[Ovarian torsion in childhood]

A six year old afebrile girl was referred to the emergency department with abdominal pain in the right lower region. A retrouterine partially cystic lesion with an inhomogene echogenity was demonstrated by transabdominal ultrasound. Pelvic MR showed an enlarged right-sided ovary and a thickened vascular pedicle as well as few adjacent free fluid. Diagnosis of ovarian torsion was confirmed intraoperatively. Conservative ovary-sparing treatment was not possible, so right-sided adnexectomy followed. Histopathologically a haemorrhagic infarction of the ovary and the tube was seen. No signs of malignancy and no tumor could be detected.

Measurement of the magnitude of force applied by students when learning a mobilisation technique

Passive accessory intervertebral movements (PAIVM’s) are frequently used by physiotherapists in the  assessment and management of patients. Studies investigating the reliability of passive mobilisation techniques have shown conflicting results. Therefore, standardisation of PAIVM’s is essential for research and teaching purposes, which could result in better clinical management. In order to standardise graded passive mobilisation techniques, a reliable, easy-to-use, objective measurement tool must be used. The aim of this  study was to determine whether it is necessary to quantify the magnitude of force applied when teaching a grade I central  posteroanterior (PA) mobilisation technique (according to Maitland) on the cervical spine. An objective measurement tool (FlexiForceTM) was used to determine the consistency of force applied by third and fourth year physiotherapy students while performing this technique. Twenty third- and 20 fourth year physiotherapy students (n=40) were randomly selected. Each subject performed a grade I central PA on sensors placed on C6 for 25 seconds. The average maximum grade 1 force applied by the third year students was  significantly higher than the force applied by the fourth year students (p=0.034). There was a significantly larger variation in applied force among third years (p=0.00043). The results indicate that the current teaching method is insufficient to ensure inter-therapist reliability amongst students, emphasising the need for an objective measurement tool to be used for teaching students. The measurement tool used in this study is economical, easily applied and is an efficient method of measuring the magnitude of force. Further research is needed to demonstrate the reliability and validity of the tool to assist teaching and research in a clinical setting.

A new design of a polysomnography-based multi-center treatment study for the restless legs syndrome

Periodic limb movements (PLM) cause sleep disorders and daytime symptoms and are frequently associated with restless legs syndrome (RLS). Treatment of RLS with increased PLM during sleep (PLMS) has been evaluated in studies limited in size, methodology and study length. This long-term, placebo-controlled, multi-center, study with polysomnography (PSG) recordings has been designed in order to assess efficacy and safety parameters of pergolide treatment in RLS. This novel approach for a study was created to assure consistently high quality of sleep recording and analysis. Using defined criteria, 21 sleep centers were approved for the study after a pilot phase. Seventeen centers with 16 different PSG systems randomized 100 patients. Digital sleep recordings from 4 visits (baseline, 6 weeks, 6 months, 1 year) were submitted to one central evaluation center following previously defined standardized operating procedures. Visual scoring of all recordings was performed by one independent scorer. Reliability of scoring was evaluated for 20 randomly selected baseline recordings. The mean epoch by epoch agreement for sleep stages was 88% (range 81-96%), mean arousal re-scoring differed by 0.5 (range: -16 to 20), and mean PLM index re-scoring differed by 0.1 (range: -1.5 to 2.1). Using one scorer with a demonstrated high reliability in PSG scoring for all sleep recordings was very effective in terms of study cost, study duration, and data quality.

Interventional ultrasound

Modern cross-sectional imaging methods of computed tomography, sonography and lately MRI have contributed greatly to non-invasive studies of different parenchymal organs and permit the evaluation of pathological changes in different areas of the body. Although these techniques have reached a very high level of refinement, it is often not possible to define whether a focal lesion is benign or malignant. Ultrasound-guided fine-needle aspiration biopsy (FNA) or core-needle biopsy (including high-speed- and vacuum-assisted techniques) are essential to find out the character of the disease in these cases. Experience of more than 10,000 interventions of different organs are presented. Technique, results, problems, as well as risks are discussed. Moreover, it is shown how the results of percutaneous biopsies often change the treatment of a patient. This is especially of interest in those suffering from lymphomas, pancreatic carcinomas, and breast cancers, as well as relapsing tumors.

