Francesco Toso

MRI scoring system including dynamic motility evaluation in assessing the activity of Crohn's disease of the terminal ileum

RATIONALE AND OBJECTIVES We sought to investigate the value of a MRI scoring system including dynamic motility evaluation in the assessment of small bowel Crohns disease activity. MATERIALS AND METHODS From March 2005 to December 2006, 52 patients with suspected Crohns disease onset or relapse underwent MRI on a 1.5-T magnet. Bowel distention was achieved orally assuming a mean of 1.6 L of a polyethyleneglycol (PEG) preparation. Per-patient assessment of disease activity was based on a scoring system including evaluation of morphology and motility of the small bowel and perivisceral structures (true-FISP, cine-true-FISP, and HASTE T2W sequences) and dynamic assessment of parietal contrast enhancement (FLASH T1W sequence). Patients were included in three categories, using endoscopic biopsy as the standard reference: no activity/quiescent disease, mild activity, or moderate-to-severe activity. Patients without terminal ileum involvement were excluded from data analysis. RESULTS MRI allowed a detailed and panoramic evaluation of the small bowel in all subjects examined. MRI properly assessed 14 of 16 (87.5%) cases of no activity/quiescent disease, 12 of 14 (85.7%) cases of mild activity, and 15 of 15 (100%) cases of severe activity. Overall, activity score led to a per-patient misdiagnosis of disease activity in a nonsignificant proportion of subjects (4 of 45; 8.8%) (P > .05), determining two false-positive and two false-negative results of mild disease activity. Sensitivity, specificity, PPV, NPV, and overall accuracy in assessing disease activity were 93.1%, 87.5%, 93.1%, 87.5%, and 91.1%, respectively. CONCLUSION Accurate assessment of Crohns disease activity is achieved by using an activity score providing an overall interpretation of MRI findings.

Prevention of postoperative recurrence of Crohn's disease by infliximab

The prevention of the recurrence of Crohns disease after surgery remains difficult. The monoclonal antibody anti-TNF-alpha, infliximab, is very effective in inducing and maintaining the remission of uncomplicated, active Crohns disease. We present here the case of a 23-year-old white woman who underwent resection for a sigmoid stricture caused by Crohns disease. Surgery removed the involved colon, and pathology confirmed the stricture to be fibrotic. Two weeks after the operation she was given infliximab at the dose of 5 mg/kg body weight and followed in time. Since then, she has been disease free for approximately 4 years after surgery on clinical, radiological and endoscopic/histological grounds (Crohns Disease Activity Index < or = 110 on all occasions). Up to now, she has had no increase in inflammatory indices, no anaemia and no abnormal blood tests. In contrast, all of five control patients operated in the same period with colonic or ileocolonic resection for symptomatic strictures and treated with mesalamine or no medication developed endoscopic or clinical recurrence (abdominal pain or diarrhoea) by year 3. This is the first case, to our knowledge, in which infliximab has been successfully used to prevent the postsurgical recurrence of Crohns disease, an event so far considered to be inescapable. We believe that, with this aim in mind, clinical trials with this drug are warranted.

Supraspinatus tendon US morphology in basketball players: correlation with main pathologic models of secondary impingement syndrome in young overhead athletes. Preliminary report

Purpose.The purpose of this study was to investigate supraspinatus tendon sonographic morphology in a population of young overhead athletes in correlation with main pathologic models of secondary shoulder impingement syndrome.Subjects and methods.Between April and May 2004, 20 subjects (ten professional basketball players and ten non-athlete controls of the same age, weight and height ranges) underwent bilateral, standardised, sonographic sholulder examination to evaluate supraspinatus echotexture, supraspinatus and subacromial bursa thickness, subacromial space width (cutoff of 7 mm) and dynamic anterior impingement beneath the acromial margin.Results.All subjects were right handed. No symptomatic controls were found. Four players showed signs and symptoms of right atraumatic shoulder instability (two cases) or supraspinatus impingement with anterior pain (one right and one left shoulder). Subacromial space width was reduced in five right-dominant players’ shoulders (three symptomatic and two asymptomatic) versus zero controls (p<0.05) and in eight players’ shoulders versus zero controls on total shoulders (p<0.05). No other significant differences were observed between the two groups in sonographic parameters considered.Conclusions.Despite the study limitations, ultrasonography (US) is able to detect subacromial space narrowing in young overhead athletes as early shoulder impingement sign, according to the continuum impingement-instability pathologic model.

Isolated Bilateral Gastrocnemius Myositis in Crohn Disease Successfully Treated with Adalimumab

Extraintestinal manifestations are common in inflammatory bowel disease; however, muscular involvement in Crohn disease is rarely reported. We present a case of a 26-year-old male with ileocolonic Crohn disease who developed sudden tenderness in both calves. Doppler ultrasound was negative for deep vein thrombosis. Magnetic resonance imaging of the gastrocnemius muscle showed high intensity signal in the muscle fibers, and muscle biopsy demonstrated nonspecific lymphocytic myositis. Other relevant laboratory results included normal antineutrophil cytoplasmic antibodies and creatine kinase as well as elevated C-reactive protein, erythrocyte sedimentation rate, and anti-Saccharomyces cerevisiae IgG titer. The patient was in clinical remission, being treated with azathioprine 2.5 mg/kg. Prednisone 60 mg/day was initiated with rapid resolution of calf tenderness; however, tenderness soon returned when the dose was tapered to 10 mg/day. Subsequently, prednisone and azathioprine were discontinued, and adalimumab was started at standard induction and maintenance doses. The patient’s symptoms resolved shortly after the first induction dose. A repeat magnetic resonance imaging of the calves – 3 months after starting adalimumab – showed complete resolution of muscle inflammation. To our knowledge, this is the first case of gastrocnemius myositis – a rare extraintestinal manifestation of Crohn disease – successfully treated with anti-tumor necrosis factor agents.

Three-dimensional imaging of anomalous origin of the right coronary artery in a young athlete

We present a case of a 14-year-old male athlete to demonstrate the potential usefulness of three-dimensional echocardiography in supplementing magnetic resonance angiography in the assessment of actual anatomy in patients with anomalous origin of right coronary artery. Anomalous origin of the right coronary artery (RCA) from the left Valsalva sinus with an inter-arterial course between the great arteries is a …

A large penetrating atherosclerotic ulcer of the ascending aorta

The term ‘penetrating aortic atherosclerotic ulcer’ is used to describe a condition in which ulceration of an aortic atherosclerotic lesion penetrates the internal elastic lamina into the media. A 70-year-old woman with history of hypertension and dyslipidaemia was admitted for syncope, followed by left hemiplegia and coma. Cerebral CT scan showed …