[Tumor-like lesions]

Tumor-like bone lesions include various conditions of a non-neoplastic nature originating from or affecting the bone as solitary or sometimes multiple bone lesions. This review discusses the most important cystic tumor-like lesions, such as simple bone cyst, aneurysmal bone cyst, intraosseous ganglion, epidermoid cyst and subchondral cyst. MR is the most sensitive method of detection, and is the most accurate in depicting the extent of involvement of these lesions. MR signal characteristics may aid in differential diagnosis. Conventional radiographs are often more specific with respect to the underlying histopathology.

Photoshop-based image analysis of canine articular cartilage after subchondral damage

INTRODUCTION

The validity of histopathological grading is a major problem in the assessment of articular cartilage. Calculating the cumulative strength of signal intensity of different stains gives information regarding the amount of proteoglycan, glycoproteins, etc. Using this system, we examined the medium-term effect of subchondral lesions on initially healthy articular cartilage.

MATERIALS AND METHODS

After cadaver studies, an animal model was created to produce pure subchondral damage without affecting the articular cartilage in 12 beagle dogs under MRI control. Quantification of the different stains was provided using a Photoshop-based image analysis (pixel analysis) with the histogram command 6 months after subchondral trauma.

RESULTS

FLASH 3D sequences revealed intact cartilage after impact in all cases. The best detection of subchondral fractures was achieved with fat-suppressed TIRM sequences. Semiquantitative image analysis showed changes in proteoglycan and glycoprotein quantities in 9 of 12 samples that had not shown any evidence of damage during the initial examination. Correlation analysis showed a loss of the physiological distribution of proteoglycans and glycoproteins in the different zones of articular cartilage.

CONCLUSION

Currently available software programs can be applied for comparative analysis of histologic stains of hyaline cartilage. After subchondral fractures, significant changes in the cartilage itself occur after 6 months.

Effect of intestinal microfloras from vegetarians and meat eaters on the genotoxicity of 2-amino-3-methylimidazo[4,5-f]quinoline, a carcinogenic heterocyclic amine

Aim of this study was to investigate the impact of intestinal microfloras from vegetarians and non-vegetarians on the DNA-damaging activity of 2-amino-3-methyl-3H-imidazo[4,5-f]quinoline (IQ), a carcinogenic heterocyclic amine that is found in fried meats. Floras from four vegetarians (Seventh Day Adventists) and from four individuals who consumed high amounts of meats were collected and inoculated into germfree F344 rats. The rats were kept on isocaloric diets that either contained animal derived protein and fat (meat consumers group) or proteins and fat of plant origin (vegetarian groups). IQ (90 mg/kg bw) was administered orally, after 4 h the extent of DNA-damage in colon and liver cells was determined in single cell gel electrophoresis assays. In all groups, the IQ induced DNA-migration was in the liver substantially higher than in the colon. In animals harbouring floras of vegetarians, the extent of damage was in both organs significantly (69.2% in the liver, P<0.016 and 64.7%, P<0.042 in the colon, respectively) lower than in the meat consumer groups. Our findings show that diet related differences in the microfloras have a strong impact on the genotoxic effects of IQ and suggest that heterocyclic amines are less genotoxic and carcinogenic in individuals that consume mainly plant derived foods.

Differential diagnosis of benign tumors and tumor-like lesions in the spine. Own cases and review of the literature

Although benign tumors and tumor-like lesions of the spine are shown in every orthopedic teaching book, it is often surprising how little attention is paid to the differential diagnosis and diagnostic investigations, respectively, since surgical treatment and postoperative control depends on exact diagnosis. Clinically the importance of this fact can not be over-emphasized. The most common complaint is pain, either local or radicular in nature. Bone deviations are diagnosed radiologically. Different types of benign bone tumors and tumor-like lesions of the spine including osteochondroma, osteoblastoma, osteoid osteoma, aneurysmal bone cyst, eosinophilic granuloma, hemangioma, and giant cell tumor, their appearance relation to the age and location in the spine were reviewed and the common histologic subtypes described. Clinical, laboratory and histopathologic findings, radiologic inclusive MRT and scintigraphic features are evaluated. Diagnostic investigations including the invasive techniques of CT guided needle biopsy, Yamshidi needle biopsy and costotransversectomy for biopsy are shown. Treatment including radiation, chemotherapy and the surgical procedure as well as the postoperative treatment of patients with benign tumors and tumor-like lesions of the spine are discussed.

Simultaneous voiding cystourethrography and voiding urosonography

PURPOSE

To compare the diagnostic accuracy of contrast-enhanced voiding urosonography (VUS) and voiding cystourethrography (VCUG) during simultaneous performance of both examinations.

MATERIAL AND METHODS

A total of 24 children, 16 girls and 8 boys, with a mean age of 3.5 years referred for reflux examination were recruited for the study. After transurethral bladder catheterization, radiographic contrast medium, followed directly by the US contrast medium, were administered. Fluoroscopic VCUG and VUS were carried out concurrently in the same patient. When 1 kidney was scanned by ultrasound, fluoroscopy was performed on the contralateral side.

RESULTS

In 19 of the 47 kidney-ureter-units (KUU) vesicoureteral reflux (VUR) was detected. In 16 units the reflux was detected by both VCUG and VUS. In 3 KUUs the reflux was detected only at VCUG. All 3 cases were grade 1. Taking the VCUG as the reference standard, VUS had 84% sensitivity, 100% specificity, 100% and 90% positive and negative predictive values, respectively.

CONCLUSION

A dependable comparison could be achieved by performing VCUG and VUS at the same time and under the same conditions. It reconfirmed that VUS is reliable in the exclusion or verification of reflux.

