Effects of age and symptom status on silent ischemic lesions after carotid stenting with and without the use of distal filter devices

BACKGROUND AND PURPOSE

The routine use of distal filter devices during carotid angioplasty and stent placement (CAS) is controversial. The aim of this study was to analyze their effects on the incidence of new diffusion-weighted imaging (DWI) lesions as surrogate markers for stroke in important subgroups.

MATERIALS AND METHODS

DWI was performed immediately before and after CAS in 68 patients with and 175 without protection, and patients were further subdivided according to their age or symptom status.

RESULTS

The proportion of patients with new ipsilateral DWI lesion(s) was significantly lower after protected versus unprotected CAS (52% versus 68%), as well as in symptomatic patients (56% versus 74%) or those at or younger than 75 years of age (46% versus 67%; all P < .05). Similarly, the total number of lesions was significantly lower after protected versus unprotected CAS (median, 1; interquartile range [IQR], 0-2; versus median, 1; IQR 0-4.75) and in symptomatic patients (median, 1; IQR, 0-3; versus median, 2; IQR, 0-6) or those at or younger than 75 years of age (median, 0; IQR, 0-2; versus median, 1; IQR, 0-4; all P < .05). In contrast, for asymptomatic patients (48% versus 52%; P = .8; median, 0; IQR, 0-2; versus median, 1; IQR, 0-2.5; P = .6) or those older than 75 years of age (73% versus 69%; P = .7; median, 1; IQR, 0-4; versus median, 1.5; IQR, 0-5.75; P = .6), the proportion of patients with new lesion(s) and the total number of these lesions were not significantly different between protected and unprotected CAS.

CONCLUSIONS

The use of distal filter devices generally reduces the incidence of new DWI lesions; however, this beneficial effect might not necessarily pertain to older and asymptomatic patients.

Preprocedural C-reactive protein levels predict stroke and death in patients undergoing carotid stenting

BACKGROUND AND PURPOSE

Elevated baseline levels of C-reactive protein (CRP) are associated with an adverse outcome during coronary stent placement. The aim of this study was to evaluate whether preprocedural CRP levels also are predictive of stroke and death in patients undergoing carotid stent placement (CAS).

MATERIALS AND METHODS

We reviewed data prospectively collected from 130 patients (97 men, 33 women; mean age, 68.5 +/- 10.1 years; range, 43-89 years) who underwent CAS for symptomatic carotid stenosis and from whom preprocedural CRP values had been obtained. A CRP value of >5 mg/L was considered to be elevated. The frequency of stroke and death within 30 days was compared between patients with and without elevated baseline CRP levels using chi(2) and multivariate logistic regression analysis.

RESULTS

Baseline CRP values were normal in 94 (72.3%) patients but were elevated in 36 (27.7%) patients. The demographic and clinical characteristics were similar in both treatment groups. The 30-day stroke and death rate was significantly higher in patients with elevated CRP values (8/36; 22.2%) than in those without (3/94; 3.2%; P < .01). After adjusting for demographic characteristics, degree of carotid stenosis, and use of cerebral protection devices and/or statin therapy, an elevated CRP value before CAS remained a significant and independent predictor of stroke and death within 30 days after CAS (odds ratio, 7.7; 95% confidence interval: 1.8-32.8, P = .006).

CONCLUSIONS

Baseline CRP is a powerful predictor of outcome in patients undergoing CAS, which underscores the role of inflammation in the pathogenesis of embolic complications during this procedure.

[Positioning therapy in intensive care medicine in Germany. Results of a national survey]

BACKGROUND

The effects of a systematic change in a patient's position [prone position, continuous lateral rotational therapy (CLRT)] have been investigated in recent years in acute lung injury and have shown an improvement in oxygenation, but controversial results regarding duration of mechanical ventilation, intensive care treatment and mortality compared to conventionally treated patients. We were interested in the practice and acceptance of positioning therapy in German intensive care units (ICU) and performed a national postal survey with respect to evaluation of indications, preference of particular positions, observed complications and additional aspects (costs, influence on other intensive care measures etc.).

