[Trauma emergency room cases before and during the COVID-19 pandemic : Data from an alpine trauma center]

INTRODUCTION

The COVID-19 pandemic had a strong impact on the work of trauma medical teams. The aim of the study was to compare the trauma emergency room (TER) incidence and trauma mechanisms before and during the pandemic at a level I trauma center.

OBJECTIVE

The TER incidence before and during the pandemic should be assessed to be prepared for future pandemics or new COVID-19 outbreaks.

MATERIAL AND METHODS

Medical charts from all TER patients from March 2019 to February 2021 were analyzed. The incidence and trauma mechanisms of the 12 months before and the 12 months during the pandemic were compared. The trauma distribution and severity were described by the AIS and ISS, and the patients' country of residency was noted.

RESULTS

The TER cases decreased from 694 before the COVID-19 pandemic to 477 cases during the pandemic (Incidence rate 0.69). The strongest decrease in trauma cases was noted in sports injuries (0.55), followed by suicide attempts (0.63), traffic accidents (0.71) and leisure accidents (0.76). The rate of patients with severe injuries (ISS ≥ 16) was comparable with 40% before the pandemic and 44% during the pandemic. Foreign residency of TER patients shifted from 37% before the pandemic to 16% during the pandemic. The number of foreign patients was significantly reduced during the pandemic (257 vs. 77).

DISCUSSION

The TER incidence significantly decreased during the pandemic due to the imposed lockdowns during the peak winter tourism season. The rate of foreign TER patients changed during the pandemic, while the rate of severely injured patients remained stable.

Three-dimensional analysis for quantification of knee joint space width with weight-bearing CT: comparison with non-weight-bearing CT and weight-bearing radiography

OBJECTIVE

To compare computer-based 3D-analysis for quantification of the femorotibial joint space width (JSW) using weight-bearing cone beam CT (WB-CT), non-weight-bearing multi-detector CT (NWB-CT), and weight-bearing conventional radiographs (WB-XR).

DESIGN

Twenty-six participants prospectively underwent NWB-CT, WB-CT, and WB-XR of the knee. For WB-CT and NWB-CT, the average and minimal JSW was quantified by 3D-analysis of the minimal distance of any point of the subchondral tibial bone surface and the femur. Associations with mechanical leg axes and osteoarthritis were evaluated. Minimal JSW of WB-CT was further compared to WB-XR. Two-tailed p-values of <0.05 were considered significant.

RESULTS

Significant differences existed of the average medial and lateral JSW between WB-CT and NWB-CT (medial: 4.7 vs 5.1 mm [P = 0.028], lateral: 6.3 vs 6.8 mm [P = 0.008]). The minimal JSW on WB-XR (medial:3.1 mm, lateral:5.8 mm) were significantly wider compared to WB-CT and NWB-CT (both medial:1.8 mm, lateral:2.9 mm, all p < 0.001), but not significantly different between WB-CT and NWB-CT (all p ≥ 0.869). Significant differences between WB-CT and NWB-CT existed in participants with varus knee alignment for the average and the minimal medial JSW (p = 0.004 and p = 0.011) and for participants with valgus alignment for the average lateral JSW (p = 0.013). On WB-CT, 25% of the femorotibial compartments showed bone-on-bone apposition, which was significantly higher when compared to NWB-CT (10%,P = 0.008) and WB-XR (8%,P = 0.012).

CONCLUSION

Combining WB-CT with 3D-based assessment allows detailed quantification of the femorotibial joint space and the effect of knee alignment on JSW. WB-CT demonstrates significantly more bone-on-bone appositions, which are underestimated or even undetectable on NWB-CT and WB-XR.

Was passierte, als wir uns begegneten

Dieser Beitrag zeichnet den Weg von der Vision einer Projektidee bis hin zur erfolgreichen Umsetzung nach: die Entstehung einer Medienwerkstatt, die aus den zufälligen Begegnungen, die täglich in Bibliotheken stattfinden, eine medienversierte Community wachsen lässt. Ein Projekt, das die Potentiale untersuchen möchte, wenn sich zunächst Fremde in einem Quartier zusammenschließen, um gemeinsam für mehr Kultur, Toleranz und demokratische Werte einzustehen und zu Zukunftsgestaltern zu werden.

Nephrotoxicity and hematotoxicity one year after four cycles of peptide receptor radionuclide therapy (PRRT) and its impact on future treatment planning. A retrospective analysis

INTRODUCTION

Nephro- and hematotoxicity after peptide receptor radionuclide therapy (PRRT) have been described in multiple studies with heterogeneous cumulative activities, number of cycles or radiolabelled peptides. Though highly differentiated metastasized neuroendocrine tumours (NET) have long progression free survival, they may progress. We analysed long-term side effects in a homogenous treatment schedule in PRRT-patients and their impact on future oncologic treatment in case of progression.

