Muscle weakness is associated with non-contractile muscle tissue of the vastus medialis muscle in knee osteoarthritis

BACKGROUND

Quadriceps weakness is assumed to be associated with compositional properties of the vastus medialis muscle in patients with knee osteoarthritis (OA).

METHODS

The aim was to determine the association of non-contractile muscle tissue in the vastus medialis muscle, measured with routine MRI, with muscle extensor strength in patients with knee OA. Sagittal T1-weighted 3T MRI of 94 patients with knee OA, routinely acquired in clinical practice were used for analysis. Using the MRI's, the amount of non-contractile muscle tissue in the vastus medialis muscle was measured, expressed as a percentage of (non)-contractile tissue, dichotomized into a low and a high non-contractile percentage group. Muscle strength was assessed by isokinetic measurement of knee extensors and by conduction of the Get-Up and Go (GUG) test. In regression analyses, associations of percentage of non-contractile muscle tissue with muscle strength and GUG time were determined and controlled for sex, age, BMI and radiographic severity.

RESULTS

A high percentage of non-contractile muscle tissue (> 11.2%) was associated with lower muscle strength (B = -0.25, P = 0.006) and with longer GUG time (B = 1.09, P = 0.021). These associations were specifically confounded by sex and BMI, because these two variables decreased the regression coefficient (B) with > 10%.

CONCLUSIONS

A high percentage of non-contractile muscle tissue in the vastus medialis muscle measured by clinical T1-weighted 3T MRI is associated with muscle weakness. The association is confounded by sex and BMI. Non-contractile muscle tissue seems to be an important compositional property of the vastus medialis muscle underlying quadriceps weakness.

Direct Comparison of the Thickness of the Parietal Peritoneum Using Peritoneal Biopsy and Ultrasonography of the Abdominal Wall in Patients Treated with Peritoneal Dialysis

Background

Long-term treatment with peritoneal dialysis (PD) results in peritoneal fibrosis. Peritoneal biopsies have been used to determine the severity of fibrosis. Ultrasonography (US) of the abdominal wall has been used to measure peritoneal thickness non-invasively. However, direct comparison of both methods in the same patient has never been done. Furthermore, the validity of US to measure peritoneal thickness has not been investigated.

Methods

We performed 3 studies: 1) a human biopsy study to compare US measurement of peritoneal thickness with histological examination; 2) a human cadaver study to investigate the effect of removing the peritoneum on US results; and 3) a phantom study in which we used US to measure the thickness of membrane-like structures with a known thickness to investigate the influence of different US settings.

Results

The median thickness in biopsies of the peritoneum was 113 μm (interquartile range [IQR] 72 –129 μm), while this was 370 μm (IQR 324 – 458 μm) when measured by US ( p < 0.0001). The mean difference between the 2 measures was -257 μm (limits of agreement -4.6 and -511 μm). In the cadaver study, removal of the peritoneum did not have an effect on the presence or thickness of the hyperechoic line reported to represent the peritoneum. In the phantom study, results were highly dependent on frequency of the transducer, scan depth, and gain settings.

Conclusions

Ultrasonography results differ markedly from histological measurement using peritoneal biopsies. However, the hyperechoic line generated by US represents the interface between 2 neighboring tissues and not a separate morphological structure. Moreover, its thickness is greatly influenced by user-defined US settings.

[A patient with bilateral microcalcifications on mammography]

A 25-year-old woman with systemic lupus erythematosus presented with multiple palpable masses in both breasts. On mammography multiple, coarse, heterogeneous, microcalcificatons were seen. Histopathologic examination showed inflammation, fibrosis, fat necrosis and dystrophic microcalcifications. Based on these findings the patient was diagnosed with lupus mastitis.

Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair

BACKGROUND

The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair.

METHODS

Between 2000 and 2007, 70 patients (49 females, mean age +/- standard deviation 60.6 +/- 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 +/- 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms.

RESULTS

The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125).

CONCLUSIONS

The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.

Computer-aided detection (CAD) for breast MRI: evaluation of efficacy at 3.0 T

Objective

The purpose of the study was to evaluate the accuracy of 3.0-T breast MRI interpretation using manual and fully automated kinetic analyses.

Material and methods

Manual MRI interpretation was done on an Advantage Workstation. Retrospectively, all examinations were processed with a computer-aided detection (CAD) system. CAD data sets were interpreted by two experienced breast radiologists and two residents. For each lesion automated analysis of enhancement kinetics was evaluated at 50% and 100% thresholds. Forty-nine malignant and 22 benign lesions were evaluated.

