[Large left ventricular aneurysm after silent myocardial infarction. Documentation by serial non-invasive imaging]

HISTORY AND CLINICAL FINDINGS

A 60-year-old man had a workup for atypical angina. Noninvasive investigations, including computed tomography, showed no evidence for coronary artery disease. A few months later the patient was hospitalized because of severe epileptic seizures. Thyrotoxicosis was diagnosed and emergency thyroidectomy was performed. Two months after discharge the patient was again referred because of exercise-induced angina pectoris.

INVESTIGATIONS AND DIAGNOSIS

Echocardiography and cardiac magnetic resonance imaging (MRI) showed a large aneurysm of the lateral wall of the left ventricle with a thrombus adhering to the wall. Coronary angiography and levocardiography confirmed the aneurysm and detected an occlusion of the distal part of the circumflex artery.

TREATMENT AND COURSE

Surgical aneurysm resection with thrombectomy and endoventricular circular plasty (Dor procedure) was performed without postoperative complications. Six months after surgery the patient was in good general condition without any angina. Follow-up echocardiography as well as cardiac MRI gave proof of an excellent postoperative result.

CONCLUSIONS

Noninvasive preoperative diagnosis and documentation as well as postoperative monitoring with modern imaging modalities, such as echocardiography and MRI are of great value in patients with left ventricular aneurysm.

Klassische Geflügelpest H5N1

Die aktuell durch das hochpathogene aviäre Influenzavirus vom Subtyp H5N1 Asia“ (HPAIV H5N1) verursachte Klassische Geflügelpest bedroht seit 1997 zunehmend Geflügelbestände weltweit. Aufgrund seines zoonotischen Potentials gefährdet dieser Erreger bei direkter, massiver Exposition auch den Menschen sowie empfängliche Haussäugetiere (Katzen). Der Nachweis des Virus in Wildvogelpopulationen, drei streunenden Hauskatzen sowie in einzelnen Hausgeflügelbeständen (Huhn, Pute, Pekingenten) in Deutschland seit 2006 hat einen nachhaltigen Eindruck von der Problematik und Brisanz solcher Ausbruchsszenarien vermittelt. Infektionen des Menschen wurden bislang in Europa nicht beobachtet. Der Artikel fasst das HPAIV-H5N1-Seuchengeschehen der Jahre 2006–2007 unter besonderer Berücksichtigung der Situation in Deutschland in einer Übersicht zusammen.

[High-resolution MRI for the quantitative evaluation of subendocardial and subepicardial perfusion under pharmacological stress and at rest]

PURPOSE

MR stress perfusion imaging of the heart allows the quantification of myocardial perfusion and the evaluation of myocardial perfusion reserve (MPR) and the ratio of subendocardial to subepicardial perfusion at rest and under adenosine stress. The aim of this study was to evaluate a high-resolution GRAPPA sequence for quantitative MR first pass perfusion imaging in healthy volunteers.

MATERIALS AND METHODS

First pass stress and rest perfusion studies were performed on 10 healthy volunteers using a 1.5 T MR scanner with a multislice SR-TrueFISP first pass perfusion sequence with a GRAPPA algorithm (acceleration factor 3) in prebolus technique and an image resolution of 1.8 x 1.8 mm. For the comparison group, we examined 12 different healthy volunteers with a standard first pass perfusion SR-TrueFISP sequence using a resolution of 2.7 x 3.3 mm. Myocardial contours were manually delineated followed by an automatic division of the myocardium into two rings with an equal thickness for the subendo- and subepicardial layer. Eight sectors per slice were evaluated using contamination and baseline correction.

RESULTS

Using the GRAPPA sequence, the ratio of subendo- to subepimyocardial perfusion was 1.18 +/- 0.32 for the examination at rest. Under pharmacologically induced stress, the ratio was 1.08 +/- 0.27. For the standard sequence the ratio was 1.15 +/- 0.28 at rest and 1.11 +/- 0.33 under stress. For the high resolution sequence higher mean values for the subendo- to subepimyocardial ratio were obtained with comparable standard deviations. The difference between the sequences was not significant.