METHODS

From our database 89/384 patients receiving the same PRRT (Lu-177-DOTATATE or Y-90-DOTATOC) 4 times every 10 to 12 weeks and a follow-up at 12 months were analysed. One patient had three and 11 patients had two times four PRRT-cycles resulting in 102 cases. eGFR, Hb, WBC and platelets before the first and one year after the fourth therapy cycle were compared. eGFR-Grading was done according to chronic kidney disease classification (CKD) and grading of hematotoxicity according to Common Terminology Criteria for Adverse Events (CTCAE). Impact of age, gender, cumulative activity, type of PRRT on long-term-toxicity was also assessed.

RESULTS

eGFR grade 1-2 dropped from 87/102 at the baseline to 71 cases at follow-up (p<0.001). Before treatment grade 3a was found in 13, grade 3b in 2 cases, and at follow-up grade 3a in 25, grade 3b in 5, and grade 4 in 1 case. Anaemia prior to PRRT and at follow-up was grade 0 in 63 versus 48 (p<0.001), grade 1 in 36 versus 48, and grade 2 in three versus six cases. In white blood cell count and platelets, there were no significant changes in grading occurring. Subgroup analysis revealed that only in the age group 65 and older was there a higher incidence for anaemia (p=0.006). CONCLUSIóN: In roughly 20% of cases an increase in grading of nephro- or hematotoxicity is observed. In those patients, except in one, toxicity findings were mild or moderate one year after completion of four cycles of PRRT with either Y-90- or Lu-177-SST-analogues. In terms of safety, PRRT has no critical impact on further oncologic treatment options in the case of disease progression.

Association of mitochondrial DNA copy number with metabolic syndrome and type 2 diabetes in 14 176 individuals

BACKGROUND

Mitochondria play an important role in cellular metabolism, and their dysfunction is postulated to be involved in metabolic disturbances. Mitochondrial DNA is present in multiple copies per cell. The quantification of mitochondrial DNA copy number (mtDNA-CN) might be used to assess mitochondrial dysfunction.

OBJECTIVES

We aimed to investigate the cross-sectional association of mtDNA-CN with type 2 diabetes and the potential mediating role of metabolic syndrome.

METHODS

We examined 4812 patients from the German Chronic Kidney Disease (GCKD) study and 9364 individuals from the Cooperative Health Research in South Tyrol (CHRIS) study. MtDNA-CN was measured in whole blood using a plasmid-normalized qPCR-based assay.

RESULTS

In both studies, mtDNA-CN showed a significant correlation with most metabolic syndrome parameters: mtDNA-CN decreased with increasing number of metabolic syndrome components. Furthermore, individuals with low mtDNA-CN had significantly higher odds of metabolic syndrome (OR = 1.025; 95% CI = 1.011-1.039, P = 3.19 × 10-4 , for each decrease of 10 mtDNA copies) and type 2 diabetes (OR = 1.027; 95% CI = 1.012-1.041; P = 2.84 × 10-4 ) in a model adjusted for age, sex, smoking and kidney function in the meta-analysis of both studies. Mediation analysis revealed that the association of mtDNA-CN with type 2 diabetes was mainly mediated by waist circumference in the GCKD study (66%) and by several metabolic syndrome parameters, especially body mass index and triglycerides, in the CHRIS study (41%).

CONCLUSIONS

Our data show an inverse association of mtDNA-CN with higher risk of metabolic syndrome and type 2 diabetes. A major part of the total effect of mtDNA-CN on type 2 diabetes is mediated by obesity parameters.

Helical computed tomographic-dacryocystography in adult pet dwarf rabbits: procedure and normal appearance

Partial or complete nasolacrimal drainage system (NLDS) occlusion is a common clinical concern in rabbits. It can be assumed that computed tomographic-dacryocystography (CTDCG) might be an efficient technique in this indication. In this prospective study, the technique of CT-DCG and the appearance of the NLDS in eight healthy rabbits on CT-DCG images are described. The quality of visualization of bony structures adjacent to the NLDS was good on pre-contrast computed tomographic images. The bony lacrimal canal had a smooth contour, a regular diameter, and its mean dimensions are provided. CT-DCG technique was easy to perform and offered a good visualization of the NLDS including anatomical narrowings and bendings. CT-DCG is a minimally invasive and informative technique for evaluating the NLDS in rabbits. Its diagnostic usefulness in exploring nasolacrimal diseases remains to be specified in this species.