METHODS

A questionnaire (12 multiple choice items) was sent to 1,763 ICUs, which were identified from the "Deutsches Krankenhausadressbuch" (German hospital address book 2005). The analysis was performed anonymously.

RESULTS

A total of 702 questionnaires (40.4%) were returned and analysed. The 135 degrees position (incomplete prone position) was most frequently used (50%), while the prone position (25%) and CLRT (18%) were less frequent. The improvement in oxygenation (95%) and the prevention of ventilator-associated complications (75.7%) were important indications for positioning therapy. Results of a blood gas analysis provided the necessary criteria for determining positional therapy. Supporters of the prone position advocated lower cost and better efficacy in comparison to CLRT. The frequency of complications during positioning therapy was reported to be high: hemodynamic instability (73.6%), accidental loss of tube/catheters (50.4%) and patient intolerance (40.7%) were often observed, and complication-free positioning therapy was reported in only 8.6%.

CONCLUSIONS

The 135 degrees position (incomplete prone position) is the most frequently used positioning therapy in Germany for improvement of oxygenation in patients with acute lung injury. Prone position and CLRT are less frequently used, probably due to an increased frequency of (expected) complications. The authors assume that clear guidelines and algorithms are needed to establish a more routine, safe practical application and a reduction in the complication rate.

TMPRSS2:ERG gene fusion associated with lethal prostate cancer in a watchful waiting cohort

The identification of the TMPRSS2:ERG fusion in prostate cancer suggests that distinct molecular subtypes may define risk for disease progression. In surgical series, TMPRSS2:ERG fusion was identified in 50% of the tumors. Here, we report on a population-based cohort of men with localized prostate cancers followed by expectant (watchful waiting) therapy with 15% (17/111) TMPRSS2:ERG fusion. We identified a statistically significant association between TMPRSS2:ERG fusion and prostate cancer specific death (cumulative incidence ratio=2.7, P<0.01, 95% confidence interval=1.3-5.8). Quantitative reverse-transcription-polymerase chain reaction demonstrated high ets-related [corrected] gene (ERG) expression to be associated with TMPRSS2:ERG fusion (P<0.005). These data suggest that TMPRSS2:ERG fusion prostate cancers may have a more aggressive phenotype, possibly mediated through increased ERG expression.

PCV chemotherapy for recurrent glioblastoma

The authors administered procarbazine, 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU, lomustine), and vincristine (PCV) to 86 patients with recurrent glioblastoma. There were three partial responses, but no complete responses. Median progression-free survival was 17.1 weeks and progression-free survival at 6 months was 38.4%. World Health Organization grade III/IV hematologic toxicity was common (25.6%), but nonhematologic toxicity was mild.

Efficacy and Safety of Outpatient Alcohol Detoxification with a Combination of Tiapride/Carbamazepine: Additional Evidence

BACKGROUND

Few medications have been tested for outpatient alcohol detoxification. Previously we had shown a combination of carbamazepine and tiapride to be effective in an open study. This database is an extension of our previous work.

METHODS

This was an open prospective study to examine the efficacy, practicability and medical safety of a combination of tiapride and carbamazepine in outpatient detoxification of alcohol dependent patients. Patients were carefully screened for relevant neuropsychiatric disorders and then seen on a daily outpatient basis.

RESULTS

A total number of 116 consecutively admitted patients entered the programme; 107 (92%) successfully ended the treatment. The mean initial dose for tiapride was 289 mg and for carbamazepine 502 mg. No serious medical complications or adverse events were observed except for one case of delirium tremens. Only four patients dropped out because of side effects. In general medication was well tolerated. Withdrawal symptomatology as indicated by CIWA-A-scores decreased over time.