[Vacuum needle biopsy of the breast with digital stereotaxic control--initial experiences with the Mammotome in Baden]

The purpose of our study was to evaluate a stereotactic, percutaneous, vacuum-assisted breast biopsy system. The Mammotome (Biopsies) was used to perform breast biopsies in 35 of 37 patients using only one small incision. In two patients a biopsy was not possible: one lesion could not be positioned into the limited field of the digital CCD-camera. One lesion was not enough dense to be seen on digital images. Biopsies were performed because of suspicious microcalcifications (34) or nodules (3). Histology revealed 32 benign and 3 malignant lesions. We encountered 4 syncopes. Because the biopsies are performed in the sitting position, they were the cause we had to break up 2 biopsies. Relevant hematomas occurred in 4 cases. Vacuum assisted core biopsy has proven to be a safe and accurate technique for obtaining a histologic diagnosis in most patients who have screening-detected lesions; it is done at a lower cost with lower resultant morbidity to the patient compared with traditional surgical excisional biopsy. A certain learning phase must be granted.

A phase I study of Onyx-015, an E1B attenuated adenovirus, administered intratumorally to patients with recurrent head and neck cancer

An E1B 55 kDa gene-deleted adenovirus, Onyx-015, which reportedly selectively replicates in and lyses p53-deficient cells, was administered by a single intratumoral injection to a total of 22 patients with recurrent head and neck cancer. The objectives of this Phase I study were to determine the safety, feasibility, and efficacy of this therapy and determine any correlation to p53 status. Six cohorts were investigated with a dose escalation from 10(7)-10(11) plaque-forming units. Toxicity was assessed using NCIC criteria. Tumor response was assessed by clinical and radiological measurement. Blood samples were taken to detect adenovirus DNA and neutralizing antibody to adenovirus. Tumor biopsies were taken to detect adenovirus by in situ hybridization. Treatment was well tolerated, with the main toxicity being grade 1/2 flu-like symptoms. Dose-limiting toxicity was not reached at the highest dose of 10(11) plaque-forming units. Twenty-one of the 22 patients treated showed an increase in neutralizing antibody to adenovirus. In situ hybridization showed viral replication in 4 of 22 patients treated, all of whom had mutant p53 tumors. Using conventional response criteria, no objective responses were observed. However, magnetic resonance imaging scans were suggestive of tumor necrosis at the site of viral injection in five patients, three of whom were classified using nonconventional criteria as partial responders, and two of whom were classified using nonconventional criteria as minor responders. Of these five cases, four had mutant p53 tumors. The response duration for the three partial responders was 4, 8, and 12 weeks. An additional eight patients had stable disease in the injected tumors lasting from 4-8 weeks. These preliminary results show that intratumoral administration of Onyx-015 is feasible, well tolerated, and associated with biological activity. Further investigation of Onyx-015, particularly with a more frequent injection protocol and in combination with systemic chemotherapy, is warranted.

Telepathology: design of a modular system

Although telepathology systems have been developed for more than a decade, they are still not a widespread tool for routine diagnostic applications. Lacking interoperability, software that is not satisfying user needs as well as high costs have been identified as reasons. In this paper we would like to demonstrate that with a clear separation of the tasks required for a telepathology application, telepathology systems can be built in a modular way, where many modules can be implemented using standard software components. With such a modular design, systems can be easily adapted to changing user needs and new technological developments and it is easier to integrate modular systems into existing environments.

[Contrast media-enhanced duplex ultrasonography of liver tumors]

The differentiation of focal liver processes is a daily clinical problem. A new option in addition to magnetic resonance tomography has been created with the development of new stable sonographic contrast agents. In this paper, Levovist was studied as a sonographic contrast agent in the detection of specific tumour perfusion patterns. All focal liver processes were proven by cytology or histology. In 19 of 22 cases there was a pathological diagnosis. In 5 of 7 haemangiomas a feeding vessel was visualised. In 3 focal nodular hyperplasias intense intratumoural enhancement was visible shortly after injection. In 2 cases of hepatocellular carcinomas tumoural neovascularisations were visualised which were not seen before the injection of Levovist. The new sonographic contrast agents provide better differentiation of specific perfusion patterns of liver tumours than normal duplex sonography.

