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Associations and Causes of Chronic Eosinophilic lung; (2) hemorrhage with or without capillari- Pneumonia Pathology tis (vasculitis involving capillaries recognized by presence of neutrophils in alveolar walls); Allergic bronchopulmonary fungal disease Simple pulmonary eosinophilia (3) bronchocentric; (4) organizing pneumonia- Systemic infection (parasites buy prandin 0.5 mg lowest price diabetes test vårdcentral, fungi) like; and (5) eosinophilic pneumonia-like buy 2 mg prandin free shipping diabetes mellitus type 2 in urdu. Churg Strauss syndrome Positive p-antineutrophil cytoplasmic antibody Hodgkin lymphoma titers generally representing autoantibodies Inﬂammatory bowel disease directed against myeloperoxidase are less spe- Lung cancer ciﬁc but have been reported to be positive in *From Uchiyama H discount 1 mg prandin with mastercard diabetes symptoms passing out, Suda T, Nakamura Y, et al. Asbestos bodies are iron-encrusted ﬁbers (one Classic pathology includes the following: type of ferruginous body, which is a more generic • Necrotizing granulomatous inﬂammation with term) that typically are beaded and dumbbell shaped geographic borders (appears more like paren- with a thin translucent core. There are no generally chymal necrosis than a true granuloma since accepted criteria deﬁning how many asbestos bodies the foci usually lack signiﬁcant numbers of epi- must be identiﬁed in any given case for a diagnosis thelioid histiocytes); of asbestosis, but the presence of even a single Centrally in foci of necrosis there is amor- asbestos body in a routine tissue section usually phous eosinophilic to basophilic debris with signiﬁes “above-background” asbestos exposure. Pulmonary Complications of Asbestos Exposure* Palisading granulomas are tiny granulomas composed of a single layer of palisading epi- Pleural disease thelioid histiocytes that either radiate around Effusion a central point or surround a central eosino- Fibrosis philic structure resembling a collagen bun- Plaques dle. As the palisaded granulomas enlarge, Pseudoneoplasms (rounded atelectasis) Parenchymal lung disease they become more microabscess-like; Asbestosis • Necrotizing segmental (involving portion of Asbestos airways disease the wall) vasculitis of arteries and veins; and Neoplasms • Randomly dispersed, darkly staining multinu- Malignant mesothelioma cleated giant cells common variants. Simple (nodular) silicosis Silicotic nodules 1 cm Upper lung zones Pulmonary Infections Complicated silicosis Conglomerate nodules 1 cm See Tables 9−12 for a listing of pulmonary infec- Upper and middle lung zones tions. Microscopic ﬁndings include: The grading scheme is strictly pathologic and • Discrete foci of concentric layers of hyalinized does not rely on clinical parameters (eg, for the collagen; diagnosis of obliterative bronchiolitis syndrome): Abundant dust-ﬁlled histiocytes; and • Grade 0, negative for rejection: normal pulmo- Birefringent particles (usually); often a mix of nary parenchyma without evidence of mono- silica and silicates); nuclear inﬁltration or alveolar hemorrhage; When necrosis is present, complication by • Grade 1, minimal acute rejection: infrequent tuberculosis should be considered. Alveolar pneumocyte damage usually is asso- Small cell carcinoma typically is peribronchial; ciated with necrosis, airspace hemorrhage, endobronchial lesions are uncommon. Anti- ically, small cell carcinomas are round-to-fusiform body-mediated rejection and pulmonary hem- nuclei, nuclear molding, faint or absent nucleoli, orrhage, capillaritis, and complement deposi- and have scant cytoplasm. Immunohisto- with extensive necrosis, large nuclei with promi- chemistry is thyroid transcription factor 1–, cyto- nent nucleoli, and no evidence of squamous or keratin 5/6, and p63. Acute rejection (perivascular, interstitial and alveolar synaptophysin: 10 to 20% , cytokeratin 7 and inﬂammation) cytokeratin 20±, and thyroid transcription factor 1. Airway inﬂammation In bronchioloalveolar carcinoma there are nod- Grade 0 – None ules or areas of consolidation, more commonly Grade 1R – Low grade Grade 2R – High grade peripheral. Chronic vascular rejection – accelerated graft vascular sclerosis well differentiated, uniform, and grows along intact Antibody-mediated rejection alveolar walls, and there is no invasion into underly- ing stroma. Neuroendocrine Cell Hyperplasia References Neuroendocrine cell hyperplasia43 is deﬁned [Note to participants regarding references: there are as increased neuroendocrine cells within bron- some primary sources quoted, but the textbooks chiolar epithelium. American Thoracic Society/European Respira- tory Society International Multidisciplinary Con- Microscopic