Double Contour Research Articles

Size matters: observations regarding the sonographic double contour sign in different joint sizes in acute gouty arthritis.

In distinguishing urate arthritis (UA) from non-crystal-related arthritides, joint sonography including the detection of the double contour sign (DCS) and hypervascularization using power Doppler ultrasound (PDUS) is an important step in the diagnostic process. But are these sonographic features equally reliable in every accessible joint under real-life conditions? We retrospectively analyzed 362patients with acute arthritis and evaluated the DCS and the degree of PDUS hypervascularization in patients with gout and in those with arthritis other than urate arthritis (non-UA). We classified all joints into the groups small, medium, and large. Sensitivities, specificities, positive and negative predictive values (PPV/NPV), and abinary regression model were calculated. We also evaluated the influence of serum uric acid levels (SUA) on the presence of aDCS in each joint category. Sensitivity of the DCS in gout was 72.5% in the entire cohort, 66.0% in large, 78.8% in medium, and 72.3% in small joints. In wrist joints the DCS sensitivity maxed at 83.3%, with aspecificity of 81.8%. The lowest rates of DCS sensitivity were found in gout patients with elbow joint involvement (42.9%). In all joints except metatarsophalangeal joint1 (MTP-1), the incidence of aDCS increased by the increment of SUA levels above 7.5 mg/dl (p < 0.001). PDUS signals were most commonly found in medium and small joints and were only scarce in large joints, independent of the underlying diagnosis. In our study we detected different rates of accuracy regarding DCS and PDUS in patients with acute arthritis. The best results were seen in medium-size joints, especially wrists.

Vertebral Fracture: Diagnostic Difficulties of a Major Medical Problem.

Vertebral Fracture: Diagnostic Difficulties of a Major Medical Problem.

Renal histopathological findings of retinal vasculopathy with cerebral leukodystrophy.

Retinal vasculopathy with cerebral leukodystrophy (RVCL) is a rare autosomal dominant systemic microvascular disease. Neurological disorders and visual disturbance are highlighted as manifestations of RVCL; however, there are few reports focused on nephropathy. Herein, we describe detailed renal histopathological findings in a daughter and father with RVCL, proven by TREX1 genetic analysis. A kidney biopsy of the daughter, 35-year-old with asymptomatic proteinuria, revealed unique and various glomerular changes. Atypical double contour (not tram track-like) of the capillary wall was widely found, an apparent characteristic finding. Glomerular findings were varied due to a combination of new and old segmental mesangial proliferative changes, mesangiolysis, and segmental glomerulosclerosis-like lesions; these changes may be related to endothelial cell damage. Collapsed tufts were also found and thought to be the result of ischemia due to arterial changes. Glomerular findings in a kidney biopsy of the father revealed similarity to the daughter's glomerulus at a relatively advanced stage, but the degree of variety in the glomerular findings was much less. Kidney biopsy findings suggesting endothelial cell damage of unknown etiology need to be considered for possible RVCL.

Ultrasonographic assessment of joint pathology in type 2 diabetes and hyperuricemia: The Fremantle Diabetes Study Phase II

AimsThe prevalence and consequences (articular and extra-articular) of hyperuricemia in type 2 diabetes, especially when asymptomatic (ASH), are incompletely understood. The aim of this study was to use ultrasonography to assess pathology associated with monosodium urate deposition in the joints of well-characterized hyperuricemic patients with type 2 diabetes. MethodsA subset of 101 participants (mean age 70.4 years, 59.8% males, median diabetes duration 14.6 years) with hyperuricemia (fasting serum uric acid ≥0.42 mmol/L) from the community-based observational Fremantle Diabetes Study Phase II were assessed by ultrasound for signs of intra-articular urate deposition and inflammation in 14 joints at increased risk of involvement in patients with gout. ResultsMost participants had evidence of crystal deposition comprising aggregates (59.4%), tophi (19.8%) or a double contour sign (27.7%), and 37% had a power Doppler signal indicative of inflammation in at least one joint. There was no difference between the prevalence of these abnormalities in those with ASH (n = 60) versus participants with a history of gout (n = 41; P ≥ 0.15). There was no association between a history of ischemic heart disease (reported by 17.8% of participants) and either any abnormality on joint ultrasound or inflammatory changes assessed by power Doppler (P ≥ 0.41). ConclusionsJoint inflammation and/or urate deposition were present in the majority of community-based patients with type 2 diabetes and hyperuricemia regardless of whether there was a history of gout. Given the potential consequences of chronic inflammation for joint damage and extra-articular complications such as cardiovascular disease, these data have potential clinical implications.