Assessment of the Clinical Impact of a Liver-Specific, BCAA-Enriched Diet in Major Liver Surgery

BACKGROUND

The relationship between nutrition and liver disease is relevant for the outcome after surgery. Patients with liver cirrhosis characteristically show protein-energy malnutrition with decreased levels of branched-chain amino acids (BCAA) and increased levels of aromatic amino acids.

MATERIALS AND METHODS

We conducted a prospective controlled clinical trial including 57 patients after liver transplantation or major liver resection surgery in order to test the effect of early postoperative nutrition on the outcome and nutrition profile of these patients. The test group received a dietetic program composed of ingredients naturally rich in BCAA (BCAA group), and the control group received standard hospital meals. Patient survival, liver function tests, subjective well-being, and a nutritional status including amino acid profiles were analyzed immediately and 14 days after major liver surgery (secondary end points). General health and well-being were assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (primary end point).

RESULTS

In-depth analysis of amino acid profiles was performed for patients undergoing liver resection (n = 21) and liver transplantation (n = 36). Interestingly, amino acid profiles did not correlate with body mass index or the Model for End-Stage Liver Disease score. Patients scheduled for liver transplantation showed significantly lower levels of BCAA pretransplant compared to patients undergoing liver resection. Patients in the liver resection subgroup were more likely to benefit from the BCAA cuisine in terms of significantly higher food intake and subjective rating. The clinical liver function tests, however, did not show statistical difference between the BCAA group and the control group in the examination period of 14 days.

CONCLUSION

Our specifically designed BCAA-enriched diet resulted in greater patient satisfaction and compliance with nutrition. A larger trial or longer-term follow-up may be required to identify an effect on survival, recovery, surgical complications, protein profiles, and amino acid profiles.

[Laparoscopic versus open gastrectomy for advanced gastric cancer : Operative and postoperative results]

BACKGROUND

Minimally invasive gastrectomy is increasingly becoming established worldwide as an alternative to open gastrectomy (OG); however, the majority of available articles in the literature refer to Asian populations and early stages of gastric cancer. This makes an international comparison difficult due to a discrepancy in patient populations and tumor biology as well as Asian and western treatment approaches. Little is known, therefore, whether laparoscopic gastrectomy (LG) can be performed in advanced cancer, in particular with respect to laparoscopic D2 lymphadenectomy, with sufficient radicality and safety in this country.

MATERIAL AND METHODS

All gastrectomies performed for the treatment of advanced gastric cancer with clinical UICC stages 2 and 3 between 2005 and 2017 were analyzed. A case match by age, gender and UICC stage was performed to compare the operative and early postoperative results of LG and OG.

RESULTS

A total of 243 patients with advanced gastric cancer were analyzed. Of these 81 patients (33.3%) underwent LG. The operative time for LG was around 74 min longer (279.2 min vs. 353.4 min, OG vs. LG; p < 0.001), the hospital stay after LG was around 4 days shorter (22.9 days vs. 18.4 days, OG vs. LG; p < 0.001). Significantly more lymph nodes were resected by LG (24.1 lymph nodes vs. 28.8 lymph nodes, OG vs. LG; p < 0.001). In terms of morbidity and mortality there were no differences between the groups.

CONCLUSION

The present study showed that minimally invasive gastrectomy can be performed safely and with comparable histopathological results to open surgery, even in advanced gastric cancer in western populations; however, larger case series and evidence from high-quality studies are urgently needed especially to compare short-term and long-term survival.

Embracing the positive: an examination of how well resilience factors at age 14 can predict distress at age 17

One-in-two people suffering from mental health problems develop such distress before or during adolescence. Research has shown that distress can predict itself well over time. Yet, little is known about how well resilience factors (RFs), i.e. those factors that decrease mental health problems, predict subsequent distress. Therefore, we investigated which RFs are the best indicators for subsequent distress and with what accuracy RFs predict subsequent distress. We examined three interpersonal (e.g. friendships) and seven intrapersonal RFs (e.g. self-esteem) and distress in 1130 adolescents, at age 14 and 17. We estimated the RFs and a continuous distress-index using factor analyses, and ordinal distress-classes using factor mixture models. We then examined how well age-14 RFs and age-14 distress predict age-17 distress, using stepwise linear regressions, relative importance analyses, as well as ordinal and linear prediction models. Low brooding, low negative and high positive self-esteem RFs were the most important indicators for age-17 distress. RFs and age-14 distress predicted age-17 distress similarly. The accuracy was acceptable for ordinal (low/moderate/high age-17 distress-classes: 62-64%), but low for linear models (37-41%). Crucially, the accuracy remained similar when only self-esteem and brooding RFs were used instead of all ten RFs (ordinal = 62%; linear = 37%); correctly predicting for about two-in-three adolescents whether they have low, moderate or high distress 3 years later. RFs, and particularly brooding and self-esteem, seem to predict subsequent distress similarly well as distress can predict itself. As assessing brooding and self-esteem can be strength-focussed and is time-efficient, those RFs may be promising for risk-detection and translational intervention research.