ﬁndings include organoid, pali- sensus Classiﬁcation of the Idiopathic Interstitial sading, trabecular patterns; large, polygonal nuclei Pneumonias. Respiratory bron- pulmonary ﬁbrosis: relationship between histo- chiolitis-associated interstitial lung disease and its pathologic features and mortality. Profusion phoid interstitial pneumonia: clinicopathologi- of ﬁbroblast foci in patients with idiopathic pulmo- cal and immunopathological ﬁndings in 18 cases. Idio- pulmonary disease caused by nonturberculous pathic nonspeciﬁc interstitial pneumonia: report of mycobacteria in immunocompetent people (hot an American Thoracic Society project. When patients with a supplied by the bronchial circulation that is situated pleural effusion are symptomatic, dyspnea and a greater distance from mesothelial surface. An may be caused by a large or massive pleural effu- ultraﬁltrate of parietal pleural capillaries increases sion in a patient with normal lungs, a moderate interstitial pressure and promotes movement of effusion in patients with some underlying lung ﬂuid into pleural space between the mesothelial cell disease, and a small-moderate effusion in patients junctions. Dyspnea is perceived by the patient with a Virtually all patients with a newly discovered large-to-massive pleural effusion because of its pleural effusion should have a thoracentesis per- effect on the previously mentioned structures with formed to obtain a diagnosis to guide manage- input from neurogenic receptors in the lung and ment. Pleuritic chest pain has been aforementioned examples; however, if the clinical described as having a “stitch in the side” or a “stab- bing” or “shooting” pain that may be exacerbated by deep inspiration, cough, or sneezing. However, the number or squamous epithelial cells on cytology and speciﬁc deﬁnitive diagnoses will vary with Fungal effusion Positive potassium hydroxide stain the population being studied. In a prospective or culture study of 129 patients with pleural effusion, tho- Chylothorax Triglyceride 110 mg/dL (high racentesis provided a deﬁnitive diagnosis in only likelihood); presence of chylomi- crons deﬁnitive 18% of patients and a presumptive diagnosis in Hemothorax Hematocrit (pleural ﬂuid/blood 55% of patients. Interleukin-5 appears to be an impor- Some diagnoses can be established at the bed- tant chemotactic factor attracting bone marrow- side by visual inspection of the ﬂuid (Table 3). In example, if pus is aspirated from the pleural space, patients who require thoracotomy for spontaneous the diagnosis of empyema is established and, if pneumothorax, eosinophilic pleuritis is commonly the pus has a putrid odor, anaerobic organisms encountered within hours of the pneumothorax. A coccidioidomycosis Drug-induced Dantrolene, bromocriptine, transudate, which is caused by imbalances in nitrofurantoin, valproic acid, hydrostatic and oncotic pressures, is associated and others 11 with a normal pleura. A metaanalysis of 1,444 patients11 determined that all effusion, they provide information helpful in man- agement strategies; and (3) in malignant effusions, of the following tests have statistically similar it provides information relating to extent of pleural involvement with tumor, ease of diagnosis, prog- nosis, and management. A Bayesian approach with application of Constrictive Bilateral effusions due to likelihood ratios to pretest estimates of the prob- pericarditis pulmonary and systemic ability of an exudative effusion improves diagnos- hypertension Trapped lung A result of remote pleural tic accuracy. However, an elevated brain natriuretic diomegaly in a patient with bilateral effusions peptide and compatible echocardiogram demon- should raise the possibility of another cause of the strating a low left ventricular ejection fraction or diastolic dysfunction supports the diagnosis. The chest radiograph usually dem- Noonan syndrome onstrates a small-to-moderate right effusion 70% Lymphangiectasia of the time; an isolated left pleural effusion and Movement of ﬂuid from abdomen to pleural space Acute pancreatitis bilateral effusions have each been reported in approximately 15% of patients. Approximately unilateral or bilateral effusions with minimal evi- 25% of patients have a refractory hepatic hydro- dence of volume loss with a normal heart size and thorax. The diag- diaphragmatic defects and perform talc poudrage nosis is presumptive based on the patient’s presen- has been used but is associated with a high rate of tation. Furthermore, chest tube drainage in these individuals is contraindicated because it promotes Nephrotic Syndrome infection, depletes protein and lymphocytes, and increases the risk of renal failure and often creates Effusions develop in 20 to 25% of patients