Progression of human monkeypox infection despite tecovirimat in an immunocompromised adult

We report a case of an immunocompromised man with monkeypox who experienced disease progression despite timely initiation of tecovirimat and ultimately required utilization of cidofovir and VIGIV for treatment. In immunocompromised patients, monkeypox might present with a more severe course of disease requiring consideration of alternative treatment strategies.

A case of herpes simplex 2 encephalitis with an unusual radiographic manifestation

Herpes Simplex Virus (HSV) continues to be an important pathogen inflicting encephalitis in adults and children globally that entails high morbidity and mortality. Prompt diagnosis and treatment are the keys to minimize potential sequelae of the disease. Although HSV encephalitis-1(HSVE-1) is well recognized for its radiographic manifestation of temporal lobe involvement owing to its pathogenesis, radiographic features of HSVE-2 are less uniform. Lumbar puncture with HSV PCR testing is the gold standard for diagnosis. However, when lumbar puncture is not immediately obtainable, consideration of HSVE should be entertained in compatible clinical setting even in the absence of characteristic radiographic finding. We report a case of type 2 HSVE with atypical radiographic manifestation involving bilateral basal ganglia.

Bidirectional shift of group III metabotropic glutamate receptor-mediated synaptic depression in the epileptic hippocampus

A common function of group III metabotropic glutamate receptors (mGluRs) located at the presynaptic site of a glutamatergic synapse is synaptic depression. Here, we studied synaptic depression mediated by group III mGluR activation at Schaffer collateral-CA1 (SC-CA1) synapses and associational-commissural-CA3 (AC-CA3) synapses by recording field excitatory postsynaptic potentials in the in vitro brain slice preparation. In order to gauge the impact of synaptic depression in chronically epileptic tissue, we compared rats after pilocarpine-induced status epilepticus (post-SE) with control animals. We observed that synaptic transmission at control AC-CA3 synapses was sensitive to the group III mGluR agonist L-AP4 (10μM), while there was no effect of this compound at SC-CA1 synapses in the same tissue. In contrast, synaptic depression at AC-CA3 synapses by L-AP4 was lost in chronically epileptic tissue, and we found a significant synaptic depression at SC-CA1 synapses in post-SE tissue by L-AP4 and by the mGluR8-selective agonist DCPG. The depression by L-AP4 and DCPG in CA1 was also demonstrated in immature control tissue suggesting developmental down-regulation of mGluR8 at this synapse as well as re-appearance of this isoform under pathological conditions. Quantitative real-time RT-PCR was used to identify mGluR isoforms and to assess their transcriptional changes in post-SE tissue. These analyses revealed down-regulation of mGluR4 and mGluR6 at AC-CA3 and up-regulation of mGluR8 at SC-CA1 synapses. We conclude that group III mGluR-mediated synaptic depression is differentially altered in chronically epileptic tissue by a bidirectional shift of the transcriptional level.

Dopamine induces contraction in the proximal, but relaxation in the distal rat isolated small intestine

In the gut, dopamine is released by enteric neurons and modulates motility of small intestine smooth muscle cells. Here, we systematically analyzed the dopamine-induced effects on the longitudinal smooth muscle of different sections of the rat isolated small intestine. We found that exogenous dopamine had biphasic effects and could lead to both an early contraction and a late relaxation, depending on the region of small intestine. Thus, dopamine-induced early contractions were commonly observed in the duodenum, but less frequently in the jejunum, and rarely in the ileum. The amplitudes of these early contractions showed a striking regional dependence (duodenum>jejunum>ileum) and were significantly blocked by SCH23390 and raclopride. Conversely, dopamine-induced late relaxations were regularly obtained in the ileum and in the jejunum, but less frequently in the duodenum. Interestingly, the amplitudes of these relaxations showed an inverse regional dependence (ileum>jejunum>duodenum), and were insensitive to dopamine receptor antagonists. Rather, they were significantly inhibited by propranolol and prazosin. We conclude that dopamine exerts differential effects on smooth muscle motility in different regions within the rat small intestine. In proximal parts, dopamine predominantly causes D(1) and D(2) dopamine receptor-dependent contraction, whereas it leads to alpha and beta adrenoceptor-dependent relaxation in more distal parts.