CONCLUSIONS

Results from this study give further evidence for a combination of tiapride and the anticonvulsant carbamazepine as an effective and safe treatment for outpatient alcohol detoxification in patients with moderate severity of withdrawal syndrome. Further randomized trials are warranted to examine the efficacy of this combination in outpatient alcohol withdrawal.

Magnetic metamaterials at telecommunication and visible frequencies

Arrays of gold split rings with a 50-nm minimum feature size and with an LC resonance at 200 THz frequency (1.5 microm wavelength) are fabricated. For normal-incidence conditions, they exhibit a pronounced fundamental magnetic mode, arising from a coupling via the electric component of the incident light. For oblique incidence, a coupling via the magnetic component is demonstrated as well. Moreover, we identify a novel higher-order magnetic resonance at around 370 THz (800 nm wavelength) that evolves out of the Mie resonance for oblique incidence. Comparison with theory delivers good agreement and also shows that the structures allow for a negative magnetic permeability.

[MR-guided core biopsy of the shoulder: possibilities and experience with a vertically open 0.5T system]

PURPOSE

The availability of open whole body MRI magnets and MR-compatible instrumentarium were essential conditions for the progression of interventional MRI. The advantages of an MR-guided biopsy at the musculoskeletal system are the visualization of the puncture site of a representative area for tumor histology, the absence of exposure to radiation and the free selection of imaging planes. The purpose of the study was the development of a new technique of a secure MR-guided biopsy of intraosseus lesions in the humeral head.

MATERIAL AND METHODS

MR-guided core biopsy of a intraosseus lesion of the humeral head was performed in five male patients on a vertical open, whole body MRI magnet (SIGNA SP/i 0.5T, GE Medical Systems). The technique using interactive MRI and the MR-compatible instrumentarium are described.

RESULTS

A secure core biopsy could be obtained from a representative area for tumor histology in all cases. No complications occurred, especially no nerve or vessel lesion, no rotator cuff lesion and no intra-articular contamination of the shoulder joint were observed.

CONCLUSION

A new technique is presented to obtain MR-guided core biopsies of intraosseous lesions of the humeral head. Furthermore, clinical indications of this technique are described.

Pediatric MR-guided interventions

MRI guided interventions are a relatively new but steadily growing field within surgery in pediatric age. Besides the advantages of MRI, such as multiplanar capability and excellent soft tissue contrast and spatial resolution, particularly relevant for the pediatric population is the lack of ionizing radiation. There is meanwhile a group of well defined diagnostic or therapeutic indications for applying MR imaging during pediatric interventions. Aim of this review is to give an overview about indications of MR-guided procedures in children as well as the advantages and disadvantages of MR-guided interventions. We also briefly discuss interventional MR-systems and MR-compatible devices. It is our opinion that MR-guidance for pediatric interventions is a promising technique at the beginning of its development.

Anterior sciatic nerve block--new landmarks and clinical experience

BACKGROUND

Anterior sciatic nerve blocks can be complicated by several problems. Pain can be caused by bony contacts and, in obese patients, identification of the landmarks is frequently difficult.

METHODS

In a first step, 100 normal anterior-posterior pelvic X-rays were analyzed. The landmarks of the classical anterior approach were drawn on these X-rays and assessed for their sufficiency. Then, in a prospective case study, 200 consecutive patients undergoing total knee replacement were investigated. These patients received femoral and sciatic nerve catheters for postoperative pain management. Using modified anatomical landmarks, sciatic nerve catheters were inserted 5 cm distal from the insertion site of the femoral nerve block perpendicularly in the midline of the lower extremity. This midline connected the insertion site of the femoral nerve catheter to the midpoint between the medial and lateral epicondyle. Correct catheter positioning was verified by magnetic resonance imaging (MRI) in six patients.