Microangiopatía trombótica/síndrome hemolítico urémico. Actualización de sus características histopatológicas

Thrombotic microangiopathy (TMA) encompasses different entities known as haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). The histopathological characteristics have remained constant since the initial description and consist in glomerular-type affectation with the presence of double contours, mesangiolysis and microthrombi. It is generally accepted that the vascular damage is related to the prognosis. Ultrastructure, together with conventional histology, shows notable changes in both capillaries and endothelial cells. A comprehensive histopathological study of the renal biopsy, using electronmicroscopy, is useful in the confirmation of a clinical suspicion and demonstrates the pathogenetic mechanisms in the microcirculatory damage. The close resemblance between the ultrastructural appearance and that seen with the light microscope of TMA and transplant glomerulopathy (TG) is precisely what suggests that both entities are subject to the same etiopathogenetic mechanism in which the endothelial cell is targeted. Recent advances in the pathology of atypical HUS, its relation with complement system and the discovery of specific therapeutic targets, has rekindled an interest in the study of TMA and the importance of renal biopsy.

Tophus size is associated with hallux valgus deformity in gout.

Hallux valgus (HV) and gout are common pathologies of the first metatarsophalangeal joint (MTP1) leading to pain and deformation. In this study, we aimed to determine the correlation between tophus size and characteristics of HV in gouty patients. In this case-control study, we included patients with gout (the presence of monosodium urate crystals in synovial fluid) and control patients with spondyloarthritis, without crystal disease disorders. Radiographic assessment and ultrasound (US) assessment were performed by two blinded operators. US features of gout (double contour [DC] sign and/or tophus) were collected. HV was defined by hallux abductus (HA) angle ≥20° and/or intermetatarsal angle (IM) ≥10°. Correlation between US findings and HV angles was estimated by Spearman correlation coefficient. We included 56 gouty patients (87.5% males, mean age of 63.9±12.2years) and 41 control patients (90% males, mean age of 59.0±12.8years). HV was more frequent in patients with gout than controls (62% vs 37%, P=.0007). Regardless of HV status, correlations were found between the size of US tophi and IM (r=.3381, P=.003) and HA angles (r=.2344, P=.043). Our results confirm a high prevalence of HV in gouty patients. We also observed a correlation between the size of the US tophus and the angles defining HV, which suggests a link between urate deposition load and HV. Early urate-lowering therapy for gout could limit the occurrence of HV.

A molecular biopsy test based on arteriolar under-hyalinosis reflects increased probability of rejection related to under-immunosuppression.

Calcineurin inhibitor immunosuppressive drugs induce changes such as arteriolar hyalinosis (ah) in kidney transplants, raising the possibility that molecular changes in biopsies related to histologic ah can provide information about drug exposure. We hypothesized that molecular changes associated with less-than-expected hyalinosismight highlight a subpopulation of patients with under-immunosuppression/nonadherence at intermediate times of biopsy posttransplant (TxBx). Using gene expression data from 562 indication biopsies, we developed a molecular classifier for predicting the expected ah lesions (Mah ) at a particular TxBx. Mah -scores increased linearly with log(TxBx), but some biopsies had lower scores than expected for TxBx. The deviation of individual Mah -scores below the predicted regression line of Mah -scores vs TxBx is defined as "low hyalinosis index." Low hyalinosis indices were frequent in biopsies between 3months and 3years posttransplant, particularly among biopsies lacking histologic hyalinosis (ah0), and were associated with T cell-mediated rejection and a subset of recent-onset antibody-mediated rejection without glomerular double contours. In patients with medical records available for review, low hyalinosis indices were frequently associated with physician-recorded concerns about nonadherence (suspected or proven). We conclude that the Mah classifier and hyalinosis index identify indication biopsies with rejection for which the possibility of patient nonadherence should be considered.

