[The prognostic significance of tumor volume in osteosarcoma with neoadjuvant chemotherapy]

In a retrospective analysis on 128 patients from the trials COSS-80, -82, -85 and -86 initial x-ray pictures were evaluated for tumor diameters in three planes and the prognostic meaning on survival was assessed. In a subset of patients (n = 27) the measured values were compared to values obtained by CT-Scan and a good correlation (r = 0.69) was found. Several parameters for tumor size were defined: absolute tumor length (ATL), relative tumor length (RTL, proportion of tumor to the length of the involved bone), absolute tumor volume (ATV, calculated by the ellipsoid formula) and relative tumor volume (RTL, tumor volume referred to the body surface area) and univariate and multivariate survival analysis were performed. Univariate analysis of metastasis free survival (MFS) revealed a high prognostic significance of the ATL, the ATV and the RTV. The RTL in this patient group demonstrated a tendency only toward an inferior prognosis in larger tumors. None of the patients with a ATV < 70 ml (n = 19) and only one of 33 patients with an ATV < 100 ml relapsed. Cox regression analysis was performed including the variables age, sex, site and response (> 90% tumor necrosis) in 84 patients. ATL and RTL do not enter the model, while the response proves its significance as a valid prognostic factor with a p-value of 0.0004. Adding the ATV as the measure of tumor size to the model it enters as the first term (p = 0.0000) followed by the response (p = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Colour-coded echographic flow imaging and spectral analysis of cerebrospinal fluid (CSF). Part III. In-vitro study of low flow velocity detection related to decreasing particle concentration (hematocrit) and tube lumen

An in-vitro steady flow system was designed to determine the lowest flow velocities that can be detected by echographic colour flow imaging and spectral analysis. The flow detection level was determined hydrostatically by reducing the fluid level to below the point at which a flow signal was visible, then increasing the height until the colour flow reappeared. This was confirmed in all instances by spectral analysis. The height (angle-corrected velocity) of the spectral envelope was also determined. Mean volume flow was then obtained by using a graduated cylinder and a stop watch. The lowest hematocrit detectable was identified using a stepwise dilution of packed human red blood cells with 0.9% sodium chloride. Three different PVC-tubes with inner diameters of 2.1 mm, 1.1 mm and 0.51 mm were used.(ABSTRACT TRUNCATED AT 250 WORDS)

Colour-coded echographic flow imaging and spectral analysis of cerebrospinal fluid (CSF) in meningitis and hemorrhage. Part I. Clinical evidence

Using echographic flow imaging (colour Doppler), flow within ventricular CSF-pathways was discovered in an infant with purulent meningitis. 22 mature and 40 premature infants were then investigated for presence of CSF-flow which was detected in a further 5 infants, all premature. Diagnostic criteria for echographic CSF-flow imaging are: 1. flow signals "within" CSF-pathways; 2. to-and-fro movement of CSF (spectral analysis); 3. specific response of CSF-flow to stimuli (respiration, crying, abdominal palpation); 4. dynamic CSF-imaging related to specific anatomical areas of intracranial CSF-pathways. Echographic detection of CSF-flow depends on optimized adjustment of controls, equipment used, meticulous examination technique and awareness of pitfalls on the part of the examiner. A further prerequisite is the presence of scattering particles within CSF, such as red or white blood cells (minimum concentration in the order of one thousand cells/microL) or air. Although echographic CSF-flow imaging is not applicable for excluding the presence of disease, it appears to be a new diagnostic tool with considerable potential allowing selected early and non-invasive diagnosis of CSF-pathology and giving new insights into CSF-hemodynamics.