RESULTS

Evaluation of pelvic X-rays showed that puncture following the classical landmarks pointed in 51% at the lesser trochanter, in 5% medial to the lesser trochanter and in 42% directly at the femur. In the latter patients, location of the sciatic nerve would have been difficult or even impossible. Using our modified anterior approach, the sciatic nerve could be blocked in 196 patients (98%). In nine patients (4.5%) blockade of the posterior femoral cutaneous nerve failed. Vascular puncture happened in 10 (5%) and bony contact in 35 patients (17.5%). Median puncturing depth was 9.5 (7.5-14) cm. Correct sciatic nerve catheter positioning was verified in all patients who underwent MRI.

CONCLUSION

Our landmarks for locating the sciatic nerve help to avoid bony contacts and thereby reduce pain during puncture. Our method reliably enabled catheter placement.

Bilateral Wallerian degeneration of the middle cerebellar peduncles due to paramedian pontine infarction: MRI findings

Wallerian degeneration is a frequent finding in lesions of the pyramidal tract, but has been observed after damage of the other fibre systems as well. Few reports exist about Wallerian degeneration of cerebellar fibres after distant lesions to the axons. Here, we report on a patient who developed degeneration of both middle cerebellar peduncles after a paramedian pontine infarction.

Das plexiforme Schwannom des Hodens

In this report we describe the case of a testicular schwannoma in a human. Histologically, the tumor presented as a plexiform schwannoma. This rare benign peripheral nerve sheath tumor is an uncommon nodular variant of schwannoma, which mimics plexiform neurofibroma by its multinodular growth.

Does tumor heterogeneity limit the use of the Weiss criteria in the evaluation of adrenocortical tumors?

Adrenal incidentalomas are detected more frequently with high-resolution imaging modalities. It is difficult to distinguish between benign and malignant lesions despite the so-called histologic Weiss criteria, imaging features, and molecular studies. We here present a 52 yr-old man who was found to have an adrenal incidentaloma during an annual check-up at his urologist. An 8 cm large adrenal lesion was detected on ultrasound, computed tomography, and magnetic resonance imaging with imaging features suggestive of malignancy. The lesion was hormonally inactive. A left-sided adrenalectomy was performed and histologic grading revealed a Weiss score of 2, suggesting a benign tumor. However, on further follow-up, the patient developed a local recurrence and pulmonary metastases diagnosed 6 yr after initial presentation. After repeat surgery in the left adrenal bed adrenocortical tumor tissue had a Weiss score of 8, clearly suggesting histologic malignancy. The patient received adjuvant mitotane therapy. Under this therapy, he developed a right-sided adrenal mass (contralateral from the primary tumor) of 2 cm size which disappeared during the following 9 months, whereas the pulmonary metastases remained unchanged, suggesting tumor clones with a variable response to treatment or spontaneous apoptosis. This case suggests that adrenal incidentalomas larger than 6 cm with imaging features such as intratumoral necrosis suggestive of malignancy, should be managed as potential cancers independent of the so-called Weiss criteria. In such patients, close follow-up examinations including high-resolution imaging (preferably 3 monthly) are needed and should be carried out by a physician familiar/specialized in endocrine oncology.

Response to combination therapy with interferon alfa-2a and ribavirin in chronic hepatitis C according to a TNF-alpha promoter polymorphism

BACKGROUND

Tumor necrosis factor-alpha (TNF-alpha) is involved in the pathogenesis of chronic active hepatitis C. Polymorphisms in the promoter region of the TNF-alpha gene can alter the TNF-alpha expression and modify the host immune response. The present study aimed at the correlation of the G308A TNF-alpha polymorphism with the response to antiviral combination therapy in chronic hepatitis C.

PATIENTS AND METHODS

62 patients with HCV and 119 healthy unrelated controls were genotyped for the G308A TNF-alpha promoter polymorphism. The patients received 3 x 3 million units of interferon alfa-2a and 1,000-1,200 mg ribavirin daily according to their body weight. A response was defined as absence of HCV-RNA and normalization of S-ALT after 6 months of combination therapy.