Development of a Superconducting Differential Double Contour Interferometer.

We study operation of a new device, the superconducting differential double contour interferometer (DDCI), in the application for the ultrasensitive detection of magnetic flux and for digital read out of the state of the superconducting flux qubit. DDCI consists of two superconducting contours weakly coupled by Josephson junctions. In such a device a change of the critical current, caused by an external magnetic flux or a nearby electric current, happens in a step-like manner when the angular momentum quantum number changes by one in one of the two contours. With a choice of parameters, the DDCI may outperform traditional superconducting quantum interference devices.

Diagnostic accuracy of ultrasound in patients with gout: A meta-analysis.

This study aimed to evaluate the diagnostic performance of ultrasound (US) for patients with gout. We searched the Medline, Embase, Pubmed, and Cochrane Library databases, and performed a meta-analysis of the diagnostic accuracy of US according to the double contour sign, tophus, snowstorm, or bony erosion in patients with gout. In total, 11 studies including 938 patients with gout, and 788 controls (patients with nongout inflammatory arthritis) were available for the meta-analysis. The pooled sensitivity and specificity of US were 65.1% ([95% confidence interval (CI): 62.0-68.2] and 89.0% (96.6-91.1), respectively. The positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 5.889 (3.365-10.30), 0.359 (0.266-0.485), and 17.61 (11.11-17.92), respectively. The area under the curve of US was 0.858 and the Q⁎ index was 0.789, indicating good diagnostic accuracy. Some between-study heterogeneity was found in the meta-analyses. Meta-regression showed that the sample size, study design, and diagnostic criteria were not sources of heterogeneity, and subgroup meta-analyses did not change the overall diagnostic accuracy. US signs of tophus, snowstorm, or bony erosion besides the double contour sign were not sensitive (54.3%, 30.8%, and 51.6%), but specific (93.2%, 90.6%, and 93.3%) enough as a diagnostic tool. Our meta-analysis of published studies demonstrates that US offers good diagnostic accuracy with high specificity and can play an important role in the diagnosis of gout.

Singular Values for Products of Two Coupled Random Matrices: Hard Edge Phase Transition

Consider the product $GX$ of two rectangular complex random matrices coupled by a constant matrix $\Omega$, where $G$ can be thought to be a Gaussian matrix and $X$ is a bi-invariant polynomial ensemble. We prove that the squared singular values form a biorthogonal ensemble in Borodin's sense, and further that for $X$ being Gaussian the correlation kernel can be expressed as a double contour integral. When all but finitely many eigenvalues of $\Omega^{} \Omega^{*}$ are equal, the corresponding correlation kernel is shown to admit a phase transition phenomenon at the hard edge in four different regimes as the coupling matrix changes. Specifically, the four limiting kernels in turn are the Meijer G-kernel for products of two independent Gaussian matrices, a new critical and interpolating kernel, the perturbed Bessel kernel and the finite coupled product kernel associated with $GX$. In the special case that $X$ is also a Gaussian matrix and $\Omega$ is scalar, such a product has been recently investigated by Akemann and Strahov. We also propose a Jacobi-type product and prove the same transition.

