[Prolonged fever and monocytosis after hemorrhoidectomy and treatment with methotrexate--listeriosis with cerebral abscess]

HISTORY AND CLINICAL FINDINGS

A 58-year-old man was admitted because of septic fever for about one week with onset two weeks after an hemorrhoidectomy. He had been receiving methotrexate (MTX) since boyhood for severe psoriasis. Fifteen years before he had undergone a splenectomy after abdominal trauma. The patient was found to have diminished cognitive functions and memory disturbance, but no focal neurological deficits.

INVESTIGATIONS

Laboratory tests were negative for inflammatory disease (normal white blood cell count, CRP and procalcitonin) and serial blood cultures remained sterile. Cranial computed tomography (CCT), done because viral encephalitis was suspected, revealed a large focus in the left hemisphere, further identified as abscess on magnetic imaging.

TREATMENT AND COURSE

The patient's fever subsided within two days of treatment with ampicillin and ciprofloxacin. The patient was sent to the department of neurosurgery for further diagnosis. Stereotactic biopsy revealed Listeria monocytogenes. Antibiotic treatment was modified in accordance with the microbiological results and the patient was transferred to a rehabilitation unit.

CONCLUSIONS

Lack of pathological levels of CRP, procalcitonin and white blood cell count does not exclude cerebral abscess in a patient with prolonged fever and without marked neurological deficits. Preceding treatment with immunosuppressive drugs, especially MTX, and failing response to cephalosporins should lead to consideration of listeriosis in the differential diagnosis.

Spin configuration in the 1/3 magnetization plateau of azurite determined by NMR

High magnetic field (63,65)Cu NMR spectra were used to determine the local spin polarization in the 1/3 magnetization plateau of azurite, Cu3(CO3)(2)(OH)(2), which is a model system for the distorted diamond antiferromagnetic spin-1/2 chain. The spin part of the hyperfine field of the Cu2 (dimer) sites is found to be field independent, negative and strongly anisotropic, corresponding to approximately 10% of fully polarized spin in a d orbital. This is close to the expected configuration of the quantum plateau, where a singlet state is stabilized on the dimer. However, the observed nonzero spin polarization points to some triplet admixture, induced by strong asymmetry of the diamond bonds J1 and J3.

Improved radar data processing algorithms for quantitative rainfall estimation in real time

This paper describes a new methodology to process C-band radar data for direct use as rainfall input to hydrologic and hydrodynamic models and in real time control of urban drainage systems. In contrast to the adjustment of radar data with the help of rain gauges, the new approach accounts for the microphysical properties of current rainfall. In a first step radar data are corrected for attenuation. This phenomenon has been identified as the main cause for the general underestimation of radar rainfall. Systematic variation of the attenuation coefficients within predefined bounds allows robust reflectivity profiling. Secondly, event specific R-Z relations are applied to the corrected radar reflectivity data in order to generate quantitative reliable radar rainfall estimates. The results of the methodology are validated by a network of 37 rain gauges located in the Emscher and Lippe river basins. Finally, the relevance of the correction methodology for radar rainfall forecasts is demonstrated. It has become clearly obvious, that the new methodology significantly improves the radar rainfall estimation and rainfall forecasts. The algorithms are applicable in real time.

[Endovascular therapy of infrarenal aortic aneurysms: preinterventional imaging and follow-up]

Imaging plays an important role in the selection of patients with infrarenal aortic aneurysms suitable for interventional therapy and preinterventional workup. It is also an important tool for follow-up after stent-graft placement. Cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) allow the delineation of the vessel lumen and side branches. Modern postprocessing techniques permit precise measurement of aneurysm properties such as the length and diameter of the proximal and distal neck and the length and diameter of the aneurysm. Evaluation of the access vessel is also possible. During follow-up after stent-graft placement, it is important to detect possible endoleaks and further growth of the aneurysm sac. Furthermore fractures of the stent struts, migration of the stent, and in-stent thrombosis must to be detected. This review provides an overview of the pros and cons of the different imaging modalities in pre- and postinterventional studies. In addition the most important criteria for the exclusion of infrarenal aortic aneurysms and for patient follow-up are presented.