with a prolonged ﬂuid leak after removal of the chest nephrotic syndrome. Liver transplantation is the best treatment for effusions is associated with the degree of hypoal- decompensated hepatic cirrhosis and, therefore, buminemia. Pulmonary embo- embolism without an infarction, an endobronchial lism should always be considered in patients with obstruction from lung cancer, acute pancreatitis, nephrotic syndrome who develop pleuritic chest splenic infarction, and subphrenic or hepatic pain when the pleural effusion is signiﬁcantly larger abscess and the absence of a sympathetic effusion. Finding a Trapped lung, the end stage of an infectious or transudate by these criteria in effusions of vascu- inﬂammatory pleural effusion, presents as a per- lar origin almost always indicates a normal sistent transudative effusion months to years after protein reﬂection coefﬁcient but also increased the acute pleural process. It is a relatively uncom- filtration and increased lymphatic bulk flow mon cause of a pleural effusion, representing 5% conditions, narrowing the differential diagnosis of effusions in the Medical University of South considerably. These patients Patients with trapped lung may present with typically have a pleural elastance of 15 cm of H2O an asymptomatic pleural effusion seen on a rou- per liter of ﬂuid removed. Failure of the lung to tine chest radiograph or with dyspnea on exertion expand on chest radiograph after removal of all months to years after the acute pleural injury. The The chest radiograph typically shows a small- pathogenesis of these effusions is decreased to-moderate unilateral effusion without signiﬁ- oncotic pressure that generally requires a serum cant mediastinal shift. It is highly unlikely a with a low nucleated cell count, typically 500/ L, patient with hypoalbuminemia presents with an and a mononuclear predominance characterized isolated pleural effusion without concomitant by a lymphocytosis 50% of the total nucleated anasarca. We still believe effusions and is generally not dyspneic at rest or that the ﬂuid should be considered a transudate with minimal activity; however, those patients with and that the pleural protein concentration depends signiﬁcant underlying pulmonary disease or heart on the plasma protein concentration, the protein disease may be breathless on exertion. The chest reﬂection coefﬁcient, solvent ﬁltration into the radiograph typically shows small-to-moderate 520 Pleural Disease (Sahn) bilateral effusions with a normal heart size. Hypoalbuminemia-induced pleural effusions are The precise incidence of urinothorax is a clinical diagnosis in a patient with a very low unknown; however, approximately 40 cases have serum albumin and when other possible causes of been reported in the literature. Acute, massive, right-sided pleu- trauma to the kidney, renal transplantation, ileal ral effusions may occur, usually in women in conduit with ureteral obstruction, bladder lacera- 1 month (range 1 day to 2 years) after starting tion, and pregnancy. Patients to-moderate pleural effusion ipsilateral to the with acute massive effusions may present with obstructed kidney; however, there are reports of acute respiratory failure and are often diagnosed bilateral and contralateral effusions. An anaerobic infection, prolonged pneumo- nia history, failure to respond to antibiotic therapy, Parapneumonic Efusions virulence of the underlying bacterial pathogen, and hypoalbuminemia also suggest the presence of a A parapneumonic effusion is defined as a complicated parapneumonic effusion. An uncomplicated parapneumonic lishes the presence of an empyema and always effusion is a small-to-moderate effusion that re- requires pleural space drainage.
Several criteria have been developed in an attempt to identify the 15% to 25% of patients who will have a more complicated course cheap prandin 1mg without a prescription diabetes mellitus diabetes insipidus. When three or more of the following criteria are present order prandin online from canada diabetes type 2 breakfast, a severe course complicated by pan- creatic necrosis can be predicted by Ranson criteria (Table 14–1) prandin 1 mg overnight delivery diabetes microvascular disease definition. The most common cause of early death in patients with pancreatitis is hypovolemic shock, which is multifactorial: third spacing and sequestration of large fluid volumes in the abdomen, as well as increased capillary permeability. Pancreatic complications include a phlegmon, which is a solid mass of inflamed pancreas, often with patchy areas of necrosis. Either necrosis or a phlegmon can become secondarily infected, resulting in pancreatic abscess. Abscesses typically develop 2 to 3 weeks after the onset of illness and should