Colour-coded echographic flow imaging and spectral analysis of cerebrospinal fluid (CSF) in infants. Part II. CSF-dynamics

41 comprehensive colour Doppler studies (including spectral analysis) of the ventricular system were performed in 6 infants with CSF-flow (age range: 2 to 27 days). Two premature infants showed no evidence of disease related to the central nervous system (CNS). Overt intraventricular hemorrhage or CNS-infection were present in the other infants. All children were examined several times until CSF-flow was no longer visible. The entire ventricular system, including the fourth ventricular outlet, was investigated for the presence of CSF-flow signals. Dynamic CSF-flow studies consisted of scanning during typical infant activity (crying, sucking, leg movement) and with external manoeuvres (abdominal or fontanellar palpation). CSF-flow was found to be: 1. synchronous with respiration 2. induced by rising intraabdominal (retrograde CSF-pulse) and transfontanellar pressure (orthograde CSF-pulse) 3. predominantly within the cerebral aqueduct, but also found at the foramina of Monro, within the third and fourth ventricles and at the foramen of Magendie. CSF-flow was not detected at the foramina of Luschka or within the lateral ventricles, except adjacent to the foramina of Monro. Dynamic CSF-flow as observed in infants may have important clinical and scientific implications. Examples of this are activity-related ventricular "reflux" of bacteria, erythrocytes, drugs, radionuclides or contrast; the importance of CSF-flow pulses for the development or progression of hydrocephalus; flow dynamics at the fourth ventricular outlet foramina and the study of CSF-pulse wave velocity and regional compliance. These issues are discussed and the new diagnostic approach is compared with other methods of CSF-investigation.

Doppler ultrasonography of malignant melanomas of the uvea

Doppler shifts were detected using duplex and color Doppler scanning in 41 of 42 patients with malignant melanomas of the uvea. Mean maximum tumor systolic velocity was 18.8 +/- 7.6 cm/s. Time-averaged maximum velocity in the tumor vessels was 12.3 +/- 5.3 cm/s. Maximum tumor velocity increased in four of eight tumors and was unchanged or had diminished in the other four 2 to 3 days after ruthenium plaque irradiation. Doppler shifts were undetectable in three tumors, markedly reduced in three tumors, and unchanged in one tumor 1 to 4 months after treatment. We detected minimal non-pulse-synchronized Doppler shifts in one of three tumors, and no shifts in the remaining two tumors 1 1/2 to 4 years after therapy. Color duplex scanning allowed a rapid overview of tumor vasculature and facilitated study of individual vessels.

Doppler ultrasonography of the ophthalmic and central retinal vessels

B-Scan-guided, pulsed Doppler ultrasonography of central retinal vessels and ophthalmic arteries of 72 normal subjects gave the following average peak flow velocities: central retinal artery, 9.5 +/- 3.1 cm/s; central retinal vein, 5.7 +/- 1.5 cm/s; and ophthalmic artery, 31.6 +/- 9.0 cm/s. Doppler shifts in the central retinal vessels were absent at intraocular pressures above 80 mm Hg. Ophthalmic artery systolic, middiastolic, and end-diastolic velocities significantly declined as a function of age. The technique is independent of the status of the ocular media, is noninvasive, requires little time, and causes minimal discomfort.

Major pitfalls in Doppler investigations. Part II. Low flow velocities and colour Doppler applications

Many pitfalls result from the limited ability of Doppler instruments to record low flow velocities. These include a misleading resistance or pulsatility index due to diastolic cut-off and taking no signal to equal no flow assuming that no signal means no flow. Comparison of actual flow velocities as measured in an in-vitro system (range: 0.8 to 3.4 cm/s) with the lowest recordable spectral or colour signals in 3 Duplexscanners showed that reduced sensitivity to low flow velocities is not only dependent on the high pass ("wall") filter setting, Doppler frequency or angle of incidence, but also on factors such as vessel diameter, impairing the signal to noise ratio. Characteristic errors of colour flow mapping (misleading vascular anatomy, imitation of pathological findings, erroneous exclusion of flow) are due to partial volume effect, limited temporal and velocity resolution, changing angle of incidence, aliasing and failure to detect low flow velocities.