Ultrasonography and dual-energy computed tomography provide different quantification of urate burden in gout: results from a cross-sectional study

BackgroundUltrasonography (US) and dual-energy computed tomography (DECT) can assess urate burden in gout. The objective of this study was to compare the quantification of urate deposition provided by US to the one provided by DECT.MethodsPatients with a diagnosis of gout were prospectively recruited to undergo quantification of urate deposition using US and DECT. US examination for tophi and the double contour (DC) sign was performed on the knees and feet and corresponding DECT scans provided volumes of tophi and of overall urate deposition. The primary endpoint was the intra-class correlation coefficient (ICC) of the volume of the index tophus measured by US and DECT and its 95% confidence interval (CI 95%).ResultsOf the 64 patients included, 34 presented with at least one tophus on US. DECT inter-reader agreement for urate deposition was perfect with an ICC of 1 (1–1) and good for the measurement of the index tophus with an ICC of 0.69 (0.47–0.83). The ICC for the measurement of the index tophus between the two techniques was poor with a value of 0.45 (0.1–0.71). The average ratio between the index tophi volume as assessed by DECT and US was 0.65. The number of DC-positive joints did not correlate with DECT volume of overall deposits (Spearman correlation coefficient of 0.23).ConclusionsDECT measurements of tophi give smaller volumes to the same tophi measured with US, and US signs of urate deposition in joints do not correlate with overall DECT volumes of extra-articular deposition.

Ultrasound double contour sign and gout.

Ultrasound double contour sign and gout.

An optimal ultrasonographic diagnostic test for early gout: A prospective controlled study.

ObjectiveTo identify the optimal sites for classification of early gout by ultrasonography.MethodsSixty patients with monosodium urate crystal-proven gout (25 with early gout [≤2-year symptom duration], 35 with late gout [>2-year symptom duration], and 36 normouricemic healthy controls) from one centre were prospectively evaluated. Standardized blinded ultrasound examination of 36 joints and the triceps and patellar tendons was performed to identify tophi and the double contour (DC) sign.ResultsUltrasonographic sensitivity was lower in early than late gout. Binary logistic regression analysis showed that two ultrasonographic signs (tophi in the first metatarsophalangeal joint [odds ratio, 16.46] and the DC sign in the ankle [odds ratio, 25.18]) significantly contributed to the final model for early gout diagnosis (sensitivity and specificity of 84% and 81%, respectively). The inter-reader reliability kappa value for the DC sign and tophi was 0.712.ConclusionsFour-joint investigation (both first metatarsophalangeal joints for tophi and both ankles for the DC sign) is feasible and reliable and could be proposed as a screening test for early ultrasonographic gout classification in daily practice.

Postpartum TTP-HUS Syndrome: A Rare Autopsy Case Report in a Tertiary Care Hospital.

Thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are the two main disorders included under Thrombotic Microangiopathy. 1 in 25,000 pregnancies present with these rare disorders, mostly seen after uncomplicated gestation and delivery . A diagnostic pentad for TTP was given by Amorosi & Ultmann in 1966: thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms and signs, renal functional abnormalities and fever without other explanation. HUS has features of TTP along with acute renal failure.12%-31% of TTP patients are women during pregnancy or postpartum period.Pathological diagnosis requires hyaline thrombi in terminal arterioles andcapillaries. We present a case of a 28 years old primigravida female, with 38 weeks of gestation, who was apparently alright earlier and presented with prolonged second stage of labour. However, day 2 postpartum she developed fever, breathlessness, loose motions and vomiting. She also developed pallor, icterus and petechial haemorrhages.Laboratory investigations revealed low platelet count, elevated bilirubin (direct more than indirect), elevated serum creatinine, and mildly raised hepatic transaminases. Day 5, she developed anuria and grade 3 dyspnoea and succumbed to death. Complete autopsy was performed .Histopathology on sections from kidneys revealed glomerular capillaries and arterioles showing platelet-fibrin thrombi and diffuse thickening of glomerular capillary wall with double contour of glomerular basement membrane. Lungs showed lobar pneumonia. Cause of death given was acute renal failure with lobar pneumonia with HUS-TTP in a postpartum female. TTP-HUS is a rare disorder and although some clinical features may suggest diagnosis, histopathological examination of renal specimen and applying special stains like PAS stain, silver stain and MSB (Mauritus,Scarlet,Blue) stain for fibrin, confirms the diagnosis. DOI: 10.21276/APALM.1240