Huge transverse magnetic polarization in the field-induced phase of the antiferromagnetic molecular wheel CsFe(8)

The 1H NMR spectrum and nuclear relaxation rate T(1)(-1) in the antiferromagnetic wheel CsFe8 were measured to characterize the previously observed magnetic field-induced low-temperature phase around the level crossing at 8 T. The data show that the phase is characterized by a huge staggered transverse polarization of the electronic Fe spins, and the opening of a gap, providing microscopic evidence for the interpretation of the phase as a field-induced magnetoelastic instability.

[Therapeutic possibilities of probiotics in antibiotic-related diarrhea]

One of the major problems associated with the use of antibiotics is the occurrence of antibiotic-related diarrhea. Although most such cases of diarrhea are harmless, in individual cases it may lead on to fulminant colitis. In 10-20% of the patients, the causal factor is infection with Clostridium difficile, which multiplies unhindered in patients on antibiotics. In the meantime, controlled, randomized studies have shown that probiotics can exercise a preventive effect in antibiotic-related diarrhea. The administration of Saccharomyces boulardii or Lactobacillus rhamnosus GG reduces the relative risk of an antibiotic-related diarrhea developing by 0.5. The data are more uniform in children than in adults.

Vergleich einer T1-gewichteten Inversion-Recovery-, Gradienten-Echo- und Spin-Echo-Sequenz zur zerebralen Bildgebung bei 3,0 Tesla

PURPOSE

The increased T1 relaxation times at 3.0 Tesla lead to a reduced T1 contrast, requiring adaptation of imaging protocols for high magnetic fields. This prospective study assesses the performance of three techniques for T1-weighted imaging (T1w) at 3.0 T with regard to gray-white differentiation and contrast-to-noise-ratio (CNR).

MATERIALS AND METHODS

Thirty-one patients were examined at a 3.0 T system with axial T1 w inversion recovery (IR), spin-echo (SE) and gradient echo (GE) sequences and after contrast enhancement (CE) with CE-SE and CE-GE sequences. For qualitative analysis, the images were ranked with regard to artifacts, gray-white differentiation, image noise and overall diagnostic quality. For quantitative analysis, the CNR was calculated, and cortex and basal ganglia were compared with the white matter.

RESULTS

In the qualitative analysis, IR was judged superior to SE and GE for gray-white differentiation, image noise and overall diagnostic quality, but inferior to the GE sequence with regard to artifacts. CE-GE proved superior to CE-SE in all categories. In the quantitative analysis, CNR of the basal ganglia was highest for IR, followed by GE and SE. For the CNR of the cortex, no significant difference was found between IR (16.9) and GE (15.4) but both were superior to the SE (9.4). The CNR of the cortex was significantly higher for CE-GE compared to CE-SE (12.7 vs. 7.6, p < 0.001), but the CNR of the basal ganglia was not significantly different.

CONCLUSION

For unenhanced T1 w imaging at 3.0 T, the IR technique is, despite increased artifacts, the method of choice due to its superior gray-white differentiation and best overall image quality. For CE-studies, GE sequences are recommended. For cerebral imaging, SE sequences give unsatisfactory results at 3.0 T.

Runoff modelling using radar data and flow measurements in a stochastic state space approach

In urban drainage the estimation of runoff with the help of models is a complex task. This is in part due to the fact that rainfall, the most important input to urban drainage modelling, is highly uncertain. Added to the uncertainty of rainfall is the complexity of performing accurate flow measurements. In terms of deterministic modelling techniques these are needed for calibration and evaluation of the applied model. Therefore, the uncertainties of rainfall and flow measurements have a severe impact on the model parameters and results. To overcome these problems a new methodology has been developed which is based on simple rain plane and runoff models that are incorporated into a stochastic state space model approach. The state estimation is done by using the extended Kalman filter in combination with a maximum likelihood criterion and an off-line optimization routine. This paper presents the results of this new methodology with respect to the combined consideration of uncertainties in distributed rainfall derived from radar data and uncertainties in measured flows in an urban catchment within the Emscher river basin, Germany.

