Forensic age estimation by MRI of the knee - comparison of two classifications for ossification stages in a German population

AIM AND OBJECTIVES

In forensic age estimation e.g. for judicial proceedings surpassed age thresholds can be legally relevant. To examine age related differences in skeletal development the recommendations by the Study Group on Forensic Age Diagnostics (AGFAD) are based on ionizing radiation (among others orthopantomograms, plain x-rays of the hand). Vieth et al. and Ottow et al. proposed MRI-classifications for the epiphyseal-diaphyseal fusion of the knee joint to define different age groups in healthy volunteers. The aim of the present study was to directly compare these two classifications in a large German patient population.

MATERIALS AND METHODS

MRI of the knee joint of 900 patients (405 female, 495 male) from 10 to 28 years of age were retrospectively analyzed. Acquired T1-weighted turbo spin-echo sequence (TSE) and T2-weighted sequence with fat suppression by turbo inversion recovery magnitude (TIRM) were analyzed for the two classifications. The different bony fusion stages of the two classifications were determined and the corresponding chronological ages assigned. Differences between the sexes were analyzed. Intra- and inter-observer agreements were determined using Cohen's kappa.

RESULTS

With the classification of Ottow et al. it was possible to determine completion of the 18th and 21st year of life in both sexes. With the classification of Vieth et al. completion of the 18th year of life for female patients and the 14th and 21st year of life in both sexes could be determined. The intra- and inter-observer agreement levels were very good (κ > 0.82).

CONCLUSION

In the large German patient cohort of this study it was possible to determine the 18th year of life with for both sexes with the classification of Ottow et al. and for female patients with the classification of Vieth et al. It was also possible to determine the 21st year of life for all bones with the classification of Ottow et al. and for the distal femur with the classification of Vieth et al.

Diagnosis of presence and extent of deep infiltrating endometriosis by preoperative MRI-improvement of staging accuracy by expert training

INTRODUCTION

This study evaluates the clinical utility of magnetic resonance imaging (MRI) for the determination of presence and extent of DIE with special emphasis on effects of MRI reporting training MATERIAL AND METHODS: Data from 80 patients with clinically suspected DIE presented at our certified endometriosis center between 2015 and 2018 were analyzed. For all patients an ENZIAN score (describing DIE related to individual anatomical localizations) was obtained based on the preoperative MRI findings. The intraoperatively determined ENZIAN score served as the reference for assessment of diagnostic performance of the MRI.

RESULTS

Overall, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of DIE by MRI were 76.9%, 53.3%, 87.7% and 34.8%, respectively. Analysis by compartment revealed a sensitivity, specificity, PPV and NPV of 59.5%, 88.2%, 86.2% and 63.9%, respectively, for compartment A, with similar values for compartment B, and 50.0%, 88.9%, 64.7% and 81.4%, respectively, for the less often affected compartment C. Expert training (n = 32 before, n = 48 after) led to a considerable increase in sensitivities for the overall detection of DIE (84.6% vs. 65.4%, p = 0.071) and for the detection of DIE in compartment A (71.4% vs. 35.7%, p = 0.026), compartment B (66.7% vs. 37.5%, p = 0.057) and compartment C (75.0% vs. 20.0%, p = 0.010), without significant loss in specificity (all p > 0.50).

DISCUSSION

After expert training, MRI has a good sensitivity with fair specificity regarding preoperative assessment of presence, location and extent of DIE.

Tiny golden angle stack-of-stars (tygaSoS) free-breathing functional lung imaging

PURPOSE

MRI of the lung parenchyma is still challenging due to cardiac and respiratory motion, and the low proton density and short T₂*. Clinical feasible MRI methods for functional lung assessment are of great interest. It was the objective of this study to evaluate the potential of combining the ultra-short echo-time stack-of-stars approach with tiny golden angle (tyGASoS) profile ordering for self-gated free-breathing lung imaging.

METHODS

Free-breathing tyGASoS data were acquired in 10 healthy volunteers (3 smoker (S), 7 non-smoker (NS)). Images in different respiratory phases were reconstructed applying an image-based self-gating technique. Resulting image quality and sharpness, and parenchyma visibility were qualitatively scored by three blinded independent reader, and the signal-to-noise ratio (SNR), proton fraction (f_P) and fractional ventilation (FV) quantified.