be suspected if there is fever or leukocytosis. Pancreatic necrosis and abscess are the leading causes of death in patients after the first week of illness. A pancreatic pseudo- cyst is a cystic collection of inflammatory fluid and pancreatic secretions, which unlike true cysts do not have an epithelial lining. Most pancreatic pseudocysts resolve spontaneously within 6 weeks, especially if they are smaller than 6 cm. However, if they are causing pain, are large or expanding, or become infected, they usually require drainage. Any of these local complications of pancreatitis should be suspected if persistent pain, fever, abdominal mass, or persistent hyperamylasemia occurs. Gallstones Gallstones usually form as a consequence of precipitation of cholesterol microcrystals in bile. When discovered incidentally, they can be followed without intervention, as only 10% of patients will develop any symptoms related to their stones within 10 years. When patients do develop symptoms because of a stone in the cystic duct or Hartmann pouch, the typical attack of biliary colic usually has a sudden onset, often pre- cipitated by a large or fatty meal, with severe steady pain in the right upper quadrant or epigastrium, lasting between 1 and 4 hours. They may have mild elevations of the alkaline phosphatase level and slight hyperbilirubinemia, but elevations of the bilirubin level over 3 g/dL suggest a common duct stone. The first diagnostic test in a patient with suspected gallstones usually is an ultra- sonogram. The test is noninvasive and very sensitive for detecting stones in the gallbladder as well as intrahepatic or extrahepatic biliary duct dilation. This is apparent ultra- sonographically as gallbladder wall thickening and pericholecystic fluid, and is characterized clinically as a persistent right upper quadrant abdominal pain, with fever and leukocytosis. Cultures of bile in the gallbladder often yield enteric flora such as Escherichia coli and Klebsiella. The positive test shows visualization of the liver by the isotope, but nonvisualization of the gallbladder may indicate an obstructed cystic duct. Treatment of acute cholecystitis usually involves making the patient npo (nil per os), intravenous fluids and antibiotics, and early cholecystectomy within 48 to 72 hours. Another complication of gallstones is cholangitis, which occurs when there is intermittent obstruction of the common bile duct, allowing reflux of bacteria up the biliary tree, followed by development of purulent infection behind the obstruction. After 3 months she is noted to have severe right upper quadrant pain, fever to 102°F, and nausea. This patient with fever, right upper quadrant pain, and a history of gallstones likely has acute cholecystitis. A pancreatic pseudocyst has a clinical presentation of abdominal pain and mass and persistent hyperamylasemia in a patient with prior pancreatitis. Clinical Pearls ➤ The most common causes of acute pancreatitis in the United States are alcohol consumption, gallstones, and hypertriglyceridemia. Cholecystectomy is per- formed for patients with symptoms of biliary colic or for those with com- plications. Initial management of acute pancreatitis: critical issues during the first 72 hours. Case 15 A 72-year-old man is brought to the emergency room after fainting while in church. His wife, who witnessed the episode, reports that he was uncon- scious for approximately 5 minutes. This has never happened to him before, but his wife does report that for the last several months he has had to curtail activi- ties, such as mowing the lawn, because he becomes weak and feels light- headed. His only medical history is osteoarthritis of his knees, for which he takes acetaminophen. He is afebrile, his heart rate is regular at 35 bpm, and his blood pressure is 118/72 mm Hg, which remains unchanged on standing. His chest is clear to auscultation, and his heart rhythm is regular but bradycardic with a nondisplaced apical impulse. Laboratory examination shows normal blood counts, renal function, and serum electrolyte levels, and negative cardiac enzymes. He has experienced decreasing exercise tolerance recently because of weakness and presyncopal symptoms. He should be evaluated for myocardial infarction and structural cardiac abnormalities. If this evaluation is negative, he may simply have conduction system disease as a consequence of aging. The causes are varied, but they all result in transiently diminished cerebral perfusion leading to loss of consciousness. The prognosis is quite varied, ranging from a benign episode in an otherwise young, healthy person with a clear precipitating event, such as emotional stress, to a more serious occurrence in an older patient with cardiac disease. In the latter