Evaluation of femoral head vascularization in slipped capital femoral epiphysis before and after cannulated screw fixation with use of contrast-enhanced MRI: initial results

In this study we used contrast-enhanced magnetic resonance imaging (MRI) to evaluate the vascularization of the femoral head in children with slipped capital femoral epiphysis (SCFE) before and after cannulated screw fixation. Eleven consecutive children with SCFE, seven boys and four girls, aged 10-15 years were included in the study. There were no preslips; four children had acute, three acute-on-chronic, and four chronic SCFE. The MRI examinations were performed in a 1.5 Tesla MR scanner with use of a coronal STIR sequence, a coronal contrast-enhanced T1-weighted spin-echo sequence, and a sagittal three-dimensional gradient-echo sequence. Morphology, signal intensities, and contrast-enhancement of the femoral head were assessed by two radiologists in consensus. Morphologic distortion of the physis, bone marrow edema within the metaphysis and epiphysis, and joint effusion were the preoperative MRI findings of SCFE in each child. In nine children, the vascularization of the femoral head before and after surgery was normal. In one child, a preoperative avascular zone in the superolateral aspect of the epiphysis revascularized completely after surgery. One child with severe SCFE developed avascular necrosis of the femoral head after open reduction of the slip. We conclude that MRI allows for accurate evaluation of the femoral head vascularization before and after surgery in children with SCFE.

An isoform of ataxin-3 accumulates in the nucleus of neuronal cells in affected brain regions of SCA3 patients

Autosomal dominant spinocerebellar ataxias (SCA) form a group of clinically and genetically heterogeneous neurodegenerative disorders. The defect responsible for SCA3/Machado-Joseph disease (MJD) has been identified as an unstable and expanded (CAG)n trinucleotide repeat in the coding region of a novel gene of unknown function. The MJD1 gene product, ataxin-3, exists in several isoforms. We generated polyclonal antisera against an alternate carboxy terminus of ataxin-3. This isoform, ataxin-3c, is expressed as a protein of approximately 42 kDa in normal individuals but is significantly enlarged in affected patients confirming that the CAG repeat is part of the ataxin-3c isoform and is translated into a polyglutamine stretch, a feature common to all known CAG repeat disorders. Ataxin-3 like immunoreactivity was observed in all human brain regions and peripheral organs studied. In neuronal cells of control individuals, ataxin-3c was expressed cytoplasmatically and had a somatodendritic and axonal distribution. In SCA3 patients, however, C-terminal ataxin-3c antibodies as well as anti-ataxin-3 monoclonal antibodies (1 H9) and anti-ubiquitin antibodies detected intranuclear inclusions (NIs) in neuronal cells of affected brain regions. A monoclonal antibody, 2B6, directed against an internal part of the protein, barely detected these NIs implying proteolytic cleavage of ataxin-3 prior to its transport into the nucleus. These findings provide evidence that the alternate isoform of ataxin-3 is involved in the pathogenesis of SCA3/MJD. Intranuclear protein aggregates appear as a common feature of neurodegenerative polyglutamine disorders.

Estimation of radiation exposure in low-dose multislice computed tomography of the heart and comparison with a calculation program

The purpose of this study was to evaluate the achievable organ dose savings in low-dose multislice computed tomography (MSCT) of the heart using different tube voltages (80 kVp, 100 kVp, 120 kVp) and compare it with calculated values. A female Alderson-Rando phantom was equipped with thermoluminescent dosimeters (TLDs) in five different positions to assess the mean doses within representative organs (thyroid gland, thymus, oesophagus, pancreas, liver). Radiation exposure was performed on a 16-row MSCT scanner with six different routine scan protocols: a 120-kV and a 100-kV CT angiography (CTA) protocol with the same collimation, two 120-kV Ca-scoring (CS) protocols with different collimations and two 80-kV CS protocols with the same collimation as the 120-kV CS protocols. Each scan protocol was repeated five times. The measured dose values for the organs were compared with the values calculated by a commercially available computer program. Directly irradiated organs, such as the esophagus, received doses of 34.7 mSv (CTA 16x0.75 120 kVp), 21.9 mSv (CTA 16x0.75 100 kVp) and 4.96 mSv (CS score 12x1.5 80 kVp), the thyroid as an organ receiving only scattered radiation collected organ doses of 2.98 mSv (CTA 16x0.75 120 kVp), 1.97 mSv (CTA 16x0.75 100 kVp) and 0.58 mSv (CS score 12x1.5 80 kVp). The measured relative organ dose reductions from standard to low-kV protocols ranged from 30.9% to 55.9% and were statistically significant (P<0.05). The comparison with the calculated organ doses showed that the calculation program can predict the relative dose reduction of cardiac low photon-energy protocols precisely.