CONCLUSION

The evaluation of subendomyocardial and subepimyocardial perfusion is feasible with a high-resolution first pass perfusion sequence. The use of a higher resolution to avoid systematic error leads to increased image noise. However, no relevant reduction in the quantitative perfusion values under stress and at rest was able to be depicted.

Long-term experience with integral photodynamic therapy of TIS bladder carcinoma

Fifteen patients in whom superficial bladder tumours (TIS GII-III) recurred after the unsuccessful application of other treatments were treated by photodynamic therapy (PDT) and observed for 24-54 months. The results of therapy were evaluated by regular three-monthly check-ups (endoscopy, cytology, bladder mapping, renal ultrasonography) as well as by computed tomography (CT) examination at 8- to 13-month intervals. In nine patients treated by PDT no tumour recurrence has been found over the whole observation period. Two patients have remained free of tumour (12 and 14 months) after repeated transurethral resection (TUR) and Nd-YAG laser therapy after PDT. Two patients required a second application of PDT before the treatment goal was achieved. In one of these cases a circumscribed dysplasia which appeared at the left ostium 26 months after PDT was treated by TUR and Nd-YAG laser. Further observations showed it had been successfully removed. In six patients slight mucosal atypia persisted for at least 2.5 years. In the short-term course of further cases (n = 12) one cystectomy has to be performed because of bladder shrinkage. According to these preliminary results, PDT (with strict patient selection--worst-case situation with recommended cystectomy) is justified for recurrent superficial TIS bladder carcinoma.

MR-Bildgebung und MR-Spektroskopie zur Charakterisierung von Kardiomyopathien bei Jugendlichen - erste Ergebnisse

PURPOSE

Cardiomyopathy is a rare but life-threatening disease in children and adolescents. Recent studies reported morphological, functional or metabolic alterations of the heart. We discuss a combined MR imaging and (31)P MR spectroscopy (MRS) protocol allowing the analysis of interdependencies between these parameters. Since normal values of cardiac MR parameters in this age group are not available, we included studies of age-matched healthy adolescents.

MATERIALS AND METHODS

2D-CINE was used to assess left ventricular (LV) parameters. Additional 3D-Chemical Shift Imaging (3D-CSI) and Spectral Localization with Optimal Pointspread Function (SLOOP) reconstruction allowed quantification of the cardiac energy metabolism. Patients (n = 4; all male; age 16.8 +/- 2.9 years) were included on the basis of an echocardiographic diagnosis of possible cardiomyopathy. The same protocol was applied to healthy young volunteers (n = 4; 1 female, 3 male; age 15.5 +/- 0.6 years).

RESULTS

The patients had a significantly higher LV mass index compared to the control group (147 +/- 41 g/m (2) versus 97 +/- 16 g/m2; p = 0.04). The other LV parameters (including LV EF with 59 +/- 22 % versus 67 +/- 10 %) showed no significant differences. The phosphocreatine to adenosine triphosphate ratio (PCr/ATP-ratio) of the patients was reduced to 1.71 +/- 0.40 versus 2.44 +/- 0.30 (p = 0.01), combined with a tendency towards decreased PCr concentrations of 9.1 +/- 2.5 versus 7.9 +/- 1.0 mmol/kg.

CONCLUSION

The combination of (31)P MR spectroscopy and MR imaging allows quantitative determination of morphologic, functional and metabolic alterations in adolescents with suspected cardiomyopathy in one examination procedure. The reduction of energy metabolism combined with unaltered global function may indicate a primary role of metabolism in the pathogenesis of cardiomyopathies in adolescents.

Bestimmung des koronaren Kalzium-Scores mittels 64-Zeilen-CT - Variabilität der Scores und Einfluss des Rekonstruktionszeitpunktes

PURPOSE

To evaluate the variability of coronary calcium scores depending on the image reconstruction interval using a 64-slice CT scanner.