RESULT

The imaging protocol was well tolerated by all volunteers. Image quality was sufficient for subsequent quantitative analysis in all cases with good to excellent inter-reader reliability. Between expiration (EX) and inspiration (IN) significant differences (p < 0.001) were observed in SNR (EX: 3.73 ± 0.89, IN: 3.14 ± 0.74) and f_P (EX: 0.27 ± 0.09, IN: 0.25 ± 0.08). A significant (p < 0.05) higher f_P (EX/IN: 0.22 ± 0.07/0.21 ± 0.07 (NS), 0.33 ± 0.07/0.30 ± 0.06 (S)) was observed in the smoker group. No significant FV differences resulted between S and NS.

CONCLUSION

The study proves the feasibility of free-breathing tyGASoS for multiphase lung imaging. Changes in f_P may indicate an initial response in the smoker group and as such proves the sensitivity of the proposed technique. A major limitation in FV quantification rises from the large inter-subject variability of breathing patterns and amplitudes, requiring further consideration.

[Improved image quality of the cervical spine neck CT using an arm traction device]

BACKGROUND

The assessment of the cervico-thoracic junction in the neck CT is frequently hampered by streak artifacts from the shoulder girdles.

PURPOSE

To evaluate the effects of an optimized patient positioning through the use of an arm traction device.

MATERIALS AND METHODS

25 patients (age [mean ± standard deviation]: 58.9 ± 11.6 years; sex [m:f]: 15:10) underwent a neck CT using an arm traction device together. Further 25 patients underwent this in standard positioning (59.8 ± 15.2 years; 16:9). An experienced neuroradiologist determined the last free accessible vertebra on the CT scout view and assessed the image quality of the intervertebral disc space of the lower neck on a three-point grading scale. The procedure was evaluated by the medical-technical radiology assistants performing it.

RESULTS

The last free accessible vertebra on CT scout was statistically significant one vertebra lower using an arm traction device, yielding on average the sixth cervical vertebra (p = 0.010). Subjective image quality increased in all evaluated intervertebral disc spaces (median and absolute frequencies [good/middle/bad]: 1.0 [53/21/8] vs. 2.0 [41/30/24]), resulting in a statistically significant effect between the cervical vertebra 6/7 (p = 0.0041). The traction device approach was rated to be suitable for daily routine in the categories of patient's cooperation (good), comprehensibility for the patient (84%) and management for the assistants (good).

CONCLUSION

Using an arm traction device on neck CT both the accessibility of vertebra on CT scout increased and image quality of the cervico-thoracic junction improved. The simply applicable device could be favourable for cooperative patients with lower neck pathology.

Sentinel lymph node mapping with indocyanine green compared to blue dye tracer in gynecologic malignancies-A single center experience of 218 patients

BACKGROUND AND OBJECTIVES

To compare the detection rates of sentinel lymph nodes after converting the tracer technique from blue dye to indocyanine green (ICG).

METHODS

Patients with uterine or cervical cancer were enrolled for sentinel lymph node (SLN) dissection. A total of 109 consecutive patients were analyzed and compared to a historical cohort of 109 consecutive patients with the sentinel blue dye technique. SLNs were analyzed by ultrastaging.

RESULTS

The bilateral mapping rate of sentinel nodes was significantly higher with the ICG (78%; n = 85) compared to the blue dye tracer (61%; n = 67; p = .006). Neither the mean number of SLN nor the rate of low volume metastases showed significant differences between both cohorts. In the subgroup of endometrial cancer patients, the number of systematic lymph node dissection (LND) was significantly lower in the ICG cohort compared to the blue dye cohort (9% vs. 28%, p = .001).

CONCLUSIONS

ICG improved the detection rate of pelvic SLN compared to blue dye and may be considered as the superior technique. In clinical practice, the rate of systematic LND further decreased after incorporating SLN mapping with ICG. Reliable safety data are still pending.

Shape Modification is Common in Woven EndoBridge-Treated Intracranial Aneurysms: A Longitudinal Quantitative Analysis Study

BACKGROUND AND PURPOSE

After endovascular treatment of intracranial aneurysms with the Woven EndoBridge (WEB) device, worsening of aneurysm occlusion or re-opening was reported to be possibly associated with WEB shape modification. This study analyzed quantitatively the WEB shape modification with time in association with anatomic results.