P3402Validation of the SCORE O.P. for prediction of cardiovascular disease mortality in a large population of elderly individuals

Background

Estimation of absolute cardiovascular risk in apparently healthy individuals, using SCORE (Systematic COronary Risk Evaluation) is recommended by the ESC guidelines on cardiovascular disease (CVD) prevention in clinical practice. Recently, the SCORE system has been extended by the SCORE O.P. aiming to improve estimates of cardiovascular risk specifically in older persons (65 years and older).

Purpose

The aim of this study was to validate the SCORE O.P. in an Austrian population of 34,909 healthy individuals aged between 65 and 80 years which were prospectively followed for a minimum of 10 years.

Methods

Predicted fatal CVD and coronary heart disease (CHD) event rates within 10 years were calculated using the “SCORE O.P. risk function for low risk regions” and compared to the actually observed rates, thereby assessing calibration. In addition, predicted probabilities were plotted against observed mortality by deciles of predicted risk. Regarding discrimination, receiver operating characteristics (ROC) analysis and corresponding c-statistics were used.

Results

In 14,586 males, 1,509 deaths from CVD (10.4%) and 847 deaths from CHD (5.8%) occurred within 10 years of follow-up. SCORE O.P. predicted 1,699 fatal CVD (11.7%) and 872 CHD (6.0%) events. In male high risk individuals (10th decile), SCORE O.P. overestimated mortality from CVD and CHD. C-statistics were 0.68 (95% CI 0.67–0.70) for CVD and 0.67 (0.65–0.69) for CHD.

In 20,323 females, 1,340 deaths from CVD (6.6%) and 672 deaths from CHD (3.3%) were observed. SCORE O.P. predicted 1,232 fatal CVD (6.1%) and 539 CHD events (2.7%). In female high risk individuals (8–10th deciles), SCORE O.P. underestimated mortality from CVD and CHD. C-statistics were 0.77 (0.75–0.78) for CVD and 0.77 (0.75–0.79) for CHD.

Conclusion

With regard to overall accuracy, the SCORE O.P. performed considerably well in this elderly Austrian population. However, in high-risk individuals, cardiovascular risk was overestimated for males and underestimated for females. SCORE O.P. was able to discriminate high-risk from low-risk individuals, better in women than in men.

P6427Positive family history of cardiovascular disease and long-term outcomes after coronary artery bypass grafting in younger patients: a genetic paradox?

Background

Parental cardiovascular disease (CVD) is a known risk factor for premature CVD in both men and women. It is unknown whether a positive family history (PFH) of premature CVD also affects long-term outcomes after coronary artery bypass grafting (CABG).

Purpose

We estimated the prevalence of PFH of premature CVD in a large population of CABG patients younger than 60 years of age. We evaluated whether PFH is an independent predictor of survival and freedom from major adverse cardiac and cerebrovascular events (MACCEs) following CABG.

Methods

Data come from a prospective longitudinal study of first, non-emergent, CABG patients consecutively recruited at the Innsbruck Medical University between August 2001 and February 2018 (n=5389). Patients were followed up for a median of 8 years. From this study, 2553 patients with premature CAD undergoing CABG under the age of 60 years were identified. Self-reported PFH data was available for 99.3% of patients; n=2535 patients were eligible for these analyses. In line with the Framingham offspring study, a premature PFH of CVD was defined when a patient's father and/or mother experienced their first CV event at <55 (father) and <65 (mother) years of age, respectively. Adjusted multivariable Cox proportional hazards regression was used to assess the effect of PFH on overall and MACCE-free survival.

Results

Premature PFH was found in 54.2% of patients (n=1375). Within these patients, 66.1% had a father who experienced a premature CV event (n=909), 27.8% a mother (n=382) and 6.1% both a mother and a father (n=84). In the majority of cases the patient's parent had experienced a premature cardiac event (85.9%, n=1181), 14.1% of patients with PFH reported their parent(s) had a premature stroke (n=194). Patients with a PFH had lower rates of smoking, diabetes and renal disease but were more likely to be hypertensive. Following CABG, PFH was associated with improved long-term survival (adjusted HR, 0.66; 95% CI, 0.50–0.91; p=0.011) and MACCE-free survival (adjusted HR, 0.73; 95% CI, 0.68–0.89; p=0.01). Among the covariates adjusted for, age, diabetes, renal insufficiency, peripheral arterial disease, impaired left ventricular function, previous cerebrovascular events and previous mediastinal radiation were associated with poorer outcomes. In contrast, multiple arterial grafting by bilateral internal thoracic arteries improved both survival (adjusted HR, 0.52; 95% CI, 0.36–0.74; p<0.001), and MACCE-free survival (adjusted HR, 0.41; 95% CI, 0.31–0.54; p<0.001).