RESULTS

With respect to the allele and genotype frequency, a significant difference was not observed between controls and patients with chronic hepatitis C. Furthermore, such a difference was also not observed if responders and non-responders to antiviral therapy were compared.

CONCLUSIONS

The promoter polymorphism of the TNF-alpha gene investigated herein is equally distributed in healthy individuals and patients with hepatitis C and does not seem to predict the response to therapy with interferon alfa-2a and ribavirin.

Diffusion-weighted MRI in herpes simplex encephalitis: a report of three cases

Herpes simplex virus encephalitis (HSVE) is the most frequent fatal viral infection of the brain. Because antiviral treatment may improve the prognosis significantly, early diagnosis is mandatory. Imaging diagnosis rests on conventional MRI for the visualization of lesions in the limbic system, the hallmark of HSVE. Diffusion-weighted MRI (DW-MRI) has not been used for the evaluation of HSVE. We report on the DW-MRI findings in three patients with HSVE, who had cortical diffusion abnormalities in affected brain parenchyma, partially as the initial or most sensitive sign of encephalitis. Sequential imaging showed that the diffusion abnormality started to return to normal after 2 weeks in the presence of persistent contrast uptake. Thus, DW-MRI may be a valuable tool for early detection and diagnosis of HSVE whereas contrast-enhanced images are indispensable after the first week.

[MRI-guided pediatric interventions]

AIM

There are only a few diagnostic or therapeutic procedures where MR imaging is applied during pediatric interventions. This study will describe indications, complications as well as the advantages and disadvantages of MRI-guided interventions based on a case study in an open MRI scanner.

MATERIALS AND METHODS

14 procedures were performed in an open MRI scanner (Signa SP/i, GEMS) on 13 children (1 - 16 yr) with bone, soft tissue and brain lesions (1 - 4 cm diameter). Localization of the pathology, targeting and final control of the result were based on images acquired with SE-, 3D-, GE-sequences pre- and post-contrast as well as FSE-sequences. Interactive MRI-guided instrument navigation was performed using a multiplanar T1w GE-sequence.

RESULTS

Eight biopsies (incl. 1 rebiopsy), two tumor resections, one removal of a free joint mouse and three tumor-markings were performed without complications. Five biopsies provided appropriate sample quality for a histological diagnosis while two samples were too fragmented requiring a second biopsy (one of them MRI-guided). Surgical progress during tumor resection and marking could be controlled during the intervention without repositioning the patient.

DISCUSSION

MR image guided pediatric interventions combine the advantage of an imaging system without ionizing radiation and the high soft-tissue contrast. The low number of these kinds of procedures can be explained by the relatively high costs for the intervention, the increased duration for each procedure and the limited availability of open MRI systems. The integrated localization-system helps during planning of the access path when facing complex anatomical structures and provides safe navigation in sensitive regions like the epiphyseal cartilage. Recent and expected developments of the required MR-compatible biopsy instruments could provide higher efficiency for appropriate sample size and quality. Summarizing, MRI-guided pediatric interventions have shown to be a promising method at the beginning of its development.

The effects of working conditions and antenatal leave for the risk of premature birth in Berlin

OBJECTIVES

The influence a job--including its physical and psychological aspects--has on pregnant woman's chances of delivering prematurely.

METHODS

Seven hundred and seven women who had given birth participated. Statements regarding her job and its stresses were obtained with a standardised questionnaire.

RESULTS

Two hundred and thirty-seven of the 707 women delivered prematurely (<37 weeks), 471 at term. No increased incidence of premature deliveries was observed in working mothers or found in relation to physical stress. A link was observed due to a mother's dissatisfaction with her job ( p<0.001).

CONCLUSION

With changes in the workplace and adherence to laws protecting pregnant women, effective factors are in place that help prevent premature births. A prerequisite for this is the pregnant woman's contentment with her work.