Major pitfalls in Doppler investigations with particular reference to the cerebral vascular system. Part I. Sources of error, resulting pitfalls and measures to prevent errors

Major pitfalls in Doppler investigations are presented based on 340 evaluated cerebral Doppler examinations in infants. Substantial pitfalls may result from: A. Physics of sound waves and Doppler instruments (errors due to high pass filter cut off, aliasing, rapid image update). B. Quality and adjustment of the Doppler instrument (errors due to low sensitivity, inappropriate adjustment of Doppler controls, inadequate wall filter). C. Examination technique (errors due to an unfavourable angle of incidence or due to transducer-induced pressure: decrease predominantly in diastolic flow velocity-increase in maximum flow velocity in the straight sinus). D. Hemodynamics (errors due to spatial or temporal variations of the flow profile, pulsatility, non-uniform distribution of cerebral blood flow/CBF). E. Cerebral vascular anatomy (errors due to an unfavourable probe position as related to the three-dimensional arrangement of vessels, inadequate separation of closely adjacent vessels). F. Interpretation (flow velocity or Resistance Index/RI is taken to equal CBF, RI is taken to equal peripheral vascular resistance, one artery is taken to represent the cerebral circulation). Pitfalls may be avoided by using adequate means (low wall filter adjustment, high Doppler frequency, critical assessment of velocity spectra) to reduce the likelihood of errors occurring.

Duplex-scanning of the deep venous drainage in the evaluation of blood flow velocity of the cerebral vascular system in infants

Doppler investigations of the anterior cerebral (pericallosal) or internal carotid arteries have two major limitations: (1) flow velocity in one cerebral artery does not necessarily represent flow velocity in other cerebral arteries; (2) flow velocity spectra are influenced significantly by transducer-transferred pressure. Furthermore, there are substantial pitfalls in the interpretation of arterial flow velocity data. We therefore examined Doppler-shift waveforms of the deep venous drainage in addition to arterial flow velocity recordings in 186 infants, including a reference group of 49 infants without significant disease. In this group, mean values of peak velocities were 13.2 cm/s, 5.6 cm/s, 5.9 cm/s and 5.6 cm/s for the straight sinus, the vein of Galen, the right and the left basilar veins respectively. Venous flow velocities were increasing significantly with age, but not or only marginally with the weight at the time of examination. Three main flow velocity patterns were observed: (1) bandlike (straight sinus 25%, vein of Galen 59% and basilar veins 63%); (2) sinusoid and synchronous with arterial pulse (46%, 27% and 29% respectively; (3) intermittent (3%, 0% and 0% respectively). In contrast to the reference group, the intermittent pattern was common in severely ill premature infants and was associated with increased intrathoracic pressure and adverse outcome, indicating reduced venous volume flow irrespective of the arterial flow velocity pattern. Although difficult to perform, transcranial and transfontanellar Duplex-scanning of the deep cerebral veins might help to avoid pitfalls of arterial velocity interpretation, reveal further pathophysiological aspects of intensive care and be an important factor for the prediction of outcome.

[New signs for the echographic identification of the adrenal glands in children and adolescents]

Although the shape of the adrenal glands was found to vary according to the angle and position of the transducer, the most common appearance was that of a triangle, helmet or cap. This caplike appearance and the similarity in echo intensity make it difficult or even impossible to distinguish the adrenal glands from the upper pole of the kidney in many cases. By closely examining the approximate transition zone between adrenal gland and kidney, additional signs have been found that enable a better delineation of the adrenal glands. These may take the form of slight indentations ("waist form") or small, jutting edges ("step form"), seen in up to 42% of examinations. Further means of identification result from reflective interfaces at the base of the adrenal glands. These might include capsular veins or interposed fat ("vessel sign" and "reflective base"). These signs provide assistance in delineating and measuring the normal adrenal glands and make the detection of minor abnormalities possible.

[Massive fatty liver in cystic fibrosis in infancy]

Cystic fibrosis is diagnosed in an infant with dystrophy and hepatomegaly by ultrasonography, liver-biopsy and sweat-test.

[Large bladder diverticulum or double bladder--diagnosis and differential diagnosis]

We report a case of a 13 year old boy with trisomy 21 syndrome who presented with recurrent urinary tract infections. A duplication of the urinary bladder was diagnosed by echography and x-ray examination with each portion of the duplicated bladder having its own uretral opening: Surgery and histology showed however the lesion to be a large diverticulum of the urinary bladder with the right uretral orifice being located in the wall of the diverticulum.