Conclusion

In this cohort of high-risk patients undergoing CABG under 60 years of age, PFH was highly prevalent. Whilst it is evident that a PFH increases the risk of requiring CABG at younger ages, this study shows that PFH is also, paradoxically, protective regarding long-term outcomes; PFH is associated with both improved overall and MACCE-free survival following CABG.

A cluster of two human cases of tick-borne encephalitis (TBE) transmitted by unpasteurised goat milk and cheese in Germany, May 2016

In May 2016, two cases of tick-borne encephalitis (TBE) were confirmed by serology (positive IgM and IgG antibodies against TBE virus (TBEV) in serum), with a possible link to raw milk and cheese from a goat farm in a region in Baden-Württemberg, Germany not previously known as TBE-endemic. The outbreak investigation identified 32 consumers of goat dairy products (29 consumers, one farm employee, two owners) of whom none had IgM antibodies against TBEV 3–8 weeks after consumption. Of the 27 notified TBE cases in the State, none reported consumption of raw goat milk or cheese from the suspected farm. Five of 22 cheese samples from 18 different batches were RT-qPCR-positive for TBEV -genome, and two of the five samples were confirmed by virus isolation, indicating viability of TBEV in the cheese. Nine of the 45 goats had neutralising TBEV antibodies, two of them with a high titre indicating recent infection. One of 412 Ixodes ricinus was RT-qPCR-positive, and sequencing of the E gene from nucleic acid extracted from the tick confirmed TBEV. Phylogenetic analyses of tick and cheese isolates showed 100% amino acid homology in the E gene and a close relation to TBEV strains from Switzerland and Austria.

Medical management of Echinococcus multilocularis infection mimicking a locally aggressive cavitary tumor with pulmonary metastases in a dog

A two-year-old Labrador retriever living in the French Alps was presented with abdominal distension, lethargy and weight loss but no other specific clinical signs. CT examination revealed a large, cavitary liver mass invading the caudal vena cava, associated with multiple hepatic lesions of similar appearance, lymphadenopathy and pulmonary nodules. The condition was initially mistaken for a malignant neoplasm. However, cytologic and histologic examinations of the largest liver mass were consistent with cestodiasis and PCR testing confirmed infection with Echinococcus multilocularis. Medical treatment with albendazole was initiated. The dog remained clinically well for ten months following the diagnosis, but had to be euthanized because the owners had to return to Great-Britain and the dog could not be legally imported. To the authors’ knowledge, this is the first case report, in which long-term follow-up of Echinococcus sp. infection in a dog, managed medically, is described. This case also shows that medical management may be a viable option in case surgery is not feasible.

Computed tomography textural analysis for the differentiation of chronic lymphocytic leukemia and diffuse large B cell lymphoma of Richter syndrome

OBJECTIVE

To test the hypothesis that both indolent and aggressive chronic lymphocytic leukemia (CLL) can be differentiated from diffuse large B cell lymphoma (DLBCL) of Richter syndrome (RS) by CT texture analysis (CTTA) of involved lymph nodes.

MATERIAL AND METHODS

We retrospectively included 52 patients with indolent CLL (26/52), aggressive CLL (8/52), and DLBCL of RS (18/52), who underwent standardized contrast-enhanced CT. In main lymphoma tissue, VOIs were generated from which CTTA features including first-, second-, and higher-order textural features were extracted. CTTA features were compared between the entire CLL group, the indolent CLL subtype, the aggressive CLL subtype, and DLBCL using a Kruskal-Wallis test. All p values were adjusted after the Bonferroni correction. ROC analyses for significant CTTA features were performed to determine cut-off values for differentiation between the groups.

RESULTS

Compared with DLBCL of RS, CTTA of the entire CLL group showed significant differences of entropy heterogeneity (p < 0.001), mean intensity (p < 0.001), mean average (p = 0.02), and number non-uniformity gray-level dependence matrix (NGLDM) (p = 0.03). Indolent CLL significantly differed for entropy (p < 0.001), uniformity of heterogeneity (p = 0.02), mean intensity (p < 0.001), and mean average (p = 0.01). Aggressive CLL showed significant differences in mean intensity (p = 0.04). For differentiation between CLL and DLBCL of RS, cut-off values for mean intensity and entropy of heterogeneity were defined (e.g., 6.63 for entropy heterogeneity [aggressive CLL vs. DLBCL]; sensitivity 0.78; specificity 0.63).