MRI-diffusion imaging of neuroblastomas: first results and correlation to histology

The purpose of this study was to evaluate diffusion-weighted MR imaging in neuroblastomas. We prospectively examined seven children (age range 1-3 years) with seven solid body neuroblastomas. Diagnosis was established histologically. Diffusion-weighted echo-planar imaging (EPI) sequence was performed in all patients, with a repetition time of 5400 ms and an echo time of 103 ms, and with a b-value of 1000 s/mm(2). The contrast of tumour tissue depicted with T2-weighted images and diffusion-weighted images were evaluated by means of region-of-interest measurements and a calculation of the apparent diffusion coefficient (ADC) was done. The ADC calculation showed a mean ADC of 1.1x10(-3) (SD 0.14x10(-3), range 0.9-1.2x10(-3)) mm(2)/s of all tumours. Diffusion-weighted images showed an increased tumour signal. Water proton diffusion within the tumour matrix of neuroblastomas is especially restricted by the molecular and macromolecular barriers due to the very dense structure of this tumour tissue. We hypothesize that high nuclear-to-cytoplasm ratio of neuroblastoma cells limits intracellular motion. Furthermore, the very densely packed tumour cells inhibit effective motion of extracellular water protons. Restricted proton motion leads to a reduction in the rate of apparent diffusion and to a marked increase in signal on diffusion-weighted EPI MR images.

Genotoxic effects of ochratoxin A in human-derived hepatoma (HepG2) cells

Ochratoxin A (OTA) is a widespread mycotoxin that occurs in many commodities from grains to coffee beans all over the world. Evidence is accumulating that OTA may cause cancer in humans. The compound was tested in micronucleus (MN) and single-cell gel electrophoresis (SCGE) assays in human-derived hepatoma (HepG2) cells and caused pronounced dose-dependent effects at exposure concentrations of 5 microg/ml and greater. On the contrary, no induction of His(+) revertants was found in Salmonella microsome assays with strains TA98 and TA100 with HepG2-derived enzyme (S9) mix in liquid incubation assays under identical exposure concentrations. Taken together, our results indicate that OTA is clastogenic in the human-derived cells. These findings support the assumption that this mycotoxin may cause genotoxic effects in hepatic tissue of humans.

Protective effects of Brussels sprouts towards B[a]P-induced DNA damage: a model study with the single-cell gel electrophoresis (SCGE)/Hep G2 assay

The aim of this study was to investigate the chemoprotective effects of Brussels sprouts juice towards benzo[a]pyrene (B(a)P)-induced DNA damage in the single-cell gel electrophoresis (SCGE)/Hep G2 test system. This assay combines the advantages of the SCGE assay with that of the use of human-derived cells possessing inducible phase I and phase II enzymes. Co-treatment of Hep G2 cells with small amounts of Brussels sprouts juice (0.25-2.0 microl/ml) and B(a)P reduced the genotoxic effect of the latter in a dose-dependent manner. Contrary to the results with the crude juice, unexpected synergistic effects were observed with allyl isothiocyanate (AITC, 1.0-6.0 microM), a breakdown product of sinigrin, which is the most abundant glucosinolate in Brussels sprouts. Although these concentrations of AITC did not cause DNA damage per se, at higher concentrations (> or =25 microM), the compound caused a pronounced dose-dependent DNA damage by itself. Mechanistic studies showed that Brussels sprouts juice causes induction of activities of ethoxyresorufin O-deethylase (EROD) and glutathione S-transferase (GST) at dose levels which were protective towards B(a)P. In combined treatment experiments with (+/-)-anti-benzo[a]pyrene-7,8-dihydrodiol-9,10-epoxide (BPDE, 5.0 microM), the main genotoxic metabolite of B(a)P, and Brussels sprouts juice, only weak protection was found indicating that the mechanism of chemoprotection of Brussels sprouts is not mediated through inactivation of this metabolite. In conclusion, our findings show that Brussels sprouts are highly protective against B(a)P-induced DNA damage in human-derived cells.

Respiratory syncytial virus infection of the lower respiratory tract: radiological findings in 108 children

For years the typical appearance of respiratory syncytial virus (RSV)-induced infection of the lower respiratory tract has been discussed. All available studies have led to different results. The aim of this study was to control these results, with 108 children. The age range was 1 day to 10 years (median 7 months). Within 72 h of admission, all children developed an RSV infection of the lower respiratory tract. Chest X-rays (pa-view) of 55 children under, and 53 children over, the age of 6 months (10/53>24 months) were evaluated. The diagnosis of RSV and the chest X-ray were mostly done on the same day. The major radiological findings of the two age-groups were compared by Wilcoxon's unpaired rank sum test. Major radiological findings were: normal chest X-ray (30%), central pneumonia (32%) or peribronchitis (26%). There was no statistical significance between the age-groups. Other findings were emphysema (11%), pleural effusion (6%), lobar- or broncho-pneumonia (each 6%), atelectasis (5%) or pneumothorax in one case. Therefore, the most common radiological findings in RSV-induced infection of the lower respiratory tract, supported by our results (RSV infection without bacterial superinfection) are central pneumonia, peribronchitis or normal chest X-ray. Thus an age-group separation into under or over 6 months is no longer necessary.

["Catastrophic systemic lupus erythematosus" with Rosai-Dorfman sinus histiocytosis. Successful treatment with anti-CD20/rutuximab]

HISTORY AND ADMISSION FINDINGS

A 59-year old woman was admitted with a four-month history of polyarthritis, myalgias and photosensitivity insufficiently responsive to methotrexate, corticosteroids and azathioprin. On physical examination she presented with symmetric ankle edema, polyserositis, petechial bleeding and swelling of cervical, axillary and inguinal lymph nodes.

INVESTIGATIONS

Laboratory analysis revealed a trilinear cytopenia without signs of hemolysis. Acute phase proteins were elevated. Furthermore antinuclear antibodies, anti-phospholipid IgM antibodies, hypocomplementemia, a spurious IgGkappa paraprotein were noted. CT scans confirmed lymphadenopathy and revealed a pleural and pericardial effusion. Bone marrow biopsy showed marked hypercellularity and polyclonal plasmocytosis. Based on these findings systemic lupus erythematosus was initially suspected. However when abdominal MRI showed a retroperitoneal mass, an extensive histological workup, which also included lymph nodes and spleen, revealed numerous plasma cells and histiocytes in dilated sinuses, diagnostic of Rosai-Dorfman sinus histiocytosis.

TREATMENT AND COURSE

High dose corticosteroids, intravenous gamma-globulin and repeated courses of cyclophosphamide failed to improve the pancytopenia, as did splenectomy. The patient was given the anti-CD20 monoclonal antibody Rituximab and all signs and symptoms improved dramatically. 18 months after the last treatment, the patient is in complete clinical and hematological remission.