situation, syncope has been referred to as “sudden cardiac death, averted. Traditionally, the etiologies of syncope have been divided into neurologic and cardiac. However, this probably is not a useful classification, because neu- rologic diseases are uncommon causes of syncopal episodes. Vertebrobasilar insufficiency with resultant loss of consciousness is often discussed yet rarely seen in clinical practice. Seizure episodes are a com- mon cause of transient loss of consciousness, and distinguishing seizure episodes from syncopal episodes based on history often is quite difficult. To fur- ther complicate matters, the same lack of cerebral blood flow that produced the loss of consciousness can lead to postsyncopal seizure activity. Seizures are best discussed elsewhere, so our discussion here is confined to syncope. The only neurologic diseases that commonly cause syncope are disturbances in autonomic function leading to orthostatic hypotension as occurs in dia- betes, parkinsonism, or idiopathic dysautonomia. For patients in whom a definitive diagnosis of syncope can be ascertained, the causes usually are excess vagal activity, orthostatic hypotension, or cardiac disease—either arrhythmias or outflow obstructions. By far, the most useful evaluation for diagnosing the cause of syncope is the patient’s history. Vasovagal syncope refers to excessive vagal tone causing impaired auto- nomic responses, that is, a fall in blood pressure without appropriate rise in heart rate or vasomotor tone.
Hasan Sadikin General Hospital Bandung between Mar and cise treatment on reducing the severity of pain (p<0 prandin 0.5 mg diabetes type 2 resources. Aly2 Surabaya order generic prandin canada blood sugar 240, Indonesia 1Alexandria buy generic prandin 2mg on line nephrogenic diabetes insipidus quizlet, Egypt, 2Faculty of Medicine- Alexandria University, Introduction/Background: Musculoskeletal diseases associated with Physical Medicine- Rheumatology & Rehabilitation, Alexandria, daily activities or occupation have reached the highest proportion Egypt of epidemiology in recent years. The aim of this study was to identify the prevalence of the habilitation of Haji Hospital, Surabaya. Seferoglu 1 arthritis, painful neuropathies, carpal tunnel syndrome, periarthritis of Ataturk University Medical Faculty, Physical Medicine and Reha- the shoulder and/or osteoporosis). Results: We found that aerobic exer- therapy is often preferred for a variety of symptoms. Nevertheless, cise and aerobic exercise with Kinesio taping treatment approaches there is no effective treatment. Stress is the worst detriment to health Trig- right iliac crest was found and partially resected with complete pain gers the “fght or fight” response. In our offce, direct compression of supra-gluteal system is constantly hyperactive. We suspected off the adrenaline system and activate parasympathetic system is to cluneal nerve entrapment so patient underwent medial superior eliminate the pain and stress. The autonomic and central nervous cluneal nerve exploration and release from thoracolumbar fascia. Each treat- diagnostic injections, it is possible that patient had L4 and L5 radic- ment involved standard cleansing of the skin with alcohol and in- ulopathy. Results: The patient’s symptoms predisposed this patient to cluneal nerve entrapment. At 3 months’ symptoms and risk factors are consistent with those described in and 1 year’ follow-ups, she had minimal pain. Conclusion: Patients frequently have multiple superim- said that she felt more relaxed and better. However, there is no defnitive treatment to this painful mon to the release of many neurotransmitters including amines, condition. The aim of this study was to evaluate the effects of dry amino acids and peptides. Material and gesic effcacy in treatment of chronic pain disorders (Wheeler and Methods: Prospective case control study. All patients, before treatment, after treatment, and one month chest and back sites. The patient satisfaction survey was cular, intra-articular sites, and/or as a subcutaneous regional block. Results: The authors report the results of an ongoing Three cases are described to illustrate the versatility of the technique study in which 14 patients have been treated with dry needle ther- and the duration of its action. Subject 2 had sults suggest a dry needling can be effective in reducing symptoms chronic lower back pain assossiated with spastic lower limb diplegia and improving function in patients with non-specifc shoulder pain. This prolonged pain, which is often refractory stitute of Physical Therapy, Taipei, Taiwan, 3Taipei Medical Uni- to pain-killing medication, nerve block and surgical treatment may versity, Graduate Institute of Injury and