CONCLUSIONS

CTTA features of ultrastructure and vascularization significantly differ in CLL compared with that in DLBCL of Richter syndrome, allowing complementary to visual features for noninvasive differentiation by contrast-enhanced CT.

KEY POINTS

• Richter transformation of CLL into DLBCL results in structural changes in lymph node architecture and vascularization that can be detected by CTTA. • First-order CT textural features including intensity and heterogeneity significantly differ between both indolent CLL and aggressive CLL and DLBCL of Richter syndrome. • CT texture analysis allows for noninvasive detection of Richter syndrome which is of prognostic value.

The effect of intraparenchymal blood patching on the rate of pneumothorax in patients undergoing percutaneous CT-guided core biopsy of the lung

PURPOSE

To assess the effect of intraparenchymal blood patching (IBP) as well as tumor- and operator-related risk factors on the rate of pneumothoraxes after percutaneous CT-guided core needle biopsy of the lung.

MATERIALS AND METHODS

We performed a retrospective analysis of 868 CT-guided lung biopsies that were conducted at our institution between 2003 and 2018, of which 419 (48%) received an IBP. Outcome variable included the rates of pneumothorax and chest tube placement, as well as lesion size (<3 cm versus ≥3 cm long axis diameter), lesion depth (≤2 cm, >2-4 cm, >4-5 cm and >5 cm distance to the pleura), location within the lungs (upper lobe, lower lobe, middle lobe), needle caliber (13 G, 15 G, 17 G, 19 G), number of samples taken (1-3 versus ≥4 samples), and experience of the performing physician.

RESULTS

The rate of pneumothorax was significantly (p < 0.05) lower in the group with IBP (10.7%) compared to the group without IBP (15.4%). The number of post-interventional chest tube placements was also lower in the IBP group (3.1% vs. 5.8%) but not statistically significant. The lesion size correlated negatively with the rate of pneumothoraxes, whereas in both groups (±IBP) lesions ≥ 3 cm showed a significantly lower rate of pneumothorax (p < 0.05). With increasing lesion depth, the pneumothorax rate increased with (p < 0.01) and without (p < 0.001) IBP. The rate of pneumothorax was significantly lower (p < 0.05) for 17 G needles with IBP, but not for other calibers. For biopsies in the lower lobe, the pneumothorax rate reduced significantly (p < 0.001) with IBP. In case of ≥4 tissue samples, the pneumothorax rate was significantly lower with IBP (p < 0.01). For experienced operators, the overall pneumothorax rate was significantly lower compared to less experienced operators (p < 0001).

CONCLUSIONS

IBP significantly reduces the rate of pneumothorax following CT-guided lung biopsies in particular for lesions located deeper in the lungs, when ≥4 samples are taken, when samples are taken by less-experienced operators, and when sampling from the lower lobes.

A Network Model of Resilience Factors for Adolescents with and without Exposure to Childhood Adversity

Resilience factors (RFs) help prevent mental health problems after childhood adversity (CA). RFs are known to be related, but it is currently unknown how their interrelations facilitate mental health. Here, we used network analysis to examine the interrelations between ten RFs in 14-year-old adolescents exposed ('CA'; n = 638) and not exposed to CA ('no-CA'; n = 501). We found that the degree to which RFs are assumed to enhance each other is higher in the no-CA compared to the CA group. Upon correction for general distress levels, the global RF connectivity also differed between the two groups. More specifically, in the no-CA network almost all RFs were positively interrelated and thus may enhance each other, whereas in the CA network some RFs were negatively interrelated and thus may hamper each other. Moreover, the CA group showed more direct connections between the RFs and current distress. Therefore, CA seems to influence how RFs relate to each other and to current distress, potentially leading to a dysfunctional RF system. Translational research could explore whether intervening on negative RF interrelations so that they turn positive and RFs can enhance each other, may alter 'RF-mental distress' relations, resulting in a lower risk for subsequent mental health problems.

Extended physical education in children aged 6-15 years was associated with improved academic achievement in boys

AIM

Physical activity (PA) has been associated with enhanced cognition, brain development and concentration. This study evaluated whether increased physical education (PE) improved academic achievement.

METHODS

We recruited 304 children (55% boys) from a Swedish school in Skane County in 1998-2002 when they were six to seven years of age and followed them through all nine mandatory school years. Their PE level was increased from 60 to 200 minutes per week, and their results were compared with 73 885 control children (51% boys) in the county who graduated in the same years and did the standard 60 minutes of PE per week. Their academic achievements were measured as their final grade scores and the proportion of students eligible for upper secondary school.

RESULTS

The eligibility for further education increased in the intervention boys by 6.8 percentage points and the mean grade score by 12.1 points, while in the control group as a whole, the eligibility rate decreased by 0.7 percentage points and the mean grade score increased by 1.7 points. No changes in eligibility rates or mean grade scores were seen in the intervention girls.