MATERIALS AND METHODS

Thirty patients with 32 WEB-treated intracranial aneurysms fulfilled the inclusion criteria of cranial CT at baseline (day of intervention) and a follow-up CT at least >1 months' later (median follow-up time, 11.4 months; interquartile range, 6.5-21.5 months). Adequate occlusion was observed in 84.4%, and aneurysm remnant, in 15.6%. WEB shape modification was quantified by a semiautomated approach on CT scans. Time courses were evaluated graphically and analytically; association analyses were performed by linear mixed-effects regression models.

RESULTS

In 29/32 WEB devices (90.6%), the reduction in height was found to be at least 5%. The decrease in height with time was significantly associated with the time interval in days since the intervention (P < .0001): A stronger decrease in WEB height was associated with a longer time since the intervention (median reduction in 1 year, 19.2%; range, 8.6%-52.3%). No significant association was found with the quality of aneurysm occlusion, device size, rupture status of the aneurysm, aneurysm location, and reintervention rate.

CONCLUSIONS

Shape modification was common in WEB-treated intracranial aneurysms with a median height reduction of 19.2% in 1 year. The quality of aneurysm occlusion was not associated with WEB modification.

[Hepatolienal candidosis as a rare differential diagnosis of disseminated small parenchym lesions]

HISTORY

We report about a 17-year-old patient with the secondary malignancy of acute myeloid leukemia (AML). He developed fever of unclear origin during the hematopoietic stem cell transplantation.History We report about a 17-year-old patient with the secondary malignancy of acute myeloid leukemia (AML). He developed fever of unclear origin during the hematopoietic stem cell transplantation.

EXAMINATIONS

In the focus search, the routine sonography of the abdomen showed disseminated hypoechoic small- parenchymal lesions of the liver. In the complementary MRI, disseminated small lesions of the liver parenchyma and the spleen were demarked after contrast agent administration.

DIAGNOSIS

Imaging revealed suspicion of hepatolienal candiasis.Diagnosis Imaging revealed suspicion of hepatolienal candiasis.

THERAPY

Empirical therapy with amphotericin B was used. A sonographic punch biopsy of the liver was performed. The pathological examination showed oval particles in the PAS staining in the sense of an opportunistic mycosis of the Candida infection type.

CONCLUSION

The case shows that in immunosuppressed patients, candidiasis must always be considered as a differential diagnosis with simultaneous parenchymal changes in the liver and/or spleen. In addition, in the screening situation, a suitable linear transducer should be used when asking about fungal lesions in the liver and spleen. Alternatively, if suspected hepato-lienal candidiasis could be diagnosed by a contrast-enhanced MRI of the upper abdomen/abdomen.

A cluster of two human cases of tick-borne encephalitis (TBE) transmitted by unpasteurised goat milk and cheese in Germany, May 2016

In May 2016, two cases of tick-borne encephalitis (TBE) were confirmed by serology (positive IgM and IgG antibodies against TBE virus (TBEV) in serum), with a possible link to raw milk and cheese from a goat farm in a region in Baden-Württemberg, Germany not previously known as TBE-endemic. The outbreak investigation identified 32 consumers of goat dairy products (29 consumers, one farm employee, two owners) of whom none had IgM antibodies against TBEV 3–8 weeks after consumption. Of the 27 notified TBE cases in the State, none reported consumption of raw goat milk or cheese from the suspected farm. Five of 22 cheese samples from 18 different batches were RT-qPCR-positive for TBEV -genome, and two of the five samples were confirmed by virus isolation, indicating viability of TBEV in the cheese. Nine of the 45 goats had neutralising TBEV antibodies, two of them with a high titre indicating recent infection. One of 412 Ixodes ricinus was RT-qPCR-positive, and sequencing of the E gene from nucleic acid extracted from the tick confirmed TBEV. Phylogenetic analyses of tick and cheese isolates showed 100% amino acid homology in the E gene and a close relation to TBEV strains from Switzerland and Austria.