Nuclear magnetic resonance study of the electron-doped high-temperature superconducting cuprates

Nuclear magnetic resonance (NMR) measurements have been made on two of the electron-doped high-temperature superconducting cuprates (HTSCs), Pr(2-x)Ce(x)CuO(4) and Sr(0.9)La(0.1)CuO(2) that represent the two known electron-doped structures. The results are compared with the more-studied hole-doped HTSCs. We show that the electron and hole-doped HTSCs probe a similar antiferromagnetic spin fluctuation spectrum in the normal state, which provides support for theories of superconductivity where the pairing is mediated by antiferromagnetic spin fluctuations and the superconducting order parameter has a [Formula: see text] symmetry. Contrary to results from underdoped and hole-doped HTSCs, there is no evidence for a normal-state pseudogap in the NMR data from measurements on the electron-doped HTSCs. Therefore, the electron-doped HTSCs can be better compared with overdoped and hole-doped HTSCs where the normal-state pseudogap is absent. The antiferromagnetic spin fluctuation spectrum as probed by the Cu spin-lattice relaxation rate, is independent of the doped electrons per Cu. A similar effect is observed in the overdoped and hole-doped HTSC, Y(1-x)Ca(x)Ba(2)Cu(3)O(7-delta) for a hole concentration range of approximately 0.063. The anomalous Cu NMR linewidth anisotropy observed in the electron-doped HTSCs suggests a small and static spin variation for temperatures up to room temperature.

[First experiences with a new vacuum-assisted device for breast biopsy]

OBJECTIVE AND METHODS

Stereotaxic and sonographically guided vacuum biopsies are standard methods in interventional breast procedures. We report about the newly developed sonographically guided and vacuum-assisted VacuFlash (VF) method for breast biopsy. In comparison to the Mammotome system, all components for vacuum biopsy are integrated in the hand-held gun of the VF biopsy system. Our first preliminary results in 5 patients are reported.

RESULTS

VF was performed in five patients with a nonpalpable, sonographically detectable lesion. The histopathological examination diagnosed a fibroadenoma in 4 patients and established unremarkable breast parenchyma in 1 patient. Subsequent sonography immediately after the biopsy revealed that 3 of the 5 lesions were completely removed.

CONCLUSION

The VF biopsy system is a new, technically perfected and applicable diagnostic method. Its costs, risks and accuracy have to be compared with high-speed core cut biopsy, hand-held Mammotome system and open surgical biopsy. Indications for the VF-biopsy are lesions that are too small, superficial or deep for conventional core biopsy as well as abnormalities where wide sampling is considered important. Complete removal can only be expected when the lesion is small and plays a secondary role in a diagnostic process. High-speed core cut biopsy remains the standard procedure in percutaneous breast interventions to clarify sonographically detected breast lesions.

Ductal carcinoma in situ of the breast: diagnosis and management

Currently, no precise morphologic or biologic prognostic factors reliably identify patients with ductal carcinoma in situ (DCIS) who are at high risk of disease progression. DCIS is a disease with an extremely favorable prognosis and a small likelihood of dying from breast cancer, regardless of what type of treatment is received. No retrospective or prospective study to date has demonstrated a significant difference in breast cancer specific mortality regardless of treatment. The similarities between DCIS and invasive cancer suggest that an important area for future research should be elucidating the processes that can either unleash or contain the invasive potential of DCIS cells. Thus, an understanding of the biology of DCIS can assist in the prevention, the assessment, and the diagnosis of invasive breast cancer.