CONCLUSION

Increasing weekly PE over nine years was associated with improved academic achievement in boys.

Discriminatory CT-textural features in splenic infiltration of lymphoma versus splenomegaly in liver cirrhosis versus normal spleens in controls and evaluation of their role for longitudinal lymphoma monitoring

PURPOSE

To find CT-texture analysis (CTTA) features for the discrimination of splenomegaly due to diffuse lymphoma involvement and liver cirrhosis versus normal-sized spleens in controls and to assess their potential role for longitudinal lymphoma monitoring.

MATERIAL AND METHODS

We had retrospectively identified 74 subjects with diffuse splenic involvement due to lymphoma (n = 29) and liver cirrhosis (n = 30), and healthy controls (n = 15), who underwent contrast-enhanced abdominal CT between August 2013 and October 2017. CTTA evaluation included heterogeneity, intensity, average, deviation, skewness, entropy of co-occurrence, number non-uniformity (NGLDM) and entropy NGLDM. A greater than 50% reduction of spleen volume after chemotherapy was considered proof for splenic involvement.

RESULTS

There were significant differences of splenic CTTA-values before and after treatment of patients with lymphoma, including mean of entropy(p < .001), uniformity of average(p < .001), uniformity of deviation(p = .002) and entropy of skewness(p < .001). Significant differences of splenic CTTA-values in subjects with lymphoma vs. healthy controls were found for mean intensity(p < .001), mean average(p < .001), and entropy of deviation(p < .001). No significant differences in splenic CTTA-values were found in subjects with lymphoma that reached complete remission vs. controls. Splenic CTTA values mean intensity(p = .002) and mean average(p = .004) were significantly different between subjects with untreated lymphoma and subjects with liver cirrhosis. At end-of-treatment all lymphomas reached complete remission. Entropy/uniformity of heterogeneity(p < .001), mean intensity(p = .007), mean average (p = .007), uniformity of average(p = .008) and mean/entropy/uniformity of skewness(p = .001) measured at this time differed significantly from baseline.

CONCLUSIONS

CTTA features in subjects with splenomegaly due to lymphoma and liver cirrhosis differ significantly from those of healthy controls and can be also used for monitoring lymphoma treatment. Quantitative CTTA features may increase the accuracy of diagnosing causes of splenomegaly.

Relation between travel strategy and social organization of migrating birds with special consideration of formation flight in the northern bald ibis

A considerable proportion of the world's bird species undertake seasonal long-distance migrations. These journeys are energetically demanding. Two major behavioural means to reduce energy expenditure have been suggested: the use of thermal uplifts for a soaring-gliding migration style and travelling in echelon or V-shaped formation. Both strategies have immediate consequences for the social organization of the birds as they either cause large aggregations or require travelling in small and stable groups. Here, we first discuss those consequences, and second present an analysis of formation flight in a flock of northern bald ibis on their first southbound migration. We observe clear correlations between leading and trailing on the dyadic level but only a weak correlation on the individual level during independent flight and no convincing correlation during the human guided part of the migration. This pattern is suggestive of direct reciprocation as a means for establishing cooperation during formation flight. In general, we conclude that behavioural adaptations for dealing with physiological constraints on long-distance migrations either necessitate or ultimately foster formation of social groups with different characteristics. Patterns and social organization of birds travelling in groups have been elusive to study; however, new tracking technology-foremost lightweight GPS units-will provide more insights in the near future.This article is part of the themed issue 'Physiological determinants of social behaviour in animals'.

Chest CT texture analysis for response assessment in systemic sclerosis

PURPOSE

To evaluate the role of CT-textural features for monitoring lung involvement in subjects with systemic sclerosis(SSc) undergoing autologous stem cell transplantation(SCT) by comparison with semi-quantitative chest-CT, pulmonary function tests(PFT) and clinical parameters (modified Rodnan skin score[mRSS]).

METHODS

In a retrospective single centre analysis, we identified 23 consecutive subjects(11male) with SSc between 07/2005 and 11/2016 that underwent chest CTs before, 6 and 12 months post-SCT. Response to therapy was defined at 6 months after transplantation as stabilisation or improvement in FVC > 10% and DLCO_SB > 10%. CT-texture analysis(CTTA) including mean, entropy and uniformity were calculated.

RESULTS

PFT classified the subjects into responders(18/23;78%) and non-responders(5/23;22%). mRSS improved in responders from 28.46 ± 9.53 to 15.70 ± 10.07 6 months after auto-SCT(p = .001) whereas in non-responders no significant improvement was registered. Fibrosis score increased significantly(mean2.33 ± 1.23 vs.1.41 ± 0.78; p = .005) in non-responders after 6 and 12months. Significant lower mean intensity and entropy of skewness and higher uniformity of skewness was found in responders vs. non-responders at baseline. Significant changes in CTTA-parameters were found in both responders and non-responders at 6months and only in responders also at 12months post-SCT.