Can Ultrasonography Help Diagnose Gout

Ultrasound is used increasingly for diagnosing gout. Three sonographic features of monosodium urate (MSU) crystal deposition are double contour sign

Value of ultrasonography in the diagnosis of gout in patients presenting with acute arthritis

To evaluate the value of ultrasonographic features of crystal deposition for diagnosing gout in patients presenting with acute arthritis. Ultrasound scanning of the most inflamed joint was performed on 89 consecutively enrolled patients with acute arthritis. Two radiologists independently reviewed the ultrasound images, and a consensus was achieved with a third radiologist when the interpretations of four key ultrasound features of gout differed. Arthrocentesis and crystal analysis using compensated polarized light microscopy of aspirates are considered the gold standards for gout diagnosis. Fifty-three (60%) patients had gout, whereas the remaining 36 (40%) had non-gout arthritis. The mean serum uric acid level was 7.1mg/dl in patients with gout and 4.7mg/dl in patients with non-gout arthritis. Three US features differed significantly (p < 0.001) between patients with gout and non-gout arthritis: the double contour sign (42 vs. 8%, respectively), intra-articular aggregates (58 vs. 8%), and tophi (40 vs. 0%). No statistically significant differences in detecting intra-tendinous aggregates (32 vs. 17%, p = 0.14) were observed. The sensitivity and specificity of the double contour sign were 42 and 92%, respectively; those of the intra-articular aggregates were 58 and 92%; and those of tophi were 40 and 100%. The positive predictive values for these three features ranged from 88 to 100%, whereas the negative predictive values ranged from 52 to 60%. When the prevalence is high, these three ultrasound features may be a useful adjunct in the diagnosis of acute gout, particularly when specialized microscopic techniques are not available.

THE RELATIONSHIP BETWEEN CLINICAL SYMPTOMS AND ULTRASONOGRAPHIC SIGNS IN GOUT

For the first time, the new ACR/EULAR gout classification criteria incorporate ultrasound (US) evidence of double contour sign (DC), an articular cartilage abnormality related to the deposition of crystals on the surface of the hyaline cartilage, as a sign specific to gout. US recently has been used as an objective diagnostic tool for detecting urate deposition (tophus (T), DC) or joint damage (erosion) in gout. Objective: Our aim was to investigate the relationship between clinical gout activity and load of US changes, also to examine the concordance between patient reported joint attack (PRGA) and ultrasonographic intraarticular changes. Methods: Sixty monosodium-urate-crystal-confirmed gout patients and 36 healthy controls were prospectively included in one centre. The relationship between clinical symptoms and ultrasonographic gout-related changes investigating 36 joints and 4 tendons (m. triceps and patellar) was evaluated using Spearman’s correlation and agreement analysis (kappa coefficient). Results: moderate, positive correlation was observed between the number of subcutaneous tophi and total US tophus area (rs=0,628), total number of DC (rs=0,612), and erosions (rs=0,526), all p&lt;0, 0001, found per patient on US. Gout attacks and disease duration significantly positively correlated with the load of all investigated US changes (p&lt;0, 01). Investigating 1980 joints in 55 gout patients irrespective of treatment and disease duration, symptoms were reported in 307 (15,5%) joints while ultrasound detected signs of urate deposition and erosions in 416 (20,9%) and 143 (7,2%) joints, respectively. The overall concordance rate with PRGA in the joint was fair for tophus (κ= 0,333), especially in the wrist and ankle, also fair for DC (κ= 0,275) and erosion (κ= 0,217). There was large number of clinically false negative joints with T and/or DC found on US, but also negative intraarticular US in patient-reported arthritis. Better concordance, considered as moderate between PRGA and any sign of urate deposition (US T or DC) was found, investigating 1008 joints in untreated (28) gout subgroup (κ= 0,498) compared to treated (κ= 0,231). The specificity of US T, DC, and erosion was 81% (p&lt;0, 0001), 86% (p&lt;0, 0001), and 70% (p&lt;0, 01), respectively. Conclusions: Ultrasonographic changes positively correlate with disease activity and duration in gout with fair to moderate concordance between patientreported gout attack and intraarticular US findings. Not only symptomatic joints should be used for US gout classification in clinical practice.