Prevention, Taipei, Tai- severely affect the patient’s quality of life. The phenomenon of wan, 4National Taipei University of Nursing and Health Sciences, phantom limb pain has been investigated using neurological, neu- Department of Exercise and Health Science, Taipei, Taiwan rophysiological and psychopathological approaches. This therapy works on the principle of Database, WorldWideScience, Biosis, and Google Scholar data- mirror neuron system. A mirror neuron fres both when a person bases, was performed to identify quasi-randomized or randomized acts or when a person observes same action performed by another. The selected studies were subjected to a meta-analysis integrate the mismatch between proprioception and visual feedback and risk of bias assessment. Tomanova 1 1Inje University Sanggye Paik Hospital, Rehabilitation Medicine, Charles University in Prague, The Third Faculty of Medicine and General Teaching Hospital, Prague, Germany; 2Rehabilitation Seoul, Republic of Korea Clinic Brandýs nad Orlicí, Rehabilitation Clinic, Brandýs nad Or- Introduction/Background: To investigate the effect of ultrasound- licí, Czech Republic guided subarcromial-subdeltoid bursa injection of different volume Introduction/Background: The local injection of Botulinumtoxin of lidocaine and corticosteroid in patients with rotator cuff syn- is proven particularly in diseases associated with increased muscle drome. Material and Methods: 16 Study participants were outpa- tone as an effective symptomatic therapy. Inclusion criteria are at least one of ter- gests that botulinum toxin affects afferent nerve fbers, especially minal arc pain, Neer’s test, and Hawkin’s test, Rotator cuff lesion the pain fbers. Therefore, an infuence of neuropathic pain by the (partial tear, bursitis, tendinosis) in ultrasound exam, limitation of neurotoxin seems possible. So far there are in the literature but only shoulder motion due to pain, more than 1 month of pain duration, isolated reports. Subjects were injected with 3cc volume duction of neuropathic pain has been demonstrated in a patient fol- of 0. The patient was signif- amcinolone, and 10 patients were injected with 3 cc volume of 0. Of crucial duration, current pain medication, last shoulder injection, passive importance, however, was that the patient over an almost complete range of motion, terminal arc pain. Rotator cuff lesion was examined cessation of pain syndrome reported (pain scale 0–1). Ultrasound-guided sub- good to move passively and in the meantime could be started with a acromial-subdeltoid bursa injection was done by same physiatrist. Conclusion: Subacromial-subdeltoid bursa in- 1Ludhiana, India jection of the same total volume of lidocaine with different amount J Rehabil Med Suppl 55 Poster Abstracts 73 of steroid has signifcantly different therapeutic effect. The patient was diagnosed histopathologically as diffuse large to inject appropriate dose of triamcinolone as required. However, scintigraphy is valuable in staging, it can detect multifocal involvement which alters therapy. Conclusion: As mentioned above all imaging methods who developed diffuse anterior thigh edema as a result of an injury have different properties complementig each other that should be while attempting a jump-over during pentathlon training described benefted from for diagnosis and handled in manipulation of am- here. Material and Methods: A 37-year-old man with pain on his biguous lesions ran into on classical imaging techniques. He had a history of injury to his left lower extremity 7 months ago while jumping 237 over during a penthatlon training. Arslan 1Gülhane Military Medical Academy, Nuclear Medicine, Ankara, pulses were normal bilaterally. Firstly, he had been treated with Turkey, 2Gülhane Military Medical Academy, Physical Medicine ice, elevation, immobilization and some nonsteroidal anti-infam- matory drugs. He had taken some analgesics and myorelaxant and Rehabilitation, Ankara, Turkey drugs with the diagnosis of myalgia but his symptoms were not Introduction/Background: Chronic recurrent multifocal osteomy- relieved through 7 months. Patients may complain of pain, tenderness, swelling and of edema anterior compartment of the thigh. It is characterized by noninfectious bone lesions at ed the presence of extensive edema in the anterior compartment of multiple sites. Involvement of metaphysis adjacent to the growth the left thigh from groin level to suprapatellar area. The patient was consulted with male was complaining of joint stiffness at mornings and backache an orthopedic surgeon and non-surgical treatments were suggested. Pelvic X-ray graphy showed sclerosis and contour Conservative treatments are going on and symptoms are decreased irregularity at right sacroiliac joint.