Virtual intra-arterial angioscopy (VIA) of the carotid artery based on helical CT data

The purpose of this study was to visualize both the vessel wall and atherosclerotic plaques in virtual intra-arterial angioscopy (VIA) based on helical CT data sets. To achieve this in vitro, the optimal reconstruction threshold of the vessel wall was determined to be 56.4% of the maximum enhancement. Using this threshold, 20 patients suffering from symptomatic carotid disease were examined in a helical CT scanner. The degree of stenosis was defined using the North American Symptomatic Endarterectomy Trial (NASCET) criteria and compared with results from digital substraction angiography (DSA). Grading of stenoses was only possible by adding the separately computed plaque geometry to the geometry of the vessel wall in a second step. Correlation between VIA and DSA in low grade, medium grade and high grade stenosis was 88%, 93% and 71%, respectively. Complete occlusions were diagnosed correctly in all patients. Sensitivity and specificity for the correct diagnosis of high grade stenosis was 93.7% and 91.3%, respectively. A realistic depiction of intraluminal structures in carotid arteries can only be generated by displaying both the vessel wall and plaque structures simultaneously.

Plasmon energy mapping in energy-filtering transmission electron microscopy

In this paper, we demonstrate the two-dimensional mapping of plasmon energies by energy-filtering transmission electron microscopy. The maps are obtained from a series of energy-filtered images in the plasmon energy region. Examples are shown for a nano-crystalline Si-B-C-N ceramic. This material contains SiC and Si(3)N(4) grains as well as intergranular regions composed of hexagonal BN (h-BN) and turbostratic carbon (t-C). The different phases can be clearly identified by their specific plasmon energies. An energy resolution of < or =0.1eV is achieved. In addition, the plasmon map of an amorphous carbon film is used to visualize the non-isochromaticity of the Corrected Omega filter (90 degrees filter) of the SESAM2. A procedure is proposed for the correction of the non-isochromaticity.

[Occupational disease 2108. Degenerative changes of the cervical spine as a causality criterion in the assessment of discogenic diseases according to BeKV 2108]

With the second amendment to the Ordinance on Occupational Diseases (BeKV) of 18 December 1992, discogenic diseases of the spine are included in the disease register of occupational diseases for the first time. If occupations that impose stress on the spine have been practised for many years, the possibility exists of recognizing degenerative diseases as an occupational disease. In assessment practice, the radiological data on the spine exposed to stress is compared with that of regions which are remote from the stress (cervical/thoracic spine). This pattern of the distribution of degenerative disease is then used as the basis for determining a causal relationship between the occupation causing the stress and disease of the axial skeleton. The pattern of degeneration of the cervical spine was investigated in two groups, one with ( n =153) and one without ( n =333) occupations that impose stress on the lumbar spine. A cumulative score of degenerative changes was elaborated and presented as a new classification. No differences were found between the groups with regard to either the frequency of occurrence, segmental distribution or severity of disease. In both groups, degenerative changes correlated with age. The prevailing assessment practice is discussed on the basis of these data.

[Sonographical breast biopsy: how many core biopsy specimens are needed?]

PURPOSE

To determine the optimum number of specimens of a sonographically guided core biopsy of the breast.

MATERIALS AND METHODS

From January 2001 to April 2001, sonographically guided core biopsies (coaxial needle: 11 G; core needle: 12 G) were performed on 106 patients with 115 BI-RADS trade mark 4-5 lesions that had corresponding sonographic findings. Five specimens were obtained in anteroposterior direction parallel to the chest wall and each specimen examined histologically.