[Imaging of paranasal sinuses today]

CT is accepted as the gold standard for pathological-anatomical evaluation of paranasal sinus disease, CT is especially considered an obligatory part of planning surgical procedures. Indications for paranasal sinus CT include trauma, malignant disease, and chronic sinusitis, which accounts for the major part of examinations. Due to the benign character of the disease and the relatively moderate age of the patients involved, the radiation dose of paranasal sinus CT plays an important role. The use of a low-dose spiral CT technique and the reformation of coronal images out of the axial CT data instead of an additional direct coronal scan allow the effective dose of paranasal sinus CT to be reduced to the order of a chest radiogram. MRI is the preferred imaging modality in malignant disease or complications of inflammatory sinus disease that extend beyond the limits of the paranasal sinuses. The clinical value of other imaging modalities, including plain film radiography, ultrasound, or scintigraphy, is limited to special indications.

Laserbasierte Qualitätssicherung für die robotergestützte Fräsabtragung an der Schädelbasis

BACKGROUND

Implanting active hearing devices in the lateral base of the skull requires high-precision, secure fixation of the electromagnetic transducer and long-life anchorage using osteosynthetic fixation plates referred to as mountain brackets. Nonlinear distortion in the acoustic signal path and consecutive implant loosening can only be avoided by exact osseous milling to create the necessary cavity bed while avoiding excessive milling. Robot technology is ideal for high-precision milling. However, safety measures are necessary in order to prevent errors from occurring during the reduction process. Ideally, a robot should be guided by a navigation system. However, robotic systems so far available do not yet have an integrated global navigation system.

MATERIALS AND METHODS

We used an animal model under laboratory conditions to examine the extent to which the semiautomatic ROBIN assistant system developed could be expected to increase osseous milling accuracy before implanting active electronic hearing devices into the recipient tissue in the cranium. An existing prototype system for robot-assisted skull base surgery was equipped with laser sensors for geometric measurement of the operation site. The three-dimensional measurement data was compared with CT simulation data before, during, and after the robot-assisted operation. The experiments were conducted on test objects as well as on animal models.

RESULTS

Under ideal conditions, the operation site could be measured at a spatial resolution of better than 0.02 mm in each dimension. However, reflections and impurities in the operation site from bleeding and rinsing fluids did have a considerable effect on data collection, necessitating specialised registering procedures. Using an error-tolerant procedure specifically developed, the effective registering error could be kept under 0.3 mm. After milling, the resulting shape matched the intended form at an accuracy level of 0.8 mm.

CONCLUSION

The results show that robot systems can reach the accuracy required for reliable microsurgery on the cranial base. High-resolution laser-based geometric measurement of the operation site enables head registration without additional artificial landmarks. During the navigated operation, the procedure can be used to ensure that the resulting cavity matches the intended shape as determined in the preoperative planning phase. This will enable quantitative analysis of, and improvement in the quality of robot-assisted surgery in the future.

[CT-based assessment score after ventral spondylodesis for thoracolumbar spine fracture]

BACKGROUND

Dorsoventral stabilization is a common procedure to treat thoracolumbar spine fractures. Especially in respect of the evaluation of alternative procedures to autogenous bone graft, a standardized evaluation score for ventral spondylodesis is necessary.

PATIENTS AND METHODS

In a group of 44 patients a follow-up CT scan was evaluated with a standardized scoring system by four different independent evaluators (a trauma surgeon, an orthopedic surgeon, and two radiologists). The score is based on the morphologic classification of the region between graft and vertebral body. It allows a classification of the spondylodesis as sufficient, partial, and not sufficient.