Two new oxystominid species (Nematoda: Enoplida) from an abyssal plain in the southern Philippine Sea

Two new species of free-living marine nematodes, Litinium dispariseta sp. nov. and Wieseria minor sp. nov. are described from an abyssal plain with a water depth of 4117–5035 m near the Southern Kyushu-Palau Ridge in the tropical Western Pacific Ocean. Litinium dispariseta sp. nov. is characterized by having distinct inner labial setae two times longer than the outer labial setae, wrench-like amphideal foveas, a single preanal midventral supplementary seta and a short cylindrical tail with bluntly rounded tip. It differs from congeners by its distinctly long inner labial setae relative to the outer labial setae (two times longer vs shorter or equal in length) and peculiar wrench-like amphideal foveas (vs horseshoe shaped or ovoid with round to oval anterior aperture). Wieseria minor sp. nov. has a clavate tail, a character found only in the four congeners W. glandulosa (Kreis, 1929), W. longiseta (Allgén, 1947), W. clavata Gerlach, 1956 and W. inaequalis Gerlach, 1956. However, Wieseria minor sp. nov. differs from these congeners by its much smaller body size (1045 µm vs 2120–3125 µm) and oblong amphideal foveas with double contour (vs a single oblong or ovoid loop). An emended diagnosis for Wieseria and pictorial keys for Litinium and Wieseria are provided.

Thrombotic microangiopathy mimicking membranoproliferative glomerulonephritis.

A 4-year-old boy presented with proteinuria and developed progressive renal failure over 6 years. In the patient's family, five individuals were affected with atypical haemolytic uraemic syndrome (aHUS) but not the patient. Renal biopsies (n = 3) showed glomerular basement membrane thickening with double contours, endothelial swelling and deposits of C3 and C1q. Electron microscopy revealed mesangial and subendothelial electron-dense deposits. Complement mutations in membrane cofactor protein (Y155D) and C3 (R713W and G1094R) were detected in all affected family members. The patient also had transient autoantibodies to factor H. The findings suggest that aHUS and glomerulopathy resembling membranoproliferative glomerulonephritis may have a common molecular background.

Relationship between the morphological variation of sella turcica with age and gender: A digital radiographic study

Introduction: Sella turcica is a saddle-shaped concavity located in the middle cranial fossa of the skull. The exact dimensions of sella turcica are an important consideration in the diagnosis, prognosis, and treatment of diseases related to the pituitary gland and brain. The sella turcica size and morphology is different from person to person. Thus, obtaining any data in this regard will be a great help in detecting abnormalities within this anatomic area. Aim: The objective of this study was to find out the correlation between the morphological variations of sella turcica with age and gender. Materials and Methods: Study sample consisted of 311 cephalograms of patients with age ranging 6–40 years. The contour of the sella turcica was traced and the linear measurements – length, depth, and diameter of sella turcica – were measured according to Silverman. Results: Morphology of sella turcica appeared to be normal shape in 27.3% of the study population followed by combination (26.7%), irregular (15.8%), pyramidal (10.6%), bridge (10%), oblique anterior wall (5.5%), and double contour (4.2%). Gender-wise comparison of the linear measurement was not statistically significant. Among the linear measurement, the parameter depth and diameter were statistically significant (P < 0.001) when correlated with age. On comparison of shape of sella turcica with linear measurements, the parameter length was statistically significant (P < 0.001). Conclusion: There is no significant relationship between the linear measurements and gender. There exists a significant relationship between the mean depth and mean diameter with age. That is, as age increases, the depth and diameter increase. There is a significant relationship between the length and the different shapes of sella turcica.