RESULTS

A total of 575 core biopsies produced 545 specimens (94.8 %), with no material obtained in 30 biopsies (5.2 %). The first and second specimen confirmed the diagnosis in 99 of 115 lesions (86 %), with subsequent specimens confirming the diagnosis in 87 % (3 rd specimen), 88 % (4 th specimen) and 82 % (5 th specimen). The additive accuracy of the five core breast specimens was 86 %, 96 %, 98 %, 99 % and 100 %. The possible volume of 78.9 mm 3 as determined by the sample notch of the core needle only furnished an average volume of 38.1 mm 3 (41.1 mm 3 for the 1 st, 40.1 mm 3 for the 2 nd, 37.5 mm 3 for the 3 rd, 36.7 mm 3 for the 4 th and 35.0 mm 3 for 5 th core specimen).

CONCLUSION

Sonographically guided core breast biopsy (coaxial needle: 11 G; core needle: 12 G) may require five passes to achieve a diagnostic accuracy of more than 99 %.

[Scar or recurrence--comparison of MRI and color-coded ultrasound with echo signal amplifiers]

PURPOSE

MRI is the most reliable method to differentiate scar and recurrent carcinoma of the breast after surgical treatment. This study compares MRI and color-coded ultrasound with and without echo signal amplifier (ESA).

MATERIALS AND METHODS

Forty-two patients with suspected recurrent tumors were enrolled in this prospective study, with 38 patients after breast conserving therapy and 4 after mastectomy. All patients had a clinical examination, mammography (n = 38), real time ultrasound (US), color-coded ultrasound without and with ESA (Levovist(R), Schering, Berlin), and dynamic MRI. The criteria used for duplex ultrasound were tumor vascularisation and flow pattern. The results were compared with histologic findings or the results of follow-up examinations for at least 12 months.

RESULTS

The detection of penetrating or central vessels proved to be an accurate sign of malignancy in duplex ultrasound. With the application of ESA, additional vessels were detected within the lesions, increasing the diagnostic accuracy (83 % with ESA versus 79 % without ESA). The sensitivity of color-coded ultrasound improved from 64 % to 86 % with echo signal amplifier. The specificity was 86 % without and 82 % with echo signal amplifier. MRI was found to have a sensitivity of 100 % and a specificity of 82 %. The same 5 lesions were false positive on MRI and color-coded US after Levovist(R). No lesion without signs of vascularity within or in its vicinity was malignant.

CONCLUSION

Color-coded ultrasound seems to be a promising method in the differentiation between scar and recurrence. Lesions with penetrating or central vessels have a high probability of being malignant, whereas lesions without any signs of vascularity inside or nearby have a high probability of being benign. Advantage of contrast-enhanced US is its ubiquitous availability.

[Neointimal hyperplasia by luminal cell recruitment and not be transmural migration. The role of Bcl-2 and HSP47 after balloon angioplasty]

Restenosis post angioplasty remains the major limitation of several therapeutic interventions including stent implantation. This explains the ongoing interest in its basic pathogenic mechanisms and factors. The aim of the present study was to assess the localization and maximal expression of Bcl-2, a central antiapoptotic protooncogene, and of heat shock protein 47 (HSP47), a marker of early collagen synthesis, in the context with hyperplastic neointima formation as well as concomitant transmural remodeling processes following angioplasty. 0, 4, 24 and 48 hours, 4, 7 and 14 days post balloon traumatization by use of a rat carotid artery model, specific vascular wall compartments were evaluated concerning area, cell density as well as Bcl-2 and HSP47 expression by immunohistochemistry and morphometry, supplemented by electron microscopy (TEM). Neointimal cell accumulation was detected 4 days post angioplasty, characterized by luminal cells adherent to the internal elastic lamina, associated with maximal Bcl-2 and HSP47 expression amounting to 49% and 41%, respectively. With ongoing neointimal formation, a luminal prevalence of both key determinants and a decreasing expression in basal neointimal areas were found. In the media, a temporally reduced cell density was observed significant at 48 hours post trauma. Constitutive HSP47 expression of the media was constant during the entire observation period, whereas sparse Bcl-2 signalling was induced post angioplasty maximal on day 2 with 3% and on day 14 with 5%. The adventitia demonstrated a transient structural separation between day 4 and 7, exhibiting an inner layer with sparse cellularity and an outer layer with extremely high cell density as well as pronounced neovascularization. In this outer adventitia layer, a high frequency of signals for both Bcl-2 and HSP47 were observed amounting to 29% and 57%, respectively. Complementary TEM analysis gave no evidence of transmural migratory events propagated by adventitial cells and thereby supports early neointimal formation by luminal cell recruitment and marked co-expression of anti-apoptotic Bcl-2 and matrix-generating HSP47 as important survival factors. Clinical implications of these findings may be seen in the integration of proapoptotic substances with temporal efficacy in order to prevent restenosis, e.g., by use of coated stents.