Eosinophilic gastroenteritis with severe protein-losing enteropathy: successful treatment with budesonide

We report the clinical, laboratory, endoscopic and histopathological findings in a 40-year-old woman with watery diarrhoea and hypoproteinaemia. Elevated alpha(1)-antitrypsin clearance confirmed massive protein-losing enteropathy. Gastroscopic and colonoscopic biopsies showed abundant infiltration of the small bowel wall with eosinophils in proximal duodenum and terminal ileum, respectively. These findings established the diagnosis of eosinophilic gastroenteritis. Both the inflammatory alterations and the severe intestinal protein loss were successfully treated with budesonide, a topically active corticosteroid preparation with controlled small bowel release. The case report illustrates that remission of protein-losing enteropathy secondary to eosinophilic gastroenteritis can be achieved with budesonide, thus supporting its use for this uncommon disease characterised by inflammatory intestinal lesions.

Differential indication for histological evaluation of endometrial fluid in postmenopause

OBJECTIVES

The endometrium carcinoma is the most frequent malignancy of the female genital tract. Approximately, 10-20% of all patients with an endometrial carcinoma are free of symptoms until the time of diagnosis. The frequent occurrence of an endometrial carcinoma in connection with intrauterine cavity fluid collection (sero- or mucometra) has been discussed controversially in literature. What are the hysteroscopic and histological findings in patients with sonographically determined endometrial fluid in postmenopause, and how should these findings be interpreted?

METHODS

74 patients, in whom endometrial fluid without bleeding disorders had been diagnosed during routine transvaginal sonography, underwent hysteroscopy conducted with a 4.5 mm optics and dilatation and curettage (D&C). The median age of the patients was 68 years with a range of 32 years.

RESULTS

The simple thickness of the endometrium, i.e. single layer measured sonographically at the point of maximal thickness, was on average 5.7 mm +/- 3.6 mm (2-15 mm). Hysteroscopically, an endometrium polyp was found in 23 cases (31.1%), endometrium hyperplasia in 12 (16.2%), and an atrophy in 35 cases (47.3%). In four cases (5.4%), an endometrial carcinoma was suspected. The histological results were consistent with the hysteroscopic findings. In all instances, in which the simple endometrial thickness amounted to 3 mm or less, an atrophic endometrium was found. The frequency of intrauterine pathologies increased significantly with a greater thickness of the endometrium. In 80% of patients, a cervical stenosis existed.

CONCLUSIONS

Endometrial fluid by itself, without assessment of the endometrium, does not indicate the requirement for additional histological clarification. As diagnostics, the authors suggest especially the endometrial morphology.

[Diagnostic evaluation of chronic inflammatory intestinal diseases in children and adolescents: MRI with true-FISP as new gold standard?]

PURPOSE

To evaluate the impact of magnetic resonance imaging (MRI) with use of True-FISP sequences in the evaluation of inflammatory bowel-wall changes in children and adolescents with Crohn's disease. Furthermore, the diagnostic procedure in children and adolescents with chronic inflammatory bowel disease (IBD) will be discussed in light of the relevant literature.