[Sonographically determined normal values of the intracranial ventricular system in the first year of life]

In 175 Infants aged 1 day to 1 year the size of the ventricular system was measured. Standardized sections were used in coronal (approach: through the anterior fontanelle) and axial (approach: transcranial) planes. Only mature infants were taken who had no neurological signs or symptoms and who had a normal sonogram. The ventricle-hemispheric ratio (cella media width: hemispheric width) was calculated from measurements on both sides in the axial plane. Normal values are between 0.2 and 0.33. The width of the third ventricle was examined in coronal and axial sections, with mean values of 2.8 mm in the first 3 month and 3.8 mm between the 9th and 12th month of life. The fourth ventricle was examined through the anterior fontanelle and from the area of the posterior fontanelle. The latter approach resulted in the following measurements (mean values): depth 2.9 mm and 3.5 mm for the first three and the 9th to 12th month respectively. The height of the fourth ventricle was measured in the coronal plane. Mean values were 3.5 mm in the first three and 3.8 mm from the 9th to the 12th month of life.

Sonographic examination of the brain stem area in infants. An echographic and anatomic analysis

For differentiation of diseases with impaired cerebrospinal fluid circulation and pathological alterations of the midbrain an exact and reproducible sonographic visualization of the brain stem area is of paramount importance. The approach through the anterior fontanelle has proved to be insufficient to accomplish this task. Therefore, we have developed 5 standard sonographic sections enabling detailed study of the brain stem. Typical sonographic views are compared with equivalent anatomical brain sections. To date, 330 infants have been examined using this method, making evaluation of brain stem, aqueduct, fourth ventricle, basilar artery and basal cisterns possible.

Age-related incidence of pineal gland calcification in children: a roentgenological study of 1,044 skull films and a review of the literature

Anterior-posterior and lateral skull roentgenograms of 1,044 children aged 0-18 yr were examined for pineal gland calcification. Eighty children with pineal calcification were identified. Cranial computed tomograms (CCT) existing for half of the 80 cases provided confirmation. In contrast to existing reports on pineal calcification in the first decade of life, we found a significant percentage of "physiological" calcification even between 0 and 6 yr of age (range 2.9-4.2%). Contrary to current opinion we were not able to detect any signs of pineal gland tumors in these cases. We were able to confirm other reports which note a steep rise of the incidence of pineal calcification during the second decade of life.

[Radioimmunologic detection of IgE and IgG antibodies against drugs. Conclusions after experience with over 1200 patients]

Based on the radioallergosorbent test (RAST), the authors have developed a series of assays to detect IgE and IgG antibodies against a number of frequently used drugs. In this system drugs bound covalently to cellulose paper are incubated with serum and washed; the hapten-specific IgE and IgG antibodies are then qualified and quantified by means of 125I-labelled anti-human IgE and IgG respectively. Thus far the sera of 1,228 patients have been analyzed following therapy with betalactam antibiotics, co-trimoxazole, salicylates, pyrazolones, flavonoids and tetrahydroisoquinoline. The induction of IgG antibodies is a frequent occurrence and that of IgE rare. Isolated high titers of IgE are associated mainly with anaphylactic reactions; in the presence of simultaneously raised IgG titers such side reactions are often absent. Highest IgG titers were found in patients with immune hemolysis after betalactam antibiotics, flavonoids and tetrahydroisoquinoline. In the other types of side reaction specific IgG titers were not significantly higher than in patients without side reactions. The estimation of circulating antibodies against drugs cannot yet be utilized diagnostically except in the rare cases of anaphylactic side reactions. However, the method described permits specific and sensitive detection of sensitization and is suited for scientific purposes.