MATERIALS AND METHODS

30 patients (18 male, 12 female; mean age 57 +/- 9 yrs; mean heart rate 66 +/- 10 bpm) underwent coronary calcium scoring using a 64-slice CT scanner (Somatom Sensation 64, Siemens Medical Solutions, Erlangen) and a standardized scanning protocol. Oral beta-blockers were administered to 12 patients with a baseline heart rate > 70 bpm. Images were reconstructed in 10 % increments from 10 - 100 % of the RR interval. Two blinded experienced observers independently calculated Agatston (AS), calcium mass (MS) and volume scores (VS) for every reconstructed image series. The results were compared to similar studies for 16-slice CT scanners.

RESULTS

The mean values and mean coefficients of variation among all patients were as follows: AS, 397 +/- 829, 109 % MS, 88 +/- 225, 154 % VS, 335 +/- 669, 100 %. Regarding the reconstruction intervals, the mean coefficients of variation were as follows: 107 % (AS), 97 % (VS), 116 % (MS). No specific image reconstruction interval with statistically significant lower variability for each score could be identified. High inter-observer agreement was achieved (K = 0.98). With statistical significance (p < 0.05) 10/30 patients (pts) were able to be allocated to more than one risk group (RG): 6 pts = 2 RG; 3 pts = 3 RG; 1 pts = 4 RG. The scores for 5/30 patients were zero for at least one reconstruction interval, but further reconstructions revealed calcifications. The number of patients assignable to different risk groups was significantly lower compared to published data using a 16-slice scanner (p < 0.05).

CONCLUSION

Coronary calcium scores determined using a 64-slice scanner display a wide range of variability depending on the image reconstruction interval as already described for 16-slice CT scanners. However, compared to previous studies, our data indicate that this vendor's generation of scanners reduces the influence of score variations on the risk stratification.

Evaluation of the optimal image reconstruction interval for coronary artery imaging using 64-slice computed tomography

BACKGROUND

Cardiac computed tomography (CT) has become an established complement in cardiac imaging. Thus, optimized image quality is diagnostically crucial.

PURPOSE

To prospectively evaluate whether, by using 64-slice CT, a specific reconstruction interval can be identified providing best image quality for all coronary artery segments and each individual coronary artery.

MATERIAL AND METHODS

311 coronary segments of 14 men and seven women were analyzed using 64-slice CT. Data reconstruction was performed in 5% increments from 5-100% of the R-R interval. Four experienced observers independently evaluated image quality of the coronary arteries according to the AHA classification. A three-point ranking scale was applied: 1, very poor, no evaluation possible; 2, diagnostically sufficient quality; 3, highest image quality, no artifacts.

RESULTS

The best reconstruction point for all segments was found to be 65% of the R-R interval (mean value 2.4+/-0.5; P<0.05). On a per-artery basis, best image quality was again achieved at 65% of the R-R interval: RCA 2.2+/-0.4, LCA 2.4+/-0.5, LM 2.5+/-0.2, LAD 2.3+/-0.4, LCX 2.3+/-0.5.

CONCLUSION

By using 64-slice CT, the need for adjusting the reconstruction point to each coronary segment might be overcome. Best image quality was achieved with image reconstruction at 65% of the R-R interval for all coronary segments as well as each coronary artery.

Pathology of natural infections by H5N1 highly pathogenic avian influenza virus in mute (Cygnus olor) and whooper (Cygnus cygnus) swans