MATERIAL AND METHODS

Twenty-four children and adolescents aged between 7 and 21 years with suspected or known IBD underwent MRI on a 1.5 T-scanner (Philips ACS-NT, Best, Netherlands). One hour after 1 l of a 2.5 % mannitol solution was given orally, MR imaging was performed using coronal HASTE-M2D, coronal fat-suppressed T2-TSE, axial dynamic T1-weighted GE-sequences before and after i. v.-contrast material injection (0.1 mmol/kg Gd-DTPA) and using a 2D-balanced-FFE-sequence (True-FISP) before and after i. v.-contrast material injection in coronal and axial planes. The MR-images were correlated with endoscopy and the clinical findings. In 14 patients, a recently performed conventional radiographic enteroclysis was available. Each performed MRI sequence was evaluated by three experienced radiologists regarding the sensitivity and specificity of each sequence in the detection of inflammatory bowel wall changes. In addition, the image quality was assessed regarding the different tissue contrasts and the susceptibility to artifacts. The distension of the bowel wall and the patients' acceptance of the MRI examination were recorded.

RESULTS

With a sensitivity in detecting inflammatory small bowel changes of 93.3 % (axial pre-contrast, coronal post-contrast) and 100 % (axial post-contrast, coronal pre-contrast), the True-FISP outnumbers the other performed sequences (T1 = 80 %, HASTE = 13.3 % and T2-TSE = 53.3 %). The difference between True-FISP and contrast-enhanced T1 was not statistically significant, whereas the difference between True-FISP and HASTE and T2-TSE, respectively, was statistically significant. The True-FISP sequences revealed a statistically significant superiority regarding the soft-tissue differentiation in comparison to all other performed MR-sequences. The distension of the bowel wall was good in all patients. The patients' acceptance of the MRI examination was excellent.

CONCLUSION

The described small bowel MRI examination is appropriate for children and adolescents. With the use of True-FISP sequences, it is a convincing method with an outstanding sensitivity in the diagnosis of IBD. Not least because of the lack of radiation exposure, small bowel MRI ought to replace conventional enteroclysis as a gold standard for IBD diagnosis in children and adolescents.

Are there predictors for the outcome of a PGE1 treatment in peripheral arterial disease with critical limb ischaemia?

BACKGROUND

In a multivariate retrospective analysis was conducted to examine whether and to what extent PGE1 is therapeutically effective and whether there are predictors of response.

PATIENTS AND METHODS

The examination included 767 patients (448 women, 319 men) of a mean age of 71.2 years and with peripheral arterial disease (PAD) having existed for 44.7 months on the average. They suffered from critical limb ischaemia (Fontaine's stages III/IV) and showed average tcpO2 values at the instep of 2 mmHg (0 to 15) and average systolic malleolar artery pressures of 18 mmHg (0 to 35 mmHg). Between 1989 and 2001, the patients had received treatments in hospital with i.v. PGE1 doses (2x20 microg or 1x60 microg/day) for an average of 34.2 days (mean of responder- and non-responder group). Patients were called responders when pain had markedly decreased or disappeared, necroses had been reduced or healed completely, and vascular reconstruction, PTA or amputations were not necessary.

RESULTS

The clinical analysis showed 82.4% of the patients to be responders and 17.6% to be non-responders. It was demonstrated that the outcome of the therapy was not dependent on the supine or sitting tcpO2, the malleolar artery pressure, the patient's age or sex, the duration of PAD, the number or kind of concomitant diseases, the patient's general condition, the localization and number of vascular occlusions, the kind of prior therapy, or the number of previous amputations, although differences in some of the parameters, while clinically irrelevant, were found to be statistically significant. They are not predictors of the outcome of a PGE, therapy.

CONCLUSIONS

Even in extremely bad haemodynamic situations at the beginning of a therapy (malleolar artery pressures from 0 to 35 mmHg, tcpO2 0 to 15 mmHg, multilevel occlusive disease, multiple previous operations and concomitant diseases), PGE, therapies of more than 20 days - on the average 35.6 days (mean of responder group) - duration allow clinically relevant positive results to be achieved.

First measurement of the transverse spin asymmetries of the deuteron in semi-inclusive deep inelastic scattering

First measurements of the Collins and Sivers asymmetries of charged hadrons produced in deep-inelastic scattering of muons on a transversely polarized 6LiD target are presented. The data were taken in 2002 with the COMPASS spectrometer using the muon beam of the CERN SPS at 160 GeV/c. The Collins asymmetry turns out to be compatible with zero, as does the measured Sivers asymmetry within the present statistical errors.