[Incidence of pineal calcification in the first 18 years of life]

There are sparse or contradictory data on frequency and pathological significance of pineal calcifications in childhood. This is particularly so for children younger than 6 years of age. We therefore looked for pineal gland calcifications in 1044 consecutive a.p. and lateral skull films. Pineal calcification was diagnosed, if accepted by both authors, and if the calcified spot fitted into at least 2 of 4 localisation methods. 80 patients with pineal calcifications were detected using this method. In 40 of these patients CCT confirmed the calcification. The frequency of pineal calcification was 3% in the first 12 months of life rising gradually to 7.1% in children of 10 years of age. From 10 years onwards, there is a marked increase of frequency of calcifications of the pineal gland up to 33% in the group of children of 18 years of age. In contrast to some statements in literature, pineal calcifications seem to be physiological in a limited percentage even below the age of 6 years.

[Value of lymphography, computer tomography and ultrasound in the diagnosis of infradiaphragmatic malignant lymphomas in children]

25 children with Hodgkin's disease and 6 children with Non-Hodgkin-lymphoma were reviewed in order to compare the diagnostic value of lymphography, CT and sonography. As compared with staging-laparotomy, sensitivity for the detection of lymph node involvement was 78% for lymphography, 33% for CT and 57% for the ultrasound examination. Specifity was 55%, 88%, and 83% respectively. Undetected involvement of splenic and liver hilar lymph nodes, unspecific lymphadenitis and fluid-filled bowl loops caused most of the false negative and false positive findings. In 10 children histological examination showed splenic involvement. No splenic lesion was seen by CT in 7 of these children. Splenic disease could be clearly identified by ultrasound in only one child. Although children with lymph node involvement had always splenic manifestations of malignant lymphomatous disease it is concluded that staging laparotomy is an indispensable tool in diagnosing malignant lymphoma. Lymphography should not be abandoned with children. It should be used in combination with either CT or ultrasound examination.

The region of the midbrain. Anatomy and peculiarities of its presentation in sonography

The anatomy of the midbrain region as being presented by means of sonography is analysed. The investigation is based upon sonograms of 150 newborns and infants as well as on anatomical dissections of brains of adults and children. Characteristics of sonography which are relevant for the disposition of structures are being discussed.

Detection of 4-hydroxynonenal as a product of lipid peroxidation in native Ehrlich ascites tumor cells

4-Hydroxynonenal, which is a major product of lipid peroxidation in rat liver microsomes, was detected in native Ehrlich ascites tumor cells. Its formation was stimulated either by ferrous ions or by Fe(II)-histidinate. The identification was based on chromatographic (TLC/HPLC) and ultraviolet-spectroscopic evidence using synthetic 4-hydroxynonenal as reference. Highest values of 4-hydroxynonenal concentration (about 0.1 microM in the cell suspension) after 30 min of incubation were observed with Fe(II)-histidinate as stimulant. Saturation was already reached after an incubation period of 10 min. The results confirm the expectation by Schauenstein and Esterbauer (in Submolecular Biology and Cancer, Ciba Foundation Series 67 (1979) pp. 225-244, Excerpta Medica, Amsterdam) that endogenous lipid peroxidation gives rise to a distinct intracellular level of alpha, beta-unsaturated aldehydes. A simple hypothetical mechanism for the formation of 4-hydroxynonenal from n-6-polyunsaturated fatty acids is presented.

Ultrasonic diagnosis and follow-up of malignant brain tumors in childhood. A report of 4 cases and a review of the literature

Four patients between the ages of 2 and 20 years with malignant brain tumors were given several sonographic examinations, using an operative calvarial defect or sutural diastasis as an acoustic window. Three of our cases and 86% of cases with malignant brain tumors reported in the literature are echogenic, making possible primary sonographic diagnosis of tumor recurrence and echographic monitoring of tumor therapy.

Sonographic signs of nephritis in children. A comparison of renal echography with clinical evaluation, laboratory data and biopsy

In 40 children with histologically confirmed diagnosis of nephritis 82 sonographic examinations were performed for evaluation of echographic signs of nephritis. Increased cortical renal echointensity in comparison with the normal liver and enlarged parenchymal volume proved to be the most specific and reliable signs of nephritis, particularly if both were present. Accentuated corticomedullary differentiation was too insensitive to be of additional value. Twenty-one patients had follow up examinations in the course of their nephritis. In 15 patients sonographic signs, serum creatinine and clinical classification showed parallel changes. In two cases sonographic improvement preceded clinical and laboratory normalization by several weeks, giving valuable prognostic information.