Results

Using threshold enhancement alone, the sensitivity and specificity of CAD were 97.9% and 86.4%, respectively, for the 50% threshold, and 97.9% and 90%, respectively, for the 100% threshold. Manual interpretation by two breast radiologists showed a sensitivity of 84.6% and a specificity of 68.8%. For the same two radiologists the mean sensitivity and specificity for CAD-based interpretation was 90.4% (not significant) and 81.3% (significant at p < 0.05), respectively. With one-way ANOVA no significant differences were found between the two breast radiologists and the two residents together, or between any two readers separately.

Conclusion

CAD-based analysis improved the specificity compared with manual analysis of enhancement. Automated analysis at 50% and 100% thresholds showed a high sensitivity and specificity for readers with varying levels of experience.

Ultrasound-guided laser-induced thermal therapy for small palpable invasive breast carcinomas: a feasibility study

Background

The next step in breast-conserving surgery for small breast carcinomas could be local ablation. In this study, the feasibility of ultrasound-guided laser-induced thermal therapy (LITT) is evaluated.

Methods

Patients with large-core needle biopsy-proven invasive, palpable breast carcinoma (clinically ≤2 cm) underwent ultrasound-guided LITT, followed by surgical excision. Completeness of ablation was determined by both hematoxylin and eosin staining and nicotinamide adenosine diaphorase staining.

Results

Fourteen patients completed the treatment. The mean histological tumor size was 17 mm (range, 8–37 mm); 6 of 14 tumors were histologically larger than the clinical entry threshold of 2 cm. The power applied in all patients was 7 W, and the mean treatment time was 21.4 min (range, 15–30 min). In one patient, a skin burn occurred, and one patient had a localized pneumothorax that could be treated conservatively. In 7 (50%) of 14 patients, the tumor was completely ablated, as confirmed by nicotinamide adenosine diaphorase staining. In 11 cases, extensive in-situ carcinoma was present. In one case, the in-situ carcinoma was also completely ablated. A total of seven (88%) of eight tumors <2 cm in size were completely ablated versus one (17%) of six tumors that were ≥2 cm in size (P = .026).

Conclusions

Successful LITT of invasive breast cancer seems to be feasible when confined to small (<2 cm) nonlobular carcinomas without surrounding extensive in-situ component and angioinvasion. However, to implement LITT in a curative setting, improvements in imaging to more reliably preoperatively assess tumor size and monitoring of fiber tip placement and treatment affect are essential.

Contrast-enhanced 3.0-T breast MRI for characterization of breast lesions: increased specificity by using vascular maps

PURPOSE

To assess the diagnostic accuracy of contrast-enhanced 3.0-T breast magnetic resonance imaging (MRI) for differentiating benign from malignant breast masses and subsequently to test if specificity could be further improved by scoring of the overall ipsilateral breast vascularity.

MATERIALS AND METHODS

Fifty-four patients were prospectively enrolled in the study and underwent contrast-enhanced 3.0-T breast MRI. MR images were evaluated and classified according to the MRI BI-RADS lexicon criteria. Lesion size, number of lesions, and localization in the breast were systematically assessed. Maximum intensity projections (MIPS) were obtained by using high-resolution contrast-enhanced (0.1 mmol/kg gadobutrol) fat-saturated T1-weighted images. Breast vascularization was scored according to the methods from Sardanelli et al. by measuring the number, diameter, and length of the vessels on the MIPS. The score ranged from 0 (indicating absent or low breast vascularity) to 3 (indicating high breast vascularity).

RESULTS

Final analysis of 56 lesions revealed 25 (45%) malignant lesions and 31 (55%) benign lesions. Correlation with the MRI BI-RADS classification revealed cancer in none (0%) of the BI-RADS II lesions, in 1 (12%) of the BI-RADS III lesions, in 5 (83%) of the BI-RADS IV lesions, and in 19 (100%) of the BI-RADS V lesions. Based on morphologic and kinetic data analysis, the sensitivity and specificity of 3.0-T breast MRI was 100% (25/25) and 74% (23/31), respectively. After adjustment for the breast vascularity score, specificity significantly (p = 0.048) increased to 87% (27/31) without affecting sensitivity.