RESULTS

The statistical evaluation of the classification of the different evaluators shows very good interobserver agreement in monosegmental fusion and good agreement in bisegmental fusion.

CONCLUSION

The demonstrated score is easy to handle, does not need special equipment for CT scans, and shows good interobserver agreement in the classification of spinal fusion after ventral spondylodesis for thoracolumbar spine fracture.

Vereinfachte Herstellung multimedialer radiologischer Lernobjekte mit dem Flash-Format

PURPOSE

Evaluation of the applicability of the Flash Format for the production of radiological learning objects used in an e-learning environment.

MATERIAL AND METHODS

Five exemplary learning objects with different didactic purposes referring to radiological diagnostics are presented. They have been intended for the use within the multimedia, internet-based e-learning environment LaMedica. Interactive learning objects were composed using the Flash 5.0 software (Macromedia, San Francisco, USA) on the basis of digital CT and MR images, digitized conventional radiographs and different graphical elements prepared as TIFF files or in a vector graphics format.

RESULTS

After a short phase of initial skill adaptation training, a radiologist author was soon able to create independently all learning objects. The import of different types of images and graphical elements was carried out without complications. Despite manifold design options, handling of the program is easy due to clear arrangement and structure, thus enabling the creation of simple as well as complex learning objects that provided a high degree of attractiveness and interaction. Data volume and bandwidth demand for online use was significantly reduced by the Flash Format compression without a substantial loss of visual quality.

CONCLUSION

The universally compatible Flash Format offers an opportunity for the simple production of radiological learning objects that fulfill all relevant needs of modern internet based e-learning environments, such as interactivity, employment of multimedia and convertibility.

High-resolution magnetic resonance imaging of trabecular bone in the wrist at 3 tesla: initial results

PURPOSE

To evaluate the feasibility of high-resolution magnetic resonance imaging (MRI) of trabecular bone of the wrist at 3 Tesla (3T) in vivo and to assess the potential benefit of the increased resolution for clinical assessment of structural changes in spongy bone.

MATERIAL AND METHODS

High-resolution MRI of the wrist was performed with a whole-body 3T MR scanner using a dedicated circularly polarized transmit-receive wrist-coil. Two 3D-FISP sequences with a spatial resolution of 300 x 300 x 300 microm3 in a measuring time of TA = 7:51 min, and 200 x 200 x 200 microm3 in TA = 9:33 min were applied. Seven young healthy volunteers and three elderly subjects with suspected osteoporosis were examined. The signal-to-noise ratio (SNR) in the optimized setup at 3T was compared to measurements at 1.5T.

RESULTS

The images at 3T allow microscopic analysis of the bone structure at an isotropic spatial resolution of 200 microm in examination times of <10 min. Differences in the structure of the spongy bone between normal and markedly osteoporotic subjects are well depicted. The SNR at 3T was found up to 16 times higher than at 1.5T applying unchanged imaging parameters.

CONCLUSION

The proposed high-resolution MRI technique offers high potential in the diagnosis and follow-up of diseases with impaired bone structure of hand and/or wrist in clinical applications.

Evaluation unterschiedlicher 16-Zeilen-CT-Colonographie-Protokolle am Schweinedarmmodell

PURPOSE

To develop and to test an easily produced biological colon model with simulated polypoid lesions. Application of this phantom for the selection of an optimized scan protocol of 16-row CT colonography (CTC) for clinical use.

METHODS AND MATERIAL

Six polypoid lesions (1 - 6 mm) were simulated with sutures on the inner face of a porcine colon segment (20 cm). After distending the colon segment with air, the phantom was placed in a water quench and CT scans were performed on a MDCT-scanner (Somatom Sensation 16, Siemens, Forchheim). At constant values for collimation (16x0.75 mm) and voltage (120 kV), 54 different combinations of mAs values (50, 75 and 100 mAs), pitch factors (1, 1.25 and 1.5) and slice thicknesses (0.75, 1.0, 1.5, 2.0, 3.0 and 5.0 mm) were tested systematically. The phantom was scanned in the longitudinal and transverse axis to simulate the different orientation of the colon in the abdomen. Axial slice images and virtual endoscopic views of all data sets were presented separately to 2 radiologists who independently determined number and size of detectable polyps. Dose exposure was measured with an Alderson phantom.

