various clinical indications. Materials and Methods Four physical anthropomorphic phantoms that represent the average individual as neonate, 1-year-old, 5-year-old, and 10-year-old child were used. Standard head, thorax, and abdomen/pelvis acquisitions were performed with (1) fixed tube current, (2) ATCM, and (3) ATVS. Acquisitions were performed at various radiation dose levels to generate images at different levels of quality. Reference volume CT dose index (CTDIvol), reference image noise, and reference contrast-to-noise ratios were determined. The potential dose reductions with ATCM and ATVS were assessed. Results The percent reduction of CTDIvol with ATCM ranged from 8% to 24% for head, 16% to 39% for thorax, and 25% to 41% for abdomen/pelvis. The percent reduction of CTDIvol with ATVS varied on the clinical indication. In CT angiography, ATVS resulted to the highest dose reduction, which was up to 70% for head, 77% for thorax, and 34% for abdomen/pelvis. In noncontrast examinations, ATVS increased dose by up to 21% for head, whereas reduced dose by up to 34% for thorax and 48% for abdomen/pelvis. Conclusions In pediatric CT, the use of ATCM significantly reduces radiation dose and maintains image noise. The additional use of ATVS reduces further the radiation dose for thorax and abdomen/pelvis, and maintains contrast-to-noise ratio for the specified clinical diagnostic task. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Received for publication September 14, 2018; and accepted for publication, after revision, October 26, 2018. Conflicts of interest and sources of funding: This project has received funding from the Euratom research and training program 2014–2018 under grant agreement No. 755523 (MEDIRAD). The funding source had no role in study design, in the collection, analysis, and interpretation of data, nor in the writing or submission of the report. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (https://ift.tt/2kq7jVD). Correspondence to: Antonios E. Papadakis, PhD, Medical Physics Department, University Hospital of Heraklion, Stavrakia, 71110, Crete, Greece. E-mail: apapadak@pagni.gr. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Reduction of Metal Artifacts and Improvement in Dose Efficiency Using Photon-Counting Detector Computed Tomography and Tin Filtration

Objectives The aim of this study was to investigate the impact on metal artifacts and dose efficiency of using a tin filter in combination with high-energy threshold (TH) images of a photon-counting detector (PCD) computed tomography (CT) system. Materials and Methods A 3D-printed spine with pedicle screws was scanned on a PCD-CT system with and without tin filtration. Image noise and severity of artifacts were measured for low-energy threshold (TL) and TH images. In a prospective, institutional review board–approved, Health Insurance Portability and Accountability Act-compliant study, 20 patients having a clinical energy-integrating detector (EID) CT were scanned on a PCD-CT system using tin filtration. Images were reviewed by 3 radiologists to evaluate visualization of anatomic structures, diagnostic confidence, and image preference. Artifact severity and image noise were measured. Wilcoxon signed rank was used to test differences between PCD-CT TH and EID-CT images. Results Phantom TH images with tin filtration reduced metal artifacts and had comparable noise (32 HU) to TL images (29 HU) acquired without tin filtration. Visualization scores for the cortex, trabeculae, and implant-trabecular interface from PCD-CT TH images (4.4 ± 0.9, 4.4 ± 1.0, and 4.4 ± 1.0) were significantly higher (P

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Evaluation of lung transplant perfusion using iodine maps from novel spectral detector computed tomography

p. 436
Nils Große Hokamp, Amit Gupta
DOI:10.4103/ijri.IJRI_35_18  
We report the case of a 51-year-old patient who underwent bilateral lung transplantation and presented with an unstable condition and sepsis 6 days after transplantation. The performed contrast enhanced spectral detector computed tomography (CT) using a dual-layer detector showed absence of perfusion in the left lung on iodine maps, although branches of the pulmonary artery were patent. This prompted retrospective evaluation of CT images and total venous occlusion of the left pulmonary veins was found. Here, iodine maps helped in raising conspicuity of loss of lung perfusion.
http://www.ijri.org/currentissue.asp?sabs=y

Pulmonary atresia and ventricular septal defect,Coronary artery as the primary source of pulmonary blood flow

Collateral or fistula? Coronary artery as the primary source of pulmonary blood flow in a patient with pulmonary atresia and ventricular septal defect p. 433
Anurag Yadav, Salil Bhargava, T B S Buxi, Krishna Sirvi
DOI:10.4103/ijri.IJRI_489_17  
In patients with pulmonary atresia and ventricular septal defect (PA/VSD), a coronary artery being the primary source of pulmonary blood flow is a rare entity. We describe two cases of PA/VSD with coronary-to-pulmonary artery fistula with emphasis on the role of Computed Tomographic Angiography (CTA) in depicting all the sources of pulmonary blood supply, to predict surgical management and need for unifocalization of Major Aortopulmonary Collateral Arteries (MAPCA's).
http://www.ijri.org/currentissue.asp?sabs=y