CONCLUSION

Diagnostic accuracy of contrast-enhanced 3.0-T breast MRI increased significantly when the vascularity score was added to the standard morphologic and kinetic data analysis, resulting in a specificity of 87% without affecting sensitivity, which remained 100%.

[Three patients with indinavir-related urolithiasis]

Three HIV-seropositive patients were diagnosed with urolithiasis related to the use of indinavir. The first patient was a 45-year-old white male with severe haemophilia who presented with fever and flank pain referred to the glans penis. Ultrasound and intravenous pyelography (IVP) revealed a concrement in the left renal pelvis. Discontinuation of indinavir and acidification of the urine did not reduce the stone load. Percutaneous nephrolithotripsy was then performed. The second patient, a 41-year-old white male, presented at the emergency ward with flank pain and fever. Ultrasound examination showed dilatation of the left kidney. A percutaneous nephrostomy catheter was inserted. Antegrade contrast imaging showed a concrement in the proximal ureter. The patient underwent extracorporeal shock wave lithotripsy. A second antegrade image made a few days later showed no evidence of stone material. The third patient was a 56-year-old white male with a previous history of indinavir-associated urolithiasis. He presented at the emergency ward with flank pain and haematuria. A CT urography showed dilatation of the right kidney and distal portion of the right ureter with no evidence of concrement. The symptoms resolved after a percutaneous nephrostomy catheter was inserted and the antiviral medication was modified. The catheter was removed 2 weeks later. At last follow-up, none ofthe 3 patients had symptoms of urolithiasis. These cases illustrate that, although conservative therapy for indinavir-related urolithiasis can be sufficient, minimally invasive endourological surgery is sometimes necessary.

Accuracy of contrast-enhanced breast ultrasound for pre-operative tumor size assessment in patients diagnosed with invasive ductal carcinoma of the breast

Our aim was to assess the feasibility and accuracy of contrast-enhanced ultrasound (CEUS) of the breast with SonoVue microbubbles for pre-operative size measurement of invasive breast carcinomas. Seven patients diagnosed with nine invasive breast carcinomas prospectively underwent gray-scale ultrasound and CEUS of the breast according to a standardized protocol. CEUS of the breast was performed by a Philips iU22 scanner equipped with a 4-8 MHz linear array transducer. We used a single dose of 2.4 ml SonoVue as contrast agent. Breast lesion morphology was scored according to the sonographic BI-RADS lexicon criteria and classified accordingly. The greatest tumor dimensions on gray-scale ultrasound and CEUS of the breast were finally compared with the greatest histopathologic tumor sizes. Gray-scale ultrasound underestimated the histopathologic tumor size in 6/9 cases (67%), whereas CEUS of the breast underestimated tumor size in only 3/9 (33%) cases. CEUS of the breast was significantly more accurate for tumor size assessment. Greatest tumor dimension as measured with gray-scale ultrasound of the breast was within 2 mm of the pathologic tumor size in only 2/9 cases (22%), whereas CEUS of the breast accurately assessed tumor size within 2 mm of pathologic tumor size in 6/9 (67%) of the cases (P<0.05). CEUS of the breast proved to be a feasible and safe procedure. It is more accurate than gray-scale ultrasound of the breast for pre-operative size assessment of invasive ductal breast carcinomas.

Multiple fiber laser-induced thermotherapy for ablation of large intrahepatic tumors

OBJECTIVE

The aim of this study was to test three techniques used simultaneously to increase lesion size.

BACKGROUND DATA

Laser-induced thermotherapy (LITT) is a method of local tumor ablation, which may prolong survival in patients with unresectable liver metastases. The main limitation has been the production of lesions with sufficient tumor-free margin.

METHODS

LITT treatment was performed with water-cooled, multiple fiber application and hepatic blood flow occlusion in six patients with unresectable intrahepatic metastases. Response was measured by computed tomography scan.

RESULTS

In all patients, tumors were effectively ablated. In two patients with colorectal metastases, lesions up to 8.6 cm could be created.

CONCLUSION

The use of watercooled multiple fiber application and hepatic inflow occlusion makes LITT an effective ablative method, expanding the treatment options for patients with large intrahepatic masses.

Interobserver variability of clinical target volume delineation of glandular breast tissue and of boost volume in tangential breast irradiation

BACKGROUND AND PURPOSE

To determine the interobserver variability of clinical target volume delineation of glandular breast tissue and of boost volume in tangential breast irradiation.