[Non-invasive monitoring of intracranial pressure changes through the ear]

Otoacoustic emissions are low energy vibrations generated by the inner ear during the physiologic process of hearing. The authors measured transiently evoked otoacoustic emissions in normal hearing individuals placed in Trendelenburg position and during diagnostic elevation of intracranial pressure in neurosurgical patients. In Trendelenburg position and at elevated intracranial pressure and reproducible phase shift of otoacoustic emissions could be observed. This phase shift was linear to the pressure increase of intracranial liquids. According to the hypothesis of the authors intracranial pressure increase is transmitted to the inner ear (possibly by the cochlear aqueduct) and thereby the mechanical load on the stapes footplate is elevated. This, in turn, causes a stiffening of the annular ligament which changes the angle of the impedance vector and thereby the phase of the whole vibrating system. By measuring the phase of otoacoustic emissions it is possible to monitor intracranial pressure in various clinical states.

Intrasound vibration testing in acute ankle injuries

OBJECTIVES

To determine the accuracy of intrasound vibration testing (IVT) in comparison with plain radiography in the diagnosis of acute ankle fractures.

METHODS

A group-sequential, nonrandomized, double-blind, observational study design was used. A convenience sample of patients were studied, aged > or = 10 years, with acute ankle injuries, undergoing ankle radiography, evaluated at a community teaching hospital ED. Excluded were cases involving injuries of > 24 hours' duration, inadequate documentation, protocol violation, or positive IVT on the uninjured ankle. IVT was performed with the intrasound apparatus placed on the anterior and posterior aspects of the medial and lateral malleoli of the uninjured and injured ankles; positive IVT was defined as patient withdrawal secondary to pain.

RESULTS

Of 105 patients enrolled, 8 were excluded; 1 for inadequate documentation, 5 for protocol violation, and 2 for positive IVT of the uninjured ankle. Of the 97 patients analyzed, 13 had fractures identified by radiography, including 9 lateral malleolar, 1 medial malleolar, 1 bimalleolar, and 2 talar fractures. Only 5 of the 13 fractures were detected with IVT (sensitivity = 39%; 95% CI: 14-68%). Seventy of 84 nonfractured ankles had negative IVT (specificity = 83%; 95% CI: 74-91%). Of the 19 with positive IVT, 5 had fractures (positive predictive value of 26%; 95% CI: 9-51%). Of the 78 with negative IVT, 70 had no fracture (negative predictive value of 90%; 95% CI: 81-96%). Overall, 75 of 97 IVTs were correct (77%), most of which were among patients without fractures.

[Diagnosis of osteoporosis with ultrasound densitometry of the calcaneus]

PURPOSE

We evaluated the speed of sound (SOS) and broadband ultrasound attenuation (BUA) at the os calcis as an indicator of osteoporosis and observed the age-related changes in ultrasound values in normal women.

MATERIALS AND METHODS

BUA and SOS were measured in 236 women using the "Achilles" densitometer (Lunar, Madison, Ohio). From the BUA and SOS values the BUA/SOS Index ("Stiffness" Index) is calculated. We investigated 55 female patients with osteoporosis (aged 43-85 years) and 181 healthy women (aged 20-80 years).

RESULTS

Ultrasound values for women with osteoporosis were significantly lower than those for the normal control group. The Z-score compared with young normals was higher for the BUA/SOS Index (-3.1) than for BUA (-2.5) and SOS (-3.0). At a BUA/SOS Index of 68 the sensitivity was 85 %, and the specificity was 77 % for patients with osteoporotic fractures. We found a significant decline with age in SOS (r = -0.55), BUA (r = -0.50) and BUA/SOS Index (r = -0.57).

CONCLUSION

Ultrasound bone densitometry at the os calcis can be used as a screening test in the diagnosis of osteoporosis.