Interferon alfa-2a maintenance after salvage autologous stem cell transplantation in atypical mycosis fungoides with central nervous system involvement

Mycosis fungoides (MF) is a primary cutaneous T-cell lymphoma with unfavourable prognosis for patients with advanced stages of the disease. Refractory disease and advanced-stage disease require systemic therapy. We report on a rare case of an atypical predominantly CD8⁺ folliculotropic MF, a subtype of MF with poorer prognosis, in a 59-year-old woman. She was initially diagnosed with MF restricted to the skin, of T3N0M0B0/stage IIB according to the current World Health Organization-European Organisation for Research and Treatment of Cancer classification. First-line treatment with local percutaneous radiotherapy in combination with systemic interferon alfa-2a resulted in complete remission. However, 21 months later the disease progressed to T3N0M1B0/stage IVB with development of cerebral manifestation and thus very poor prognosis. Allogeneic stem cell transplantation (SCT) was not a therapeutic option due to the lack of a suitable donor. We initiated methotrexate and cytarabine chemotherapy, followed by high-dose chemotherapy with thiotepa and carmustine with autologous SCT. Despite rapid response and complete remission of the cerebral lesions, disease recurrence of the skin occurred soon after. Interestingly, readministration of interferon alfa-2a as a maintenance treatment after the salvage autologous SCT resulted in a durable complete remission during the follow-up period of currently 17 months after autologous SCT. What's already known about this topic? Mycosis fungoides is a primary cutaneous T-cell lymphoma with unfavourable prognosis for the advanced stages of the disease. A refractory course of disease requires systemic therapy. What does this study add? We report on an unusual case of a patient with mycosis fungoides with cerebral involvement, in which a durable complete remission was achieved upon autologous stem cell therapy and interferon alfa-2a maintenance therapy.

Population dietary salt reduction and the risk of cardiovascular disease. A scientific statement from the European Salt Action Network

The publication in the last few years of a number of prospective observational studies suggesting a J-shaped association between levels of salt (sodium) consumption and cardiovascular outcomes has opened a debate on the pertinence of population-wide salt reduction policies to reduce cardiovascular disease burden, and some have even questioned the global World Health Organization guidelines, that recommend a 30% reduction in salt consumption by 2025, aiming at an ideal target of no more than 5 g of salt consumption per day. In September 2018 the European Salt Action Network (E.S.A.N.), after appraising the quality of publications questioning the appropriateness of population salt reduction, discussed the scientific evidence and identified the pitfalls of recent data. The new evidence was deemed inadequate and, in places, biased by flawed methodology. These were identified in the biased assessment of sodium intake from spot urine and the use of the Kawasaki formula, the biased assessment of the sodium-outcome relationships in prospective observational studies using spot urine samples, the impact of reverse causality in such studies, the inadequate analytical approaches to data analysis, the lack of biological plausibility and the lack of precision in assessing long-term salt consumption, as recently demonstrated in studies using more stringent quality features in their study designs. On the basis of such appraisal, the E.S.A.N. agreed a statement confirming the support to the implementation of national and regional programmes of moderate reduction in salt intake, as recommended by the World Health Organization.

Technological advances in veterinary diagnostics: opportunities to deploy rapid decentralised tests to detect pathogens affecting livestock

Sustainable food production capable of feeding a growing human population is a significant global challenge, and is a priority encompassed within the United Nations Millennium Development Goal to 'eradicate extreme poverty and hunger'. Infectious diseases reduce the productivity of farm animals, and the globalised trade of animals and their products increases the threat of disease incursion. Accurate and rapid diagnostic tests are an essential component of contingency plans to detect, control and eradicate such diseases. Diagnosis involves a 'pipeline' that normally starts with clinical suspicion, followed by collecting samples, transporting specimens to a centralised laboratory setting (e.g. national/international Reference Laboratories), analysing these samples using a range of diagnostic tests and reporting the results. However, the transport of specimens from the field to the laboratory can be a lengthy process that can delay critical decision-making and severely affect the quality of the samples. This important limitation of centralised diagnostic testing has motivated the development of tools for the rapid, simple detection of livestock pathogens. Recent advances in the development of technologies for personalised human medicine have motivated the development of prototype diagnostic tests for a wide selection of diseases of livestock. However, many of these tests are not yet routinely used or commercially available. This paper critically reviews the most promising examples of such assays, and highlights the challenges that remain to transition these tests from applied research and development into routine use.