Progressive multifocal leukoencephalopathy: analysis of lesion development with diffusion-weighted MRI

Progressive multifocal leukoencephalopathy (PML), caused by replication of JC virus in oligodendrocytes of immunocompromised patients, is diagnosed by polymerase chain reaction-based demonstration of JC virus DNA. We investigated whether MRI might be used to assess disease activity. Diffusion-weighted imaging (DWI) was obtained in two patients with PML, in whom it was the only MRI sequence on which we could identify areas of progressive disease. The extent of abnormal diffusion appeared to correlate with the speed of clinical progression. DWI would thus seem to be of value in patients with PML.

The Delta 32 mutation of the chemokine-receptor 5 gene neither is correlated with chronic hepatitis C nor does it predict response to therapy with interferon-alpha and ribavirin

Unlike in HIV, homozygosity for a 32-bp deletion (Delta 32) of the chemokine receptor 5 (CCR5) gene was recently described in increased frequency in patients with chronic hepatitis C (HCV). Thus, it was speculated that this mutation might be relevant for disease susceptibility and influence the response to antiviral therapy. The present study sought to confirm the association between HCV and the Delta 32 mutation of the CCR5 gene and to correlate it with the response to therapy with interferon-alpha-2a and ribavirin. Sixty-two patients with HCV and 119 healthy unrelated controls were genotyped for the Delta 32 mutation. For the correlation between the Delta 32 mutation and response to therapy, only patients (n = 59) who completed 6 months of combination therapy as part of a prospective study were evaluated. The Delta 32 mutation was not observed in increased frequency in HCV. Furthermore, a significant difference of the HCV load or aminotransferase concentrations was not observed in carriers versus noncarriers of the Delta 32 mutation. After stratification for potentially confounding factors such as gender or HCV genotype, a significant difference was also not detected with respect to treatment outcome. These observations argue strongly against a role of CCR5 for susceptibility to HCV infection or response to combination therapy.

Evidence for quark-hadron duality in the proton spin asymmetry A1

Spin-dependent lepton-nucleon scattering data have been used to investigate the validity of the concept of quark-hadron duality for the spin asymmetry A1. Longitudinally polarized positrons were scattered off a longitudinally polarized hydrogen target for values of Q2 between 1.2 and 12 GeV2 and values of W2 between 1 and 4 GeV2. The average double-spin asymmetry in the nucleon resonance region is found to agree with that measured in deep-inelastic scattering at the same values of the Bjorken scaling variable x. This finding implies that the description of A1 in terms of quark degrees of freedom is valid also in the nucleon resonance region for values of Q2 above 1.6 GeV2.

[Development of mycotic aneurysms of the superior mesenteric artery after septic embolism]

Mycotic aneurysms of the aorta and the visceral arteries are life-threatening diseases, due to potential rupture and organ or limb ischemia. They occur in endocarditis, immunodeficiency, bacteremia and fungemia, and have a poor prognosis. We report on a case of a 54-year-old male patient suffering from abdominal angina after mitral valve replacement for septic mycotic endocarditis. In presence of a mycotic-embolic occlusion of the left popliteal artery and multiple septic organ infarctions a mycotic aneurysm of the superior mesenteric artery was found in abdominal spiral-CT. Based on sequential spiral-CT examinations, this case demonstrates the development of a septic aneurysm of the superior mesenteric artery.

Thyroid hypoechogenicity in patients with chronic hepatitis receiving interferon-alpha therapy: evaluation by standardized grey scale ultrasonography

BACKGROUND

Recombinant human interferon-a therapy of chronic hepatitis B and C is associated with the induction of thyroid dysfunction in up to 15%. Little is known about morphological changes of the thyroid gland, especially about its tissue echogenicity under this immunomodulative drug treatment.