CONCLUSIONS

Sinus histiocytosis of Rosai/Dorfman can be associated with or mimic severe SLE. Rituximab, an anti-CD20 monoclonal antibody, may improve the antibody-mediated pathogenetic mechanism underlying both entities.

[Biometric data on risk of pneumothorax from vertical infraclavicular brachial plexus block. A magnetic resonance imaging study]

In the present study 48 sagittal and transversal magnetic resonance images of volunteers were examined for biometric data concerning risk of pneumothorax at the vertical infraclavicular blockade (VIP) of the brachial plexus. With a correct puncture the plexus can be reached after 3 cm. The shortest way to the lung is 5.3 cm (3.1-8.7 cm) at a incorrect medial angle of puncture of 46.3 degrees (35-58 degrees). While moving the angle of puncture at a minimum of 24.1 degrees (1-51 degrees) in a medial direction, a depth of 6.1 cm (4-8.9 cm) has to be reached for fatal lung puncture. The puncture point has to be determined 2.8 cm (0-4.1 cm) towards the midline of the body to have a pleura connection by a strictly vertical puncture at 6 cm (4-8.9 cm). In asthenic women, shorter distances were obtained. A considerable lower deviation can lead to pleural damage (7.5 degrees; 4.7 cm). The plexus is very close to the skin surface (1.6-3 cm). In one case, the risk for pneumothorax could be measured even with the correct puncture technique. Overall, the VIP is a very safe method for brachial plexus anaesthesia with regard to the risk of pneumothorax. In asthenic women, the risk seems to be higher but can be minimised by reducing the maximum puncture depth.

Use of a myocutaneous flap after resection of a large lymphangioma

We report on an 11-year-old girl with a large lymphangioma involving the lower third of the abdominal wall, the mons pubis, both labia majora, the perianal region and extending into the pelvic bones. Because of an increasing lymphorrhea from the cutaneous lesions resulting in considerable discomfort and skin infections, the patient sought medical advice. After lymphological check-up excluded the existence of a chylous reflux, the patient was presented at a multidisciplinary medical council. A palliative surgical treatment was recommended consisting of the resection of the most affected suprapubic region and the coverage of the resulting tissue defect with a gracilis myocutaneous flap. Postoperatively, a venous stasis at the tip of the skin paddle developed, which was relieved by the use of leeches and required secondary closure. Despite these complications, the surgical intervention yielded an acceptable cosmetic result, a diminution of lymphorrhea and hence subjectively some relief.

CONCLUSION

Due to the variability of lymphangiomas, an assessment by a multidisciplinary consultation is proposed. With respect to therapy, the use of a myocutaneous flap represents one of the therapeutic options for large cutaneous lymphangiomas.

The knee joint in early juvenile idiopathic arthritis. An ROC study for evaluating the diagnostic accuracy of contrast-enhanced MR imaging

PURPOSE

Diagnosis of juvenile idiopathic arthritis (JIA) remains difficult due to unspecific clinical and laboratory findings, especially in early stages of the disease. The purpose of our study was to determine the sensitivity and specificity of MR imaging in diagnosing JIA of the knee joints.

MATERIAL AND METHODS

Forty children (3-17 years old) clinically diagnosed with JIA (follow-up > 1 year) of a knee joint and a control group of 40 children with painful knee joints (MR diagnosis: bone bruise of the knee (n = 7), normal knee joint (n = 12), osteomyelitis (n = 6), septic arthritis (n = 2), bone tumor (n = 7) and miscellaneous bone lesions (n = 6)) were examined using a 1.5 T MR unit. T1-weighted spin-echo (SE), T2-weighted fast SE, contrast-enhanced T1-weighted SE and 2D gradient echo sequences were performed. The receiver operating characteristic (ROC) curves evaluation was conducted by 5 independent radiologists.

RESULTS

The positive criteria for diagnosing JIA were joint effusions (n = 40), contrast-enhancing synovitis (n = 39), cartilage lesions (n = 15), subchondral erosions and bony destruction (n = 1). Sensitivity and specificity were 93.5% and 92.5%, respectively. Both cases of septic arthritis were misdiagnosed as JIA by all radiologists.

CONCLUSION

Contrast-enhanced MR imaging seems to be a highly sensitive tool in establishing the diagnosis of JIA.

Differentiation of vascular birthmarks by MR imaging. An investigation of hemangiomas, venous and lymphatic malformations

PURPOSE

To evaluate the use of MR imaging using standard sequences in the differentiation of common vascular birthmarks of soft tissues in childhood.

MATERIAL AND METHODS

Forty-three lesions in 37 children (median age 33 months) with hemangiomas (n=25), venous (n=8) and lymphatic (n=10) malformations were retrospectively studied. Images were obtained with a 0.2 T and a 1.5 T MR unit, using T1-weighted spin-echo, T2-weighted turbo spin-echo and turbo STIR sequences. In addition, 19 contrast studies were evaluated. Signal intensities and morphological characteristics were analyzed.

RESULTS

All hemangiomas were hyperintense in T2-weighted, and mostly (22/25) isointense compared to the surrounding skeletal muscle in T1-weighted images. The lesions were homogeneous or mildly inhomogeneous and well defined. Venous and lymphatic malformations showed similar patterns. Contrary to other lesions, no vessels or lobular architecture were detectable and contrast enhancement was absent in lymphatic malformations.

CONCLUSION

A reliable differentiation between hemangiomas, venous and lymphatic malformations in childhood is not possible by standard MR sequences alone. Contrast media may be helpful as lymphatic malformations show no contrast enhancement. The main role of MR imaging is to determine the local extent or infiltration of deeper tissue layers and narrow the differential diagnosis of other soft tissue tumors.