PATIENTS AND METHODS

Eighteen consecutive patients with left sided breast cancer treated by breast conserving surgery agreed to participate in our study. Volumes of the glandular breast tissue (CTV breast) and of the boost (CTV boost) were delineated by five observers. We determined 'conformity indices' (CI) and the ratio between the volume of each CTV and the mean volume of all CTVs (CTV ratio). Subsequently we determined the most medial, lateral, anterior, posterior, cranial and caudal extensions both of CTV breast and CTV boost for all observers separately.

RESULTS

The mean CI breast was 0.87. For one observer we noted the highest CTV ratio in 17 out of 18 cases. No association was noted between CI breast and menopausal status. The mean CI boost was 0.56. We did not find a relation between the presence or absence of clips and the CI boost. For another observer we noted the lowest CTV boost ratio in 10 out of 17 cases.

CONCLUSIONS

We recommend that each institute should determine its interobserver variability with respect to CTV breast and CTV boost before implementing the delineation of target volumes by planning CT in daily practice.

[A long-distance runner with a painful sesamoid bone in the forefoot]

A 38-year-old long-distance runner presented with pain in the left medial forefoot. In the presence of such symptoms, consideration should be given to a disease of or injury to a sesamoid bone. Radiology revealed a fracture line through the medial sesamoid bone under the first metatarsophalangeal joint. Conservative treatment was initially ineffective. Ultimately, local injections of lidocaine-methylprednisolone at the site of the pain, in the metatarsophalangeal joint and in the fracture line brought relief. In the diagnosis of patients with pain in the medial forefoot, apart from the patient's history and a physical examination, a skyline X-ray can be helpful to reveal a fractured or bipartite sesamoid. Almost all conditions affecting the sesamoids improve in the long run with conservative treatment. Besides reduction of weight-bearing pressure on the affected sesamoid, NSAIDs and ice massage, special attention should be paid to the foot (postural deformities), the shoe (inlays, sesamoid pad, shock absorption, stiff sole) and running on a soft surface. Insufficient therapeutic results may be due to osteonecrosis or non-union. These and persistent pain may, as a last resort, require surgical intervention such as screw fixation in case of a fracture or sesamoidectomy.

[Testicular torsion can also be present in adult men]

Five adult men, aged 34, 33, 31, 56 and 52 years respectively, were admitted with acute scrotal pain. Testicular torsion was eventually diagnosed in all the patients. Two of the patients were initially treated with antibiotics due to a suspected epididymitis. One of them required orchidectomy due to necrosis. The remaining patients underwent orchidofixation and their testicles could be preserved. The most important different diagnosis for acute pain and swelling of the testicle is either acute epididymitis or testicular torsion. The latter is uncommon in adult men. Using a physical examination to distinguish epididymitis from testicular torsion can be difficult. Doppler ultrasound is a reliable diagnostic tool for confirming testicular ischaemia. If the intratesticular flow is diminished or absent, then testicular torsion should be considered and this should be followed by immediate surgical exploration.

Effects of beta adrenergic receptor agonists and antagonists in diabetics with symptoms of postural hypotension: a double-blind, placebo-controlled study

Eleven patients with hyperadrenergic diabetic postural hypotension and vagal neuropathy were treated in a double-blind, placebo-controlled study with different beta-agonists and antagonists. A single dose of the beta 2-agonist terbutaline (5 mg) and the beta 1 + 2-agonist orciprenaline (10 mg) did not reduce the fall in systolic pressure on standing up, despite a significant increase in both supine and standing heart rates. The beta 1-antagonist with intrinsic sympathicomimetic activity (ISA) acebutolol (200 mg) and the beta 1-antagonist metoprolol (50 mg) did not influence the fall in systolic pressure either, despite a significant decrease in supine and standing heart rates and disappearance of increase in heart rate on standing up. Only the beta 1 + 2-antagonist propranolol and the beta 1 + 2-antagonist with ISA pindolol (5 mg) could significantly reduce or practically abolish the fall in systolic and diastolic pressure on standing up. This was accompanied by a slight decrease of heart rates and disappearance of difference between supine and standing heart rates, as seen with the other beta-antagonists. Thus, only beta 2-blockade reduced or abolished the fall in systolic pressure on standing up in our patients. These data were confirmed by a three-week crossover trial in 10 of these patients.