[Galactoscopy--is it a new interventional method for breast diagnosis?]

Based on experimental studies with animals we examined 22 patients with pathological (bloody) nipple discharge by cytology, ultrasonography, galactography and the newly developed galactoscopy [Endoscopic-System EndoGnost(R) (Polydiagnost)]. The duct's cannula has an outer/inner diameter of 0.45 mm/0.36 mm and a working length of 30 mm, the endoscope a length of 1200 mm, adapted to a CCD-camera (2500 pixel). All patients underwent surgery and histo-pathological diagnosis. The best diagnostic results were received with galactoscopy (21/22). By using an additional cutter it is possible to obtain a histological sample for diagnosis endoscopically. Galactoscopy is an emerging technique and will expand the spectrum of interventional methods in breast diagnosis.

[Do tissue marker clips after sonographically or stereotactically guided breast biopsy improve follow-up of small breast lesions and localisation of breast cancer after chemotherapy?]

PURPOSE

We wanted to determine if tissue marker clips after sonographically or stereotactically guided breast biopsy improve the follow-up of small breast lesions classified BI-RADS 4/5 and the localisation of breast cancer (TNM stage 2 or 3) after neoadjuvant chemotherapy.

MATERIAL AND METHODS

Prospective analysis was performed of 108 breast lesions 1 cm or smaller mammographically classified as BI-RADS 4/5 and 14 breast lesions larger than 2 cm mammographically classified as BI-RADS 5. 33 of the 108 breast lesions 1 cm or smaller underwent sonographic core cut breast biopsy (group 1) and 75 stereotactic vacuum-assisted breast biopsy (group 2). All 14 lesions greater than 2 cm were stereotactically vacuum-assisted breast biopsied (group 3). The centre of the lesion was marked by a clip after the biopsy. Mammographies were performed in all patients of group 1 and 2 with a histologically benign finding (n = 31, n = 69, respectively) and in all patients of group 3 directly after clip placement and after 6 and 12 months. Clip localisation and possible divergence from the original position were verified by a grid.

RESULTS

Two patients of group 1 and 6 patients of group 2 had breast conservative surgery (BET) because of the histological diagnosis of a ductal carcinoma in situ or invasive breast cancer. The tissue marker clips of the remaining 31 patients of group 1 and 69 patients of group 2 diverged with a mean value of 0.4 cm (standard deviation +/- 0.23 cm; range 0.1 cm to 0.9 cm) from their placement position after 6 months. After 12 months the marker clips deviated with a mean value of 0.4 cm (standard deviation +/- 0.21 cm; range 0.1 cm to 0.9 cm) in 94 patients and 0.8 cm (standard deviation +/- 0.25 cm; range 0.1 cm to 0.9 cm) in 6 patients from their original location. No tumour progression of the benign lesions in group 1 and 2 was diagnosed in follow-up mammograms. In all patients of group 3 the tissue marker clips were the only possibility to localize the tumour after neoadjuvant chemotherapy as all other diagnostic methods showed inconsistent results.

CONCLUSION

Positioning a tissue marker clip in the tumour centre seems to be reasonable after interventional biopsy of breast lesions of 1.0 cm or smaller and before neoadjuvant chemotherapy.