METHODS

116 patients with chronic hepatitis B or C were consecutively investigated. 53 patients qualified for treatment with interferon-a alone or in combination with ribavirin. Patients with normal serum aminotransferase levels, advanced liver cirrhosis, hepatocellular carcinoma, active intravenous drug or alcohol abusus and with focal thyroid lesions (nodes, cysts, calcifications) were excluded. Thyroid function was determined by measurements of FT4, TSH and thyroidal autoantibodies. Ultrasonography was performed before, during and after interferon-a therapy including volumetry and standardized grey scale analysis. The data were compared with values of 100 euthyroid volunteers as control group.

RESULTS

After six months of therapy patients differed from controls by significant TSH elevation (12.8 +/- 9.34 vs. 2.8 +/- 1.1 microU/ml, p<0.02). Six patients (11%) developed overt hypothyroidism with detectable thyroidal autoantibodies. Thyroid volume in patients was similar (13.0 +/- 4.1 ml) to that in the control group (12.6 +/- 4.7 ml). However, thyroid echogenicity of the patients was significantly lower after 6 months of therapy (21.9 +/- 2.5 grey scales) compared to the status before (25.6 +/- 2.3 grey scales) and compared to the values of controls (25.4 +/- 2.1 grey scales, p <0.002).

CONCLUSION

Beside of functional disorders interferon-alpha leads to thyroid hypoechogenicity suggesting relevant morphological changes of the organ.

Myelopathy in primary Sjögren's syndrome: diagnostic and therapeutic aspects

We report a patient with a myelopathy in primary Sjögren's syndrome, proven by salivary gland biopsy and specific antibodies. Under steroid medication, the patient had a remitting and relapsing clinical course. The severity of clinical symptoms correlated with a transient contrast uptake in spinal magnetic resonance imaging. Under a treatment with azathioprine and prednisone the patient has suffered no relapse within the last 20 months. Although this is only a case report, the combination of azathioprine and prednisone may be a valuable medication in chronic cases of Sjögren's syndrome with neurologic symptoms.

Extremely low vertical-emittance beam in the accelerator test facility at KEK

Electron beams with the lowest, normalized transverse emittance recorded so far were produced and confirmed in single-bunch-mode operation of the Accelerator Test Facility at KEK. We established a tuning method of the damping ring which achieves a small vertical dispersion and small x-y orbit coupling. The vertical emittance was less than 1% of the horizontal emittance. At the zero-intensity limit, the vertical normalized emittance was less than 2.8 x 10(-8) rad m at beam energy 1.3 GeV. At high intensity, strong effects of intrabeam scattering were observed, which had been expected in view of the extremely high particle density due to the small transverse emittance.

Unilateral thalamic edema in internal cerebral venous thrombosis: is it mostly left?

Thrombotic occlusion of the internal cerebral veins is a particularly dangerous form of cerebral venous thrombosis (CVT) as it causes venous infarction of the thalami. Because both thalami drain into the vein of Galen and straight sinus, bilateral thalamic involvement is frequently encountered in internal CVT. However, unilateral thalamic edema may also occur, even if all internal cerebral veins are occluded. This suggests collateral venous drainage of the thalami, which is commonly insufficient in internal CVT. Patients with unilateral congestion of the thalamus, including 3 patients reported here, had mostly left-sided involvement, indicating that right-sided unilateral thalamic involvement in CVT may be clinically silent.

[MR-guided preoperative localization and percutaneous core biopsy of suspected breast lesions. Possibilities and experience on the vertically open 0.5-T-system]

PURPOSE

To evaluate the feasibility of performing breast interventions in a vertically open 0.5 T MR system (SIGNA SP/i, GE Medical Systems). To develop fitted equipment and to establish preoperative wire localization and percutaneous breast core biopsy as clinical routine procedures.