RESULTS

The colon model offered a realistic imitation of a polyp-covered, human colon. The experimental set-up allowed a systematic evaluation of polyp detection related to lesion size, orientation of the colon and CTC parameters, with other influencing factors mostly excluded. Polyps were significantly better detected in the longitudinal than in the transverse orientation of the colon. For the detection of lesions of at least 3 mm, a low dose (50 mAs) 16-row CTC should be combined with a pitch of 1.5 and a maximum slice thickness of 3 mm. For the depiction of polyps smaller than 3 mm, slice thickness and pitch should amount to 1 mm and 1.0, respectively. Effective dose of this low dose protocol is 4.08 mSv.

CONCLUSION

The porcine colon phantom represents a realistic and easily produced alternative to other colonography models. It allows a preselection of a CTC-protocol for subsequent clinical testings. If the high in vitro performance of the low-dose 16-row CTC-protocol is confirmed on a human collective, the use of 16-row technique would represent a big step for CTC toward a screening method.

Stellenwert einer parameteroptimierten 3D-FISP-MR-Angiographie bei Kindern mit Aortenisthmusstenose im Vergleich zur Katheterangiographie

PURPOSE

To implement parameter-optimized 3D-FISP MR angiography (MRA) with interleaved double-slab excitation and to compare the result with catheter angiography in children with aortic coarctation.

MATERIALS AND METHODS

Eighteen children aged 2 - 15 years (mean 9.1 years) underwent MR imaging on a 1.5T body scanner (Magnetom Vision, Siemens, Germany). All patients had undergone correlative catheter angiography. T1-weighted turbo spin echo (TSE) images (TR 600 ms, TE 17 ms, flip 160 degrees, slice thickness 2 - 4 mm) were obtained in axial and parasagittal orientation, followed by an optimized 3D-FISP MR angiography in a sagittal plane (TR 12.5 ms, TE 5.5 ms, flip 22 degrees, matrix 256 x 256, slice thickness 1.25 mm). All children were sedated but on spontaneous breathing. Image quality was graded by two experienced reviewers using a 4-point scoring system. Source images and reformatted maximum intensity projections (MIP) were analyzed for blood-tissue contrast as well as size and focal stenoses of the aortic arch.

RESULTS

Aortic coarctation was found in 13 of 18 patients, using the 3D-FISP MRA. A high correlation value (r = 0.96) was found compared to catheter angiography. Image quality was high in 94 % with well defined blood-tissue contrast in all cases. The sensitivity to flow and breathing motion was low. Examination time was about 15 minutes depending on volume of interest and heart rate. Diagnostic accuracy has shown improvement using a combined analysis of source and MIP images. The mentioned technique has provided an excellent display of thoracic vasculature.

CONCLUSION

MR imaging represents an excellent tool for non-invasive examination of the cardiovascular system of children. The 3D-MRA allows the recording of a large 3D data set without the use of contrast agent and within an adequate measurement period, particularly in small infants unable to hold their breath. In addition, hemodynamic significance of aortic coarctation, the existence of collateral vessels and other congenital heart diseases can be described reliably by using this technique.

[Registration using three-dimensional laser surface scanning for navigation in oral and craniomaxillofacial surgery]

INTRODUCTION

Recent innovations in laser scanning technology provide a potentially useful tool for three-dimensional surface registration for image-guided surgery. The purpose of this study is to evaluate the clinical reliability of this technique in oral and maxillofacial surgical procedures using image-guided navigation.