CONCLUSIONS

Changes in CT-textural features after SCT are associated with visual CT evaluation of SSc-related lung abnormalities, but complementary provide information about therapy-induced, structural pulmonary changes.

Time lapse AFM on vesicle formation from mixed lipid bilayers induced by the membrane-active peptide melittin

Melittin is a model system for the action of antimicrobial peptides which are potential candidates for novel antibiotics. We investigated the membrane lysis effect of melittin on phase-separated supported lipid bilayers (DOPC-DPPC) by atomic force microscopy. AFM images show that the peptide first forms defects at the interface between the two lipid phases and then degrades preferentially the liquid-phase DOPC-enriched domains. Vesicular structures of 10-20 nm radius were observed to form, suggesting a mixed carpet-toroidal model mechanism for the resolved action of melittin.

Frequency Selective Non-Linear Blending to Improve Image Quality in Liver CT

Purpose: To evaluate the effects of a new frequency selective non-linear blending (NLB) algorithm on the contrast resolution of liver CT with low intravascular concentration of iodine contrast. Materials and Methods: Our local ethics committee approved this retrospective study. The informed consent requirement was waived. CT exams of 25 patients (60 % female, mean age: 65 ± 16 years of age) with late phase CT scans of the liver were included as a model for poor intrahepatic vascular contrast enhancement. Optimal post-processing settings to enhance the contrast of hepatic vessels were determined. Outcome variables included signal-to-noise (SNR) and contrast-to-noise ratios (CNR) of hepatic vessels and SNR of liver parenchyma of standard and post-processed images. Image quality was quantified by two independent readers using Likert scales. Results: The post-processing settings for the visualization of hepatic vasculature were optimal at a center of 115HU, delta of 25HU, and slope of 5. Image noise was statistically indifferent between standard and post-processed images. The CNR between the hepatic vasculature (HV) and liver parenchyma could be significantly increased for liver veins (CNR_Standard 1.62 ± 1.10, CNR_NLB 3.6 ± 2.94, p = 0.0002) and portal veins (CNR_Standard 1.31 ± 0.85, CNR_NLB 2.42 ± 3.03, p = 0.046). The SNR of liver parenchyma was significantly higher on post-processed images (SNR_NLB 11.26 ± 3.16, SNR_Standard 8.85 ± 2.27, p = 0.008). The overall image quality and depiction of HV were significantly higher on post-processed images (NLB_DHV: 4 [3 - 4.75], S_tandardDHV: 2 [1.3 - 2.5], p = < 0.0001; _NLBIQ: 4 [4 - 4], _StandardIQ: 2 [2 - 3], p = < 0.0001). Conclusion: The use of a frequency selective non-linear blending algorithm increases the contrast resolution of liver CT and can improve the visibility of the hepatic vasculature in the setting of a low contrast ratio between vessels and the parenchyma. Key Points: • Using the new frequency selective non-linear blending algorithm is feasible in contrast-enhanced liver CT.• Optimal post-processing settings make it possible to significantly increase the contrast resolution of liver CT without affecting image noise.• Especially in low contrast CT images, the novel algorithm is capable of significantly increasing image quality. Citation Format: • Bongers MN, Bier G, Kloth C et al. Frequency Selective Non-Linear Blending to Improve Image Quality in Liver CT. Fortschr Röntgenstr 2016; 188: 1163 - 1168.

[Treatment of Osteochondral Lesions in the Ankle: A Guideline from the Group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU)]

Background: Osteochondral lesions (OCL) of the ankle are a common cause of ankle pain. Although the precise pathophysiology has not been fully elucidated, it can be assumed that a variety of factors are responsible, mainly including traumatic events such as ankle sprains. Advances in arthroscopy and imaging techniques, in particular magnetic resonance imaging (MRI), have improved the possibilities for the diagnosis of OCLs of the ankle. Moreover, these technologies aim at developing new classification systems and modern treatment strategies. Material and Methods: This article is a review of the literature. Recommendations of the group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) for the treatment of OCLs of the ankle are presented. The review gives a concise overview on the results of clinical studies and discusses advantages and disadvantages of different treatment strategies. Results: Non-operative treatment shows good results for selected indications in children and adolescents, especially in early stages of osteochondritis dissecans (OCD). However, surgical treatment is usually indicated in OCLs in adolescents and adults, depending on the size and location of the lesion. Various arthroscopic and open procedures are frequently employed, including reattachment of the fragment, local debridement of the lesion with fragment removal and curettage of