Selective promotion of ferrous ion-dependent lipid peroxidation in Ehrlich ascites tumor cells by histidine as compared with other amino acids

Among tumors in general, Ehrlich ascites tumor cells are particularly resistant to lipid peroxidation. In this study lipid peroxidation was measured in terms of the formation of malondialdehyde-equivalent material in Ehrlich tumor cells during incubation in vitro. It was shown that the high antioxidant potential of these cells could be overcome by a strong radical-promoting agent like ferrous ion. Various amino acids were tested for their capability to augment the effect of Fe(II). Histidine and its 3-methyl-derivative turned out to be the most effective pro-oxidants, whose action could be ascribed to the presence of the imidazole group. From studies with homogenized and denatured cells it was concluded that lipid peroxidation stimulated by Fe(II)-histidinate is an autoxidation process and that no carrier effect of iron by histidine is predominating. The stimulatory action of Fe(II)-histidinate could be completely suppressed by vitamin C, which was shown to be a potent anti-oxidant under the conditions used. The combined application of Fe(II)-histidinate and vitamin C may offer a means to study lipid peroxidation of Ehrlich tumor cells in a controlled manner.

[Cerebral sonography in children and adolescents with acquired skull defects]

16 patients between 20 months and 21 years of age with acquired defects of the calvarium were examined by static and real time sonography. The first cerebral sonogram of every patient was compared with his CCT scans. There was no difference between sonographic and CCT-examination results in 8 patients. Additional diagnostic information was found in two sonographic and 6 CCT examinations when compared with each other. In large defects, detailed echographic visualization of normal and pathological anatomy was possible, resulting in prompt diagnosis of tumor recurrence. If cerebral sonography is compared with CCT, there are several advantages of sonography lack of preparation: no transport of severely ill patients, no contrast application, low cost. These advantages makes cerebral echography especially suitable for close follow up of tumor therapy and patients of intensive care units.

Life history of Hanuman langurs (Presbytis entellus). Reproductive parameters, infant mortality, and troop development

Longitudinal data of reproductive parameters from two langur troops (Presbytis entellus) at Jodhpur, Rajasthan, India, are presented. Females can reach menarche at approximately 29 months of age and conceive about 5 months later. Gestation length is about 200 days, average cycling length is 24 days, and mean interbirth interval 15.3 months. Postpartum amenorrhea, which ranges from 80-140 days will be reduced to 23-80 days in cases of stillbirths or early losses of infants, a fact that bears consequences in regard to the discussion of infanticide and reproductive advantage. Troop development showed distinct differences in two neighboring troops, especially in number of surviving female infants until sexual maturity. Both troops taken together, 77.9% of the newborns reached the infant-II stage (6 months), 59.3% survived until their mother's next infant (average, calculated for the mean birth interval of 15.3 months), and only 35.9% completed the 2nd year of life.

[The importance of history-taking in the diagnosis of inflammatory-rheumatic disease: a prospective study of 100 patients (author's transl)]

In a prospective study of 100 inpatients, "history-taking diagnosis" was analysed in terms of proven probability sequence, on the basis of an extensive history-taking plan. The most likely diagnosis, as obtained by history-taking, was the same as that in the final discharge letter in 72% of cases. In only 5% did new investigations establish a diagnosis not made by history-taking. Physical examination, radiological and laboratory tests, in some cases also special investigations such as renal biopsy, proved of importance, in the first instance in establishing the diagnosis (adding to or confirming diagnostic criteria) and the choice of diagnosis (exclusion diagnosis). It is a prerequisite for a high percentage of correct diagnoses by history-taking that the examining doctor is familiar with the clinical picture of rheumatic diseases, including their epidemiology, age and sex distribution, organ involvement and pattern of joint involvement, and takes time in obtaining a good history.