Mortality in wild aquatic birds due to infection with highly pathogenic avian influenza viruses (HPAIV) is a rare event. During the recent outbreak of highly pathogenic avian influenza in Germany, mortality due to H5N1 HPAIV was observed among mute and whooper swans as part of a rapid spread of this virus. In contrast to earlier reports, swans appeared to be highly susceptible and represented the mainly affected species. We report gross and histopathology and distribution of influenza virus antigen in mute and whooper swans that died after natural infection with H5N1 HPAIV. At necropsy, the most reliable lesions were multifocal hemorrhagic necrosis in the pancreas, pulmonary congestion and edema, and subepicardial hemorrhages. Major histologic lesions were acute pancreatic necrosis, multifocal necrotizing hepatitis, and lymphoplasmacytic encephalitis with neuronal necrosis. Adrenals displayed consistently scattered cortical and medullary necrosis. In spleen and Peyer's patches, mild lymphocyte necrosis was present. Immunohistochemical demonstration of HPAIV nucleoprotein in pancreas, adrenals, liver, and brain was strongly consistent with histologic lesions. In the brain, a large number of neurons and glial cells, especially Purkinje cells, showed immunostaining. Occasionally, ependymal cells of the spinal cord were also positive. In the lungs, influenza virus antigen was identified in a few endothelial cells but not within pneumocytes. The infection of the central nervous system supports the view that the neurotropism of H5N1 HPAIV leads to nervous disturbances with loss of orientation. More investigations are necessary to clarify the mechanisms of the final circulatory failure, lung edema, and rapid death of the swans.

A universal heterologous internal control system for duplex real-time RT-PCR assays used in a detection system for pestiviruses

A heterologous in vitro transcript based on a specific primer-probe HEX system was generated as a universal internal control (IC) to improve virus-specific real-time reverse-transcriptase PCR (RT-PCR) assays. By using a set of different primers, several PCR fragments of desired sizes of an in vitro transcript of the enhanced green fluorescent protein (EGFP) gene were generated, and the fragments were detected using a HEX-labelled probe. For long-term storage of the in vitro transcript a special RNA-safe buffer (RSB) was developed. Freezing and thawing of the IC diluted in RSB did not result in any substantial loss of detectable IC copy numbers. The new IC system was used for the first time in a duplex real-time RT-PCR assay for the detection of pestivirus-derived RNA, in particular from bovine viral diarrhea virus (BVDV). Primers and TaqMan probes for the 'panpesti' assay were selected by analysing the consensus sequence of the 5' non-translated region (5' NTR) of more than 600 different pestiviruses. Finally, the optimised primer probe combination showed an analytical sensitivity of less than 10 copies/reaction. In the duplex set-up, the analytical sensitivity of the validated real-time RT-PCR was identical to the sensitivity of the single assay without IC, and the diagnostic sensitivity of the duplex assay was equal or higher if compared to virus isolation.

Diagnostic Evaluation of a Real-Time RT-PCR assay for Routine Diagnosis of Classical Swine Fever in Wild Boar

The aim of the study was to evaluate a real-time reverse transcription-polymerase chain reaction (RT-PCR) assay for routine diagnosis of classical swine fever (CSF) in wild boar by using 1000 spleen homogenates that were tested previously negative by virus isolation and 26 homogenates from which CSF virus could be isolated. All 26 positive samples in the virus isolation assay also were found to be positive in real-time RT-PCR. Additionally further 10 samples were detected by real-time RT-PCR out of the 1000 negative samples in the virus isolation. With a commercial CSF antigen-ELISA only 14 out of the 36 real-time RT-PCR positive samples could be detected. The sequence analysis of all ten samples that tested positive by real-time RT-PCR and negative by virus isolation revealed CSF virus-specific sequences. Based on the assumption that all samples with a CSF virus-specific sequence or positive in the virus isolation test originated from truly CSF virus-infected wild boar, the following sensitivity values were calculated as antigen-ELISA, 39%; virus isolation, 72% and real-time RT-PCR, 100%. The use of real-time RT-PCR instead of antigen-ELISA and virus isolation as a routine tool for control and eradication of CSF in wild boar populations is recommended.

Effective NSAID treatment indicates that hyperprostaglandinism is affecting the clinical severity of childhood hypophosphatasia

Background

Hypophosphatasia (HP) is an inborn error of bone metabolism characterized by a genetic defect in the gene encoding the tissue-nonspecific alkaline phosphatase (TNSALP). There is a lack of knowledge as to how the variability and clinical severity of the HP phenotype (especially pain and walking impairment) are related to metabolic disturbances or impairments, subsequent to the molecular defect.