CNS lipoma in patients with epidermal nevus syndrome

Epidermal nevus syndrome (ENS) is a congenital neurocutaneous disorder characterized by linear nevus with a significant involvement of the nervous, ophthalmological and skeletal systems. Clinical manifestations of ENS include neurological features such as mental retardation, seizures, and movement disorders which are caused by a wide range of neuropathological lesions. We describe three patients with ENS, all of whom had in addition to the characteristic features of ENS intracranial and/or intraspinal lipomas. In one patient the lipoma extended from the thoracal vertebra 8 to the 4th ventricle; in the second patient it was localized on T9, and in the third patient an intracranial lipoma was located at the right cerebellopontine angle. The intraspinal lipomas caused a significant spastic movement disorder. So far, CNS lipomas have not been described as typical neuropathological findings in ENS. The differential diagnosis to encephalocraniocutaneous lipomatosis with the typical finding of CNS lipoma is discussed.

Evaluation of the single cell gel electrophoresis assay with human hepatoma (Hep G2) cells

Human Hep G2 cells have retained the activities of phase I and phase II enzymes which are involved in the metabolism of environmental genotoxins. The present study describes the results of single cell gel electrophoresis (SCGE) assays with a panel of different model compounds with these cells. With genotoxic carcinogens such as aflatoxin B(1) (AFB(1)), benzo(a)pyrene (B(a)P), nitrosodimethylamine (NDMA) and cyclophosphamide (CP), statistically significant dose dependent induction of DNA migration was measured. With the two heterocyclic amines, 2-amino-3-methyl-3H-imidazo[4, 5-f]quinoline (IQ) and 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole (Trp-P-1), and also with rodent carcinogens such as safrole, hexamethylphosphoramide (HMPA) and the pyrrolizidine alkaloid isatidine, which give negative results in other in vitro genotoxicity tests, positive results were obtained in Hep G2/SCGE assays. Nitrosomethylurea (NMU) was the only directly acting compound tested in the study and was by far (ca. 10(3)-fold) more active than the corresponding nitrosamine. The exposure concentrations required to cause significant effects varied over a broad range. The most pronounced effect was seen with AFB(1) (0.008 microM) followed by HMPA (15 microM), B(a)P (25 microM), NMU (100 microM), isatidin (500 microM), CP (900 microM), IQ (1200 microM), safrol (4000 microM), and NDMA (90x10(3) microM). Numbers in parenthesis give the lowest concentrations, which caused a significant increase of DNA migration. With two compounds, namely, the non-carcinogen pyrene and the synthetic hormone tamoxifen (TF), negative results were obtained under all test conditions. These findings are in agreement with the results of recent investigations which indicated that human hepatocytes are unable to convert TF to DNA reactive metabolites, whereas it is activated by rat liver cells and causes DNA adducts in these cells. Comparisons of the present results with data from earlier experiments indicate that the Hep G2/SCGE assay enables the detection of genotoxins including compounds which give misleading results in other in vitro genotoxicity tests and appears to be an alternative to tests with primary liver cells from laboratory animals.

Ultrasound demonstration of mammographically detected microcalcifications

PURPOSE

To evaluate the capabilities of breast ultrasound (US) for identifying microcalcifications in benign breast changes, in situ carcinomas, and small nonpalpable invasive carcinomas.

MATERIAL AND METHODS

Forty-six consecutive patients with 49 clustered microcalcifications detected by mammography were included in this prospective study. Patients with palpable breast lesions were excluded. Breast US was performed with knowledge of mammographic findings for presence and visibility of microcalcifications, and for parenchymal structure abnormalities. Mammographic and US findings were compared with histology.

RESULTS

Nine ductal in situ carcinomas, 2 lobular in situ carcinomas, 11 invasive carcinomas and 27 benign lesions were confirmed by histology. For all lesions, US achieved a sensitivity of 75% in the detection of microcalcifications. The detection rate for microcalcification in invasive and in situ carcinomas was 100%. In 11 cases, no microcalcifications were visible on US; they all proved to be benign on histology.

CONCLUSION

Microcalcifications in malignant lesions are reliably recognized by US. They are, however, difficult to detect in fibrocystic breast changes.

A public domain image-analysis program for the single-cell gel-electrophoresis (comet) assay

The single-cell gel electrophoresis (or comet) assay has gained widespread acceptance as a cheap and simple genotoxicity test, but it requires a computer-assisted image-analysis system. As commercial programs are expensive and inflexible, we decided to develop an image-analysis system based on public domain programs and make it publicly available for the scientific community. Our system is based on the scientific image-processing program NIH Image, and was written in its Pascal-like macro language. User interaction was kept as simple as possible, to enable the measurement of a large number of cells with a few keystrokes. Therefore, the time for image analysis is very low, even on slow computers. The comet macro can be obtained from http://mailbox.univie.ac.at/christoph.helma++ +/comet/, NIH Image is available at http://rsb.info.nih.gov/nih-image/. Both programs are free of charge.

Appearance of autosomal recessive polycystic kidney disease in magnetic resonance imaging and RARE-MR-urography

PURPOSE

To describe the appearance of autosomal recessive polycystic kidney disease (ARPKD) on MRI and RARE-MR urography.

MATERIALS AND METHODS

Seven boys and one girl (aged 3 months to 14 years, median 2.5 years) were evaluated. Images were obtained with 0.23-T and 1.5-T MR systems using T1-weighted (T1-W) spin-echo, T2-weighted (T2-W) turbo-spin-echo and RARE-MR-urography sequences. Signal intensities, morphological appearance of the affected kidneys and, specifically, the picture of the urinary tract on RARE-MR-urography were evaluated.

RESULTS

All children showed kidney enlargement, reniform but humpy kidney shape, homogeneously grainy renal parenchyma, normal renal pelvis and normal calyces. Signal intensity was hyperintense in T2-W images in all cases. In six cases (n = 7), T1-W images were hypointense. On RARE-MR urography a hyperintense, linear radial pattern was seen in the cortex and medulla which represents the characteristic microcystic dilatation of collecting ducts in ARPKD. Three boys and the girl presented with a few circumscribed small subcapsular cysts.

CONCLUSIONS

In order to confirm the diagnosis of ARPKD, RARE-MR urography seems to be a non-invasive imaging tool that shows directly the microcystic dilated water-filled collecting ducts.