PATIENTS AND METHODS

Initially, we applied a localization method with the patient placed in a sitting position in 31 cases using a single loop coil and a self-developed fixation device. Subsequently, 46 wire localizations and 28 percutaneous core biopsies were carried out in prone patient position using an open breast coil with an integrated biopsy device. The used instruments were either MR-compatible (18 G biopsy needle and localization wire, 14 G coaxial needle, prototype of a 16 G double-shoot gun) or MR-safe (double-shoot gun with 16 G needle).

RESULTS

After biopsy we found the needle tip (18 G for a wire localization and 14 G for a percutaneous core biopsy, respectively) placed either within or close to the lesions (< 10 mm distance) for all patients. Out of a total of 66 benign lesions and 39 malignant tumors we missed the lesion (12 mm mean diameter, 4-25 mm range) during open biopsy in two cases and obtained a false negative result for one percutaneous biopsy of a 5 mm lesion.

CONCLUSION

Preoperative wire localization and percutaneous core biopsy of suspicious breast lesions demonstrated by MRI can be carried out a vertically open 0.5 T MR scanner. The degree of accuracy is comparable with that of X-ray or ultrasound-guided procedures. A follow-up has to be performed in cases with a negative biopsy.

Intra-individual variability in nighttime urine production and functional bladder capacity estimated by home recordings in patients with nocturnal enuresis

PURPOSE

We evaluated the intra-individual variability and reproducibility of nighttime urine production on wet nights and functional bladder capacity estimated by long-term home recordings of monosymptomatic nocturnal enuresis. In particular, the intention was to evaluate the validity of 1 versus 2 weeks of recording when estimating urine volume on wet nights and 1 versus 2 weekends of recording when estimating functional bladder capacity.

MATERIALS AND METHODS

We analyzed 120, 2-week home recordings of nighttime urine volume from patients with monosymptomatic nocturnal enuresis 6 to 16 years old (mean age 9.1) with at least 3 wet nights per week. Most patients were nonresponders or partial responders to desmopressin. Nighttime urine volume was estimated by weighing diapers before and after sleep, and measuring morning urine volume. Of the home recordings 62 included frequency volume charts for 2 weekends, which were evaluated for functional bladder capacity defined as the largest voided volume observed.

RESULTS

No significant overall week-to-week differences were observed in average urine volume on wet nights and functional bladder capacity. There was a large intra-individual variability in all measured variables, which was most pronounced for functional bladder capacity and least pronounced for urine volume on wet nights. With regard to repeatability, the limits of agreement of urine volume on wet nights were -32% and 36% (95% confidence interval) as opposed to -54% and 48% for functional bladder capacity.

CONCLUSIONS

In this study intra-individual week-to-week estimates of average urine volume on wet nights demonstrated acceptable variability and repeatability in contrast to functional bladder capacity. A reliable estimate of urine volume on wet nights could be obtained by 7 nights of home recording, whereas 4 days of daytime recording were necessary when estimating functional bladder capacity. Similar studies of patients who respond to desmopressin are needed.

[Clinical relevance and treatment possibilities of rapid cycling in patients with bipolar disorder]

In the actual version of the WHO diagnostic guidelines, the ICD-10, subtypes of bipolar disorder are not specified, in contrast to the American DSM-IV, where bipolar disorder has already been differentiated in bipolar I (severe manic and depressive episodes) and bipolar II disorder (depressive and hypomanic episodes). Furthermore, aspects of the longitudinal course of the illness, like rapid cycling (RC), are reflected as well. Rapid cycling is defined as four or more affective episodes within one year of the illness. It has been postulated that rapid cycling is related with a poor response to lithium, to the same extent as mixed episodes or an atypical onset (depressive episode first) of the disease. Here, the current status of alternative pharmacological and supportive therapy of rapid cycling is presented and discussed. Furthermore, the article also displays biological parameters associated with rapid cycling like higher prevalence in women, hypothyreoidism, subtype of bipolar disorder, COMT-allele, influence of sleep or risk of antidepressant induced cycling.