Methods

We analyzed the changes in clinical symptoms and the prostaglandin (PG) metabolism in response to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) in six children affected by childhood HP. In addition, by exposing HP fibroblasts to pyridoxal phosphate and/or calcium pyrophosphate in vitro, we analyzed whether the alterations in PG levels are sequelae related to the metabolic defect.

Results

Childhood HP patients, who often complain about pain in the lower limbs without evident fractures, have systemic hyperprostaglandinism. Symptomatic anti-inflammatory treatment with NSAIDs significantly improved pain-associated physical impairment. Calcium pyrophosphate, but not pyridoxal phosphate, induced cyclooxygenase-2 (COX-2) gene expression and PG production in HP and normal fibroblasts in vitro.

Conclusion

Clinical features of childhood HP related to pain in the lower legs may be, at least in part, sequelae related to elevated PG levels, secondary to the primary metabolic defect. Consequently, NSAID treatment does improve the clinical features of childhood HP.

A versatile flow cytometry-based immunofluorescence inhibition assay for the detection of bovine viral diarrhea virus-specific antibodies

A fast, sensitive and reliable flow cytometry-based (FACS = fluorescence activated cell sorting) immunofluorescence inhibition assay (FACS-IFI) for the detection of virus-specific antibodies in sera is described. The method was evaluated using sera from cattle experimentally infected with bovine viral diarrhea virus (BVDV). Virus-infected cells, which were fixed and permeabilized, were incubated with diluted sera from immunized or control animals. Monoclonal antibodies (mabs) against different viral proteins were added, and detected with ALEXA488-conjugated goat-antimouse antibodies. The fluorescence signals were detected by flow cytometry and determined as mean channel values. Results were expressed as percent fluorescence inhibition compared to standardized negative sera. The FACS-IFI test with sera from experimentally infected animals was highly sensitive and specific. Comparison of the FACS-IFI results with a commercially available blocking ELISA, an indirect ELISA and the standard serum neutralization test showed a strong correlation. Furthermore, the detection of protein-specific antibodies was possible using the FACS-IFI test.

Case report: the significance of genotyping for the epidemiological tracing of classical swine fever (CSF)

In Germany, eleven outbreaks of CSF in domestic pig holdings were reported in 2002. They occurred exclusively in regions where CSF virus circulated in the wild boar population. In ten cases the phylogenetic analysis revealed that the isolates from domestic pigs and wild boar had identical sequences in the 5' non-translated region (5'NTR). However, in one case a subtype was isolated which was slightly different from the virus subtype found in the wild boar population of that region. This case is decribed in detail. The epidemiological significance of different diagnostic methods is discussed, in particular the genetic typing of CSF virus isolates.

Which are the polyphosphate accumulating organisms in full-scale activated sludge enhanced biological phosphate removal systems in Australia?

AIMS

To see if the compositions of the microbial communities in full scale enhanced biological phosphorus removal activated sludge systems were the same as those from laboratory scale sequencing batch reactors fed a synthetic sewage.

METHODS

Biomass samples taken from nine full scale enhanced biological phosphate removal (EBPR) activated sludge plants in the eastern states of Australia were analysed for their populations of polyphosphate (polyP)-accumulating organisms (PAO) using semi-quantitative fluorescence in situ hybridization (FISH) in combination with DAPI (4'-6-diamidino-2-phenylindole) staining for polyP.

RESULTS

Very few betaproteobacterial Rhodocyclus related organisms could be detected by FISH in most of the plants examined, and even where present, not all these cells even within a single cluster, stained positively for polyP with DAPI. In some plants in samples from aerobic reactors the Actinobacteria dominated populations containing polyP.

CONCLUSIONS

The PAO populations in full-scale EBPR systems often differ to those seen in laboratory scale reactors fed artificial sewage, and Rhodocyclus related organisms, dominating these latter communities may not be as important in full-scale systems. Instead Actinobacteria may be the major PAO.

SIGNIFICANCE AND IMPACT OF THE STUDY

These findings illustrate how little is still known about the microbial ecology of EBPR processes and that more emphasis should now be placed on analysis of full-scale plants if microbiological methods are to be applied to monitoring their performances.