Survival and dominant transmission of "lethal" platyspondylic dwarfism of the "West coast" types

Torrance, San Diego, and Luton types ("West coast" types) of neonatal platyspondylic short-limbed dwarfism are suspected to be caused by dominant mutations that are obligatorily lethal. We report on an affected mother, who passed the disease to her daughter, confirming dominant disease transmission. Survival of the mother indicates a wider phenotypic spectrum.

Tandem mass spectrometry: a helpful tool in hair analysis for the forensic expert

The Bavarian State Bureau of Investigation in Munich has the exclusive responsibility for investigation of criminal acts. One considerable expertise is that of hair analysis. According to the legal system in Germany, there is a special interest when some clients' hair tested positive for illicit drugs. An accused with a lot of drugs in his hair will be treated as a supposed addict and will be guaranteed extenuating circumstances. The instrumentation used for hair analysis is a powerful analytical tool: a Varian 3400 gas chromatograph linked to a Finnigan Tandem-MS (TSQ 700). The methanol extraction method is used for the detection of illegal drugs and metabolites: amphetamine, methamphetamine, MDA, MDMA (ecstasy), MDE, MBDB, methadone, THC, EDDP (metabolite of methadone), cocaine, benzoylecgonine, cocaethylene, opiates (dihydrocodeine, codeine, heroin, 6-monoacetylmorphine, morphine, acetylcodeine). For the detection of 9-carboxy-THC by negative chemical ionization the hair sample is hydrolyzed under alkaline conditions. Solid-phase extraction is used for clean-up. The LOQ for the determination of 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic-acid is 0.16 pg/mg hair. An unsurpassed combination for rendering an expert opinion based on hair analysis may be: a forensic expert using diligence and experience, coupled with the performance of a sophisticated analytical instrument.

Rare-MR-urography--a new diagnostic method in autosomal recessive polycystic kidney disease

PURPOSE

To describe the appearance of autosomal recessive polycystic kidney disease (ARPKD) by using a new diagnostic method: RARE-MR-urography.

MATERIAL AND METHODS

Eight children were evaluated using MR images from 0.23 T and 1.5 T MR units, using T1-weighted spin-echo and T2-weighted turbo spin-echo sequences and RARE-MR-urography. Signal intensities, morphological appearance of the affected kidneys and, specifically, the picture of the urinary tract in RARE-MR-urography, were evaluated.

RESULTS

All children showed enlargement, reniform but humpy kidney shape, homogeneous-grainy renal parenchyma, normal renal pelvis and calyces. Although ARPKD is always associated with some degree of congenital hepatic fibrosis, there was no bile duct dilatation or liver fibrosis at the time of examination. Signal intensity was hyperintense in T2-weighted images in all cases. In 5 cases, T1-weighted images were hypointense. In RARE-MR-urography, hyperintense, linear, radial patterns in cortex and medulla were seen, which represent microcystic dilatation of collecting ducts and are therefore characteristic of ARPKD. Four patients presented with a few circumscribed small subcapsular cysts.

CONCLUSION

RARE-MR-urography is a noninvasive method which demonstrates the pathognomonic water-filled cystic structures throughout the kindeys in ARPKD.

Cystic medial degeneration of the aorta is associated with p53 accumulation, Bax upregulation, apoptotic cell death, and cell proliferation

OBJECTIVE

To address a potential role for p53, Bcl2 associated protein X (Bax), and apoptosis in the processes associated with cell turnover during cystic medial degeneration (CMD) of the aorta.

METHODS

Histochemical, immunohistochemical, biochemical, and morphometric methods were used to assess the presence and distribution of p53 immunoreactivity (p53-IR) and Bax immunoreactivity (Bax-IR), as well as the presence of apoptosis and tissue repair processes.

RESULTS

Immunohistochemical staining disclosed evidence for p53-IR in all specimens in 26.1 (11.5)% of vascular smooth muscle cells (VSMCs) (controls 0.8 (1.3)%; p < 0. 001). Bax-IR was present in all specimens in 10 (5.4)% of medial cells (controls 0.3 (0.5)%; p < 0.001). Medial VSMCs (alpha-actin positive) with cytoplasmic staining for an apoptosis specific protein (c-jun/ASP) were present in 20/20 specimens (0.7 (0.6)% of VSMCs, controls 0%, p < 0.001), whereas terminal deoxynucleotidyl transferase mediated dUTP-biotin nick end labeling (TUNEL) positive VSMCs were present in 17/20 specimens (1 (1.5)% of VSMCs, controls 0%, p < 0.001). The presence of apoptosis was confirmed by electron microscopy and the demonstration of oligonucleosomal DNA fragments after agarose gel electrophoresis. As shown by double labeling and investigation of serial sections, p53-IR, Bax-IR, c-jun/ASP-IR, and positive TUNEL labeling localised to the same compartments of the aortic media, raising a possible role for p53 and Bax in the triggering of apoptosis of VSMC during CMD. MIB1/Ki-67 positive medial VSMCs (alpha-actin positive) and mesenchymal cells (vimentin positive) were present in all specimens (2.5 (2.8)% of medial cells; controls 0.3 (0.9)%, p < 0.001) mainly in the region around the vasa vasorum, indicating that cell regeneration during CMD may originate mainly from the mesenchyme surrounding the vasa vasorum.

CONCLUSION

This study shows that the formal pathogenesis of CMD is characterised by p53 accumulation, Bax upregulation, cell death by apoptosis, and cell regeneration. Nevertheless, the precise stimuli of p53 activation and Bax upregulation as well as the role of p53 and apoptosis in the dissection process itself remain elusive.

Splenic peliosis: a rare complication following liver transplantation

In this article, we report a rare case of isolated splenic peliosis in an individual who had recently undergone liver transplantation. The disorder had remained clinically and radiologically undiagnosed until he suffered a traumatic rupture of the affected organ. The relevant literature on this topic is briefly reviewed.

Indirect MR arthrography of the unexercised glenohumeral joint in patients with rotator cuff tears

RATIONALE AND OBJECTIVES

To evaluate the diagnostic utility of indirect MR arthrography of the unexercised glenohumeral joint in patients with rotator cuff tears confirmed by arthroscopy or arthrotomy as the gold standard.

METHODS

Twenty-six patients underwent conventional MR imaging and indirect MR arthrography of the stationary glenohumeral joint using a wrap-around surface coil. Unenhanced T1-weighted spin echo/T2-weighted fast spin echo sequences and T1-weighted gradient echo sequences, adding spectral fat suppression after intravenous administration of contrast medium, were performed in the oblique coronal and oblique sagittal planes. Images were analyzed by three experienced radiologists in consensus. Levels of diagnostic confidence were evaluated using a four-point scale of diagnostic certainty.

RESULTS

Performing indirect MR arthrography of the unexercised shoulder leads to a diagnostically efficient enhancement of joint fluid (120% at 4 minutes and 145% at 8 minutes after intravenous injection of gadodiamide). In terms of soft tissue delineation, characterization of rotator cuff tears was significantly improved by using enhanced fat-suppressed T1-weighted gradient echo sequences compared with conventional MR imaging.

CONCLUSIONS

Indirect MR arthrography without glenohumeral joint exercise in the diagnosis of rotator cuff tears is feasible and represents a more convenient and less time-consuming alternative to indirect MR arthrography after joint exercise.

Single-cell gel electrophoresis assays with human-derived hepatoma (Hep G2) cells

The purpose of the present study was the development of a protocol for detecting chemically-induced DNA damage, using the alkaline single-cell gel electrophoresis (SCGE) assay with human-derived, metabolically competent hepatoma (Hep G2) cells. Previous studies indicated that Hep G2 cells have retained the activities of certain phase I and phase II enzymes and reflect the metabolism of genotoxins in mammals better than other in vitro models which require addition of exogenous activation mixtures. The optimal trypsin concentration for the removal of the cells from the plates were found to be 0.1%. Dimethylsulfoxide, at concentrations up to 2%, was an appropriate solvent for water-insoluble compounds. To determine the optimal exposure periods for mutagen treatment, the time kinetics of comet formation was investigated with genotoxic chemicals representing various classes of promutagens namely benzo[a]pyrene (B[a]P), 2-amino-3-methylimidazo[4,5-f]quinoline (IQ), and N-nitrosodimethylamine (NDMA) and with N-nitrosomethylurea (NMU). All compounds caused a statistically significant induction in DNA damage. With the promutagens, comet formation increased gradually as a function of the exposure duration, and reached maximum values between 20-24 h. With NMU, comet induction maximized already after a short exposure (1 h) and remained at a constant level for up to 24 h. Based on these results, the Hep G2/SCGE assay appears to be a suitable approach for investigating DNA damaging potential of chemicals. Further experiments with IQ and B[a]P showed that the assays are highly reproducible. Comparisons of the present results with those from earlier experiments in which other endpoints (induction of sister chromatid exchanges, micronuclei and chromosomal aberrations) were measured in Hep G2 cells, indicated that the sensitivity of the SCGE assays is more or less identical. Since the SCGE assay is less time consuming than other genotoxicity assays we anticipate that it might be a suitable approach to investigate DNA damaging effects of chemicals in the human-derived, metabolically competent cell line.

[Kinematic versus static MRI study of the cervical spine in patients with rheumatoid arthritis]

PURPOSE

The objective of this study was to compare the diagnostic value of cinematic magnetic resonance imaging with static MRI examinations in patients with rheumatoid arthritis and concomitant attack of the cervical spine.

METHODS

Dynamic functional MRI examinations of the cervical spine were performed one five subjects without complaints and 20 patients with rheumatoid arthritis. For the functional studies, a positioning frame was used that allowed infinitely variable forward and backward inclinations of the head.

RESULTS

Functional magnetic resonance imaging made possible a sufficiently good differentiation of the extension of pannus tissue cranial, ventral, and dorsal of the dens with possible displacing and impinging effects on the spinal cord during flexing and stretching movements. In addition, it is suitable for demonstration of the degree of instability in the atlanto-occipital and atlanto-axial planes. In contrast to conventional X-rays, CT, and static MRI, basilary impression as well as compressions and angulations of the cervical bone marrow are better visualized by cinematic magnetic resonance tomography.

CONCLUSIONS

Functional magnetic resonance tomography is an important diagnostic method for the induction of the cervical spine in patients with rheumatoid arthritis. In particular, fusion and instabilities as well as compressions of the bone marrow often can only be detected with the help of functional MRI.

Cartilage destruction in small joints by rheumatoid arthritis: assessment of fat-suppressed three-dimensional gradient-echo MR pulse sequences in vitro

PURPOSE

To assess the accuracy of different MR sequences for the detection of articular cartilage abnormalities in rheumatoid arthritis.

DESIGN AND PATIENTS

Ten metacarpophalangeal joints and 10 metatarsophalangeal joints (specimens from arthritis patients undergoing ablative joint surgery) were examined with a fat-suppressed (FS) 3D FLASH, a FS 3D FISP, a FS 2D fast spin-echo T2-weighted, and a 2D FS spin-echo T1-weighted sequence. Each cartilage lesion and each cortical lesion was graded from 0 to 4 (modified Outerbridge staging system). Subsequently, the results of each sequence were compared with the macroscopic findings and statistically tested against each other.

RESULTS

The study shows that 3D gradient-echo sequences with fat suppression were best for imaging and grading of cartilage lesions in arthritis of the small joints of the hands and feet. Using 3D techniques, all grade 2, grade 3, and grade 4 lesions of cartilage or cortical bone were detected.

CONCLUSION

FS 3D gradient-echo techniques were best for the detection and grading of hyaline cartilage and subchondral bone lesions in rheumatoid arthritis. MRI has a great potential as an objective method of evaluating cartilage damage and bone erosions in rheumatoid arthritis.

Comparison of turbo inversion recovery magnitude (TIRM) with T2-weighted turbo spin-echo and T1-weighted spin-echo MR imaging in the early diagnosis of acute osteomyelitis in children

OBJECTIVE

To compare turbo inversion recovery magnitude (TIRM) with standard T1-weighted (T1-W) and T2-weighted (T2-W) MR sequences in the very early detection of acute osteomyelitis in children.

MATERIALS AND METHODS

In 15 children with osteomyelitis, 15 sets of T1-W spin-echo (SE) (TR/TE, 400-640/12-17), T2-W turbo spin-echo (TSE) (TR/TE/ETL, 3290-4465/112-120/11), and TIRM (TR/TE/TI, 4000-6120/60/160) images were acquired with a 1.0-T magnet. Contrast-to-noise (C/N) ratios and percentage of signal between lesion and normal bone marrow were analysed with a computer-assisted image analysing system in a region of interest (ROI).

RESULTS

In 13 of 15 patients, the absolute signal enhancement in a ROI on the TIRM images was better than on the T1-W SE and T2-W TSE images and in 14 of 15 cases, C/N ratios were also better on the TIRM images than on the other sequences. In the other cases, the TIRM signal was diagnostically equivalent. On the TIRM images, the signal difference between normal and pathological tissue was increased to 43-281% (mean 124%). On the T2-W TSE images, this signal difference was 4-79% (mean 36%) and on the T1-W SE images 6-77% (mean 37%). Conclusion. The TIRM sequence is highly sensitive for detecting bone marrow oedema in the very early stage of acute osteomyelitis in children. MRI utilising the TIRM sequence allowed for an early diagnosis. With scan time of less than 4 minutes, this sequence is superior to T1-W SE and T2-W TSE images for detecting early osteomyelitis-associated bone marrow oedema.

Human articular cartilage: in vitro correlation of MRI and histologic findings

The aim of our study was to correlate MRI with histologic findings in normal and degenerative cartilage. Twenty-two human knees derived from patients undergoing amputation were examined with 1.0- and 1. 5-T MR imaging units. Firstly, we optimized two fat-suppressed 3D gradient-echo sequences. In this pilot study two knees were examined with fast imaging with steady precession (FISP) sequences and fast low-angle shot (FLASH, SPGR) sequence by varying the flip angles (40, 60, 90 degrees) and combining each flip angle with different echo time (7, 10 or 11, 20 ms). We chose the sequences with the best visual contrast between the cartilage layers and the best measured contrast-to-noise ratio between cartilage and bone marrow. Therefore, we used a 3D FLASH fat-saturated sequence (TR/TE/flip angle = 50/11 ms/40 degrees) and a 3D FISP fat-saturated sequence (TR/TE/flip angle = 40/10 ms/40 degrees) for cartilage imaging in 22 human knees. The images were obtained at various angles of the patellar cartilage in relation to the main magnetic field (0, 55, 90 degrees). The MR appearances were classified into five categories: normal, intracartilaginous signal changes, diffuse thinning (cartilage thickness < 3 mm), superficial erosions, and cartilage ulcers. After imaging, the knees were examined macroscopically and photographed. In addition, we performed histologic studies using light microscopy with several different stainings, polarization, and dark field microscopy as well as electron microscopy. The structural characteristics with the cartilage lesions were correlated with the MR findings. We identified a hyperintense superficial zone in the MR image which did not correlate to the histologically identifiable superficial zone. The second lamina was hypointense on MRI and correlated to the bulk of the radial zone. The third (or deep) cartilage lamina in the MR image seemed to represent the combination of the lowest portion of the radial zone and the calcified cartilage. The width of the hypointense second zone correlated weakly to the accumulation of proteoglycans in the radial zone. The trilaminar MRI appearance of the cartilage was only visible when the cartilage was thicker than 2 mm. In cartilage degeneration, we found either a diffuse thinning of all layers or circumscribed lesions ("cartilage ulcer") of these cartilage layers in the MR images. Early cartilage degeneration was indicated by a signal loss in the superficial zone, correlating to the histologically proven damage of proteoglycans in the transitional and radial zone along with destruction of the superficial zone. We found a strong effect of cartilage rotation in the main magnetic field, too. A rotation of the cartilage structures caused considerable variation in the signal intensity of the second lamina. Cartilage segments in a 55 degreesangle to the magnetic main field had a homogeneous appearance, not a trilaminar appearance. The signal behavior of hyaline articular cartilage does not reflect the laminar histologic structure. Osteoarthrosis and cartilage degeneration are visible on MR images as intracartilaginous signal changes, superficial erosions, diffuse cartilage thinning, and cartilage ulceration.

Functional MR imaging of the cervical spine in patients with rheumatoid arthritis

PURPOSE

To evaluate functional MR imaging in patients with rheumatoid arthritis (RA) involving the cervical spine.

MATERIAL AND METHODS

We used a device that allows MR examination to be made of the cervical spine in infinitely variable degrees of flexion and extension. Dynamic functional MR imaging was performed on 25 patients with RA.

RESULTS

Functional MR imaging was able to show the degree of vertebral instability of the occipito-atlantal or atlanto-axial level as well as the subaxial level. By performing functional MR imaging, we were able to demonstrate the extent of synovial tissue around the dens, and the impingement and displacement of the spinal cord during flexion and extension. The basilar impression, the cord impingement into the foramen magnum, the cord compression, the slipping of vertebrae, and the angulation of the cord were all much more evident in functional than in static MR imaging.

CONCLUSION

Functional MR imaging provided additional information in patients with RA, and is valuable in patients who have a normal MR study in the neutral position and yet have signs of a neurological deficit. Functional MR imaging is important in the planning of stabilizing operations of the cervical spine.

Successful treatment of gastrointestinal vasculitis due to systemic lupus erythematosus with intravenous pulse cyclophosphamide: a clinical case report and review of the literature

Gastrointestinal vasculitis in systemic lupus erythematosus (SLE) is quite rare and almost always accompanied by evidence of active disease in other organs, although occasionally it may be the presenting feature of the disease. Gastrointestinal involvement in SLE may present as lupus peritonitis, non-necrotizing pancreatitis, gastrointestinal vasculitis or surgical abdomen. Here we report a severe case of SLE which presented initially with fever of unknown origin. Severe distress, abdominal pain, the presence of occult blood in the stool and high acute-phase proteins were explained by a lupus peritonitis and intestinal vasculitis resembling inflammatory bowel disease. Whereas high-dose prednisone treatment did not prevent a severe relapse, we observed a sustained remission following i.v. cyclophosphamide pulse therapy. In the literature, only two similar cases are reported: one died despite a change in the therapy of a bowel perforation; our case was the second that improved under pulse cyclophosphamide. We suggest the use of cyclophosphamide after failure of steroids early in the course of SLE gastrointestinal vasculitis to prevent devastating complications.

MR findings in pontocerebellar hypoplasia

We present four cases with combined hypoplasia of the cerebellum and the ventral pons-pontocerebellar hypoplasia (PCH). PCH represents an autosomal recessive neurodegenerative disorder with fetal onset. The disease is rare, with less than 20 cases having been reported. The main findings of PCH and the inclusion criteria for our cases can be summarised as progressive microcephaly from birth, pontocerebellar hypoplasia documented by MRI and marked chorea, which may change, later in childhood, to more dystonic patterns. The cerebral cortex becomes progressively atrophic. Motor and mental development are delayed, and epilepsy, mainly tonic-clonic seizures, is frequent. The MRI features in all of our cases were: (1) Hypoplastic cerebellum situated close to the tentorium. The hypoplastic cerebellum has a reduced number of folia, in contrast to the normal number of thin folia in simple cerebellar atrophy. (2) The cerebellar hemispheres are reduced to bean-like or wing-like structures. The cerebellar hemispheres appear to 'float' in the posterior fossa. (3) Markedly hypoplastic ventral pons. (4) Slight atrophy of the supratentorial gyral pattern. (5) Dilated cerebromedullary cistern and fourth ventricle. (6) Delayed myelination of the white matter. (7) No significant disorganisation of brain architecture and no severe corpus callosum defect.

Magnetic resonance diagnosis of the anterior labrum and capsule. Effect of field strength on efficacy

RATIONALE AND OBJECTIVES

The authors compare the performance of high-field and low-field magnetic resonance (MR) systems in the evaluation of shoulder instability, 35 patients were examined at field strengths of 1.0 T and of 0.2 T.

METHODS

Surface coils were used in both systems. Because arthroscopy was used as gold standard, a preselected patient-population was obtained for the study.

RESULTS

The sensitivity/specificity/accuracy of MR images acquired at 1.0 T for labrum pathology were 91%/67%/91% and 70%/80%/71% for the capsular complex. Compared with the above, the sensitivity/specificity/accuracy for 0.2 T MR images revealed 91%/67%/91% for the labrum pathology and 63%/80%/66% for the capsular complex respectively. In the evaluation of capsular lesions a comparison between the 0.2 T MR system and the 1.0 T system indicated a higher sensitivity and accuracy for the high-field images. Concerning labral lesions, the sensitivity and accuracy of the 0.2 T MR imager and the 1.0 T imager were comparable.

CONCLUSIONS

Given differences in imaging protocols, imaging at 0.2 T does not adversely affect the assessment of shoulder instability when compared with imaging at 1.0 T. These preliminary results warrant more extensive clinical comparison of results obtained at different magnetic field strengths.

Use of metabolically competent human hepatoma cells for the detection of mutagens and antimutagens

The human hepatoma line (Hep G2) has retained the activities of various phase I and phase II enzymes which play a crucial role in the activation/detoxification of genotoxic procarcinogens and reflect the metabolism of such compounds in vivo better than experimental models with metabolically incompetent cells and exogenous activation mixtures. In the last years, methodologies have been developed which enable the detection of genotoxic effects in Hep G2 cells. Appropriate endpoints are the induction of 6-TGr mutants, of micronuclei and of comets (single cell gel electrophoresis assay). It has been demonstrated that various classes of environmental carcinogens such as nitrosamines, aflatoxins, aromatic and heterocyclic amines and polycyclic aromatic hydrocarbons can be detected in genotoxicity assays with Hep G2 cells. Furthermore, it has been shown that these assays can distinguish between structurally related carcinogens and non-carcinogens, and positive results have been obtained with rodent carcinogens (such as safrole and hexamethylphosphoramide) which give false negative results in conventional in vitro assays with rat liver homogenates. Hep G2 cells have also been used in antimutagenicity studies and can identify mechanisms not detected in conventional in vitro systems such as induction of detoxifying enzymes, inactivation of endogenously formed DNA-reactive metabolites and intracellular inhibition of activating enzymes.

Diagnosis of idiopathic myositis: value of 99mtechnetium pyrophosphate muscle scintigraphy and magnetic resonance imaging in targeted muscle biopsy

Our objective was to study the value of 99mtechnetium-pyrophosphate (99mTc-PYP) muscle scintigraphy and magnetic resonance imaging (MRI) in detecting areas of likely muscle inflammation and in increasing the rate of positive muscle biopsies in patients with suspected myositis. The results showed that in 13 out of 13 patients with clinical and/or signs of inflammatory muscle disease, increased 99mTc-PYP uptake was demonstrated at different muscle sites 3 h after isotope injection. Subsequent MRI of symmetric muscle areas with enhanced 99mTc-PYP uptake revealed signal patterns suggesting inflammation in all cases. Biopsy of these targeted muscles demonstrated characteristic histopathologic signs of muscle inflammation in 9 out of 13 patients. Four of these 9 patients had clinically atypical disease or did not show elevated creatine phosphokinase levels. Seven of these 9 patients had not been pretreated with corticosteroids. In 4 patients only muscle fiber atrophy and/or necrosis without cellular infiltrations was seen. These 4 patients had received either high doses of corticosteroids or low doses over longer periods of time before muscle biopsy. In conclusion, the combination of 99mTc-PYP muscle scintigraphy and MRI demonstrated muscle areas with maximum inflammatory signal patterns. Targeting of muscles by MRI only will probably yield reliable results of muscle biopsy in cases of clinically and serologically characteristic myositis. 99mTc-PYP muscle scintigraphy may provide useful initial information about localization of inflamed muscle tissue, especially in atypical disease. Treatment with corticosteroids prior to histologic diagnosis may abolish inflammatory infiltrations in affected muscle tissue.

A mild form of Proteus syndrome

Proteus syndrome is a rare congenital hamartomatous syndrome. We report on the clinical and radiological appearances of a boy in order to illustrate the typical signs which include subcutaneous masses, in mild forms partial gigantism of hands and feet, hemihypertrophy, and bony abnormalities. We discuss how to make the definitive diagnosis on the basis of using a known rating scale, important aspects of differential diagnosis and clinical features, and diagnostic management.