[A 67-year-old patient with diarrhoea and constipation without any pathological findings in virtual colonoscopy]

Virtual colonoscopy provides a computer-simulated endoluminal perspective of the air-filled, distended colon using modern CT scanning (spiral CT). According to recent studies the sensitivity and specificity of this technique are high for adenomatous polyps > or = 10 mm. A 67-year-old patient was admitted to our hospital because of diarrhoea and constipation, associated with abdominal pain in the lower right abdomen. Prior to admission the patient had undergone virtual colonoscopy in a specialised radiological practice which had detected no abnormalities apart from colonic diverticulosis. However, conventional video-colonoscopy revealed a subtotal circular malignant stenosis in the region of the right colonic flexure. A poorly differentiated adenocarcinoma was diagnosed histologically. Staging showed peritoneal carcinosis with infiltration of the right ureter and lymphangiosis carcinomatosa of the pectoral lobe of the left lung. After right hemicolectomy because of metastasised carcinoma of the ascending colon (pT4pN1pM1) we started palliative chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin. The risk of misdiagnosis by virtual colonoscopy is clearly increased in patients with subtotal tumour stenosis of the ascending colon. Conventional video-colonoscopy remains the gold standard for the diagnosis of colorectal carcinoma.

Phase-inversion tissue harmonic imaging compared to fundamental B-mode ultrasound in the evaluation of the pathology of large and small bowel

Our purpose was to compare phase-inversion harmonic imaging (PIHI) with conventional B-mode ultrasound (US) regarding image quality in the evaluation of bowel pathology. Forty-one patients prospectively underwent intestinal ultrasound scans with US and PIHI in randomly chosen order. Crucial technical parameters were standardized. Bowel morphology as well as perienteric pathology and complications were documented. In 24 cases, the ultrasound results were compared to those of other imaging modalities. Three radiologists evaluated (1) overall image quality, (2) lesion conspicuity and diagnostic confidence, and (3) detection of free fluid on hardcopy films. The ratings for image quality were compared using the two-sample paired t test for means and Bowker's test for symmetry (p=0.05). Compared to US, PIHI provided significantly better overall image quality, lesion conspicuity and diagnostic confidence, as well as better detection of free fluid (p< 0.05). Bowel wall pathology, detected by both modalities, showed good correlation to additional imaging modalities. In 12 patients (29.3%), a gain of crucial diagnostic information was observed with PIHI when compared to US. PIHI significantly enhances sonography of the intestine by offering better overall image quality, better visualization of bowel pathology and associated changes. Additionally, PIHI adds crucial diagnostic information in several patients.

SARS-coronavirus (SARS-CoV) and the safety of a solvent/detergent (S/D) treated immunoglobulin preparation

SARS-coronavirus (SARS-CoV) is a newly emerged, highly pathogenic agent that caused over 8000 human infections with nearly 800 deaths between November 2002 and September 2003. While direct person-to-person transmission via respiratory droplets accounted for most cases, other modes have not been ruled out. SARS-CoV viraemia does not seem to reach high titres, however, it has to be excluded that virus transmission may occur via blood transfusion or application of therapeutic plasma products, e.g. fresh-frozen plasma or single components derived thereof. Manufacturing processes of all plasma derivatives are required to comprise dedicated virus inactivation/removal steps. Treatment with a mixture of solvent and detergent (SD) has successfully been applied to inactivate the most members of the transfusion-relevant viruses without affecting therapeutic properties of the products. The SD treatment irreversibly disrupts the lipid envelope of viruses such as HIV, HBV, HCV, HGV and CMV. In this study we evaluated the manufacturing process of an immunoglobulin preparation (OCTAGAM, manufactured by Octapharma Pharmazeutika Produktionsges.m.b.H., Vienna, Austria) for its capacity to inactivate the SARS-CoV. Our results demonstrate that SARS-CoV was completely inactivated below the limit of detection. This was found to occur within 1 min of SD treatment.