METHODS

In an experimental step, a stable anthropomorphic skull model with prelabeled markers was scanned and registered with laser surface scanning (z-touch, BrainLAB) and marker- based algorithms. The registration protocol was then repeated 25-times. Root mean square error (RMSE) and target difference values were compared for their suitability for this application. Twelve patients with different indications for oral and maxillofacial surgery were planned for image-guided surgery using a passive infrared surgical navigation system (VectorVision, BrainLAB). Preoperative computed tomography (CT) scans were carried out with newest 16-line multisclice CT-scanner (Siemens Somatom Sensation 16). The new markerless laser surface scanning technique was applied in all intraoperative patient registrations. Registration error was noted. The clinical application accuracy was determined for anatomical landmark localization deviation.

RESULTS

In the experimental protocol a mean registration error (RMSE) or target difference of 1.3 (0.14) or 2.08 (0.49) mm for laser scanning and 0.38 (0.01) or 0.99 (0.15) mm for marker registration was found. The differences for RMSE and target localization were statistically significant (p < 0.005). Furthermore, a strong correlation between RMSE and target difference was found for laser scanning (r = 0.96) and marker registration (r = 0.95). During various clinical procedures involving oral and maxillofacial surgery, the overall error of the registration procedure determined as RMSE was 1.21 (0.34) mm. Intraoperatively, the mean clinical application accuracy was found to be 1.8 (0.5) mm.

CONCLUSION

Three-dimensional laser surface scanning technique may be a interesting and useful approach to register the patient for image-guided procedures, particularly during oral and craniomaxillofacial surgery.

Image-guided navigation for minimal invasive approaches in craniomaxillofacial surgery

The use of minimally invasive procedures in maxillofacial surgery will require new technologies involving surgical navigation and techniques. The aim of our studies is to improve the efficacy of image-guided navigation in combination with endoscopically assisted techniques for minimally invasive craniomaxillofacial procedures. Prospective evaluation was made of all patients who underwent surgical procedures using image-guided navigation. The most common type of operations performed were endoscopically assisted interventions within the paranasal sinuses, fracture treatment, the resection of bone lesions and further miscellaneous interventions. Our experience to date suggest that image-data based techniques are eminently applicable, providing a feasible alternative to conventional surgical treatment.

The use of hybrid stereolithographic models for the planning of complex craniofacial procedures

Preoperative planning of orthognathic surgery is usually based on plaster cast models. Those are integrated in an articulator, simulating the movement of the jaws. We present a new procedure to combine the individual jaw anatomy by stereolithographical models with dental plaster casts, which are more accurately reproducing dental and bony anatomy. For image fusion the patient and the individual plaster casts are scanned by computed tomography, the occlusal planes being covered by a splint with radioopaque makers. After threshold segmentation of both, the plaster cast and the patients skull images are fused. The plaster cast volume is then subtracted from the patients upper and lower jaw, thus sparing out the place for later fusion of stereolithographic model and plaster cast.

Initial experience with intraoperative computed tomography in maxillofacial surgery

With respect to the complex anatomy in the head and neck region, computed tomography has been established as a routine method for preoperative evaluation. Whereas in neurosurgery intraoperative tomographic image data acquisition (CT, MR) serves for control of therapeutic effects on a routine base, maxillofacial surgeons aren't accustomed to use the method in this way. Using a mobile Philips Tomoscan M scanner, we examined the clinical significance and especially the ergonomy of intraoperative CT scans in maxillofacial traumatology.

[Distinctive features of the os naviculare pseudarthrosis vs the os naviculare accessorius]

We report on two cases in which the differential diagnosis between an os tibiale externum (os naviculare accessorius) and a post-traumatic pseudarthrosis of the os naviculare was subject to discussion.Both patients had suffered an acute trauma in the region of the middle foot and showed identical clinical symptoms. Conventional X-ray did not allow a definite classification of the diagnosis either.However, this was possible in both cases by virtue of typical signs evidenced by computed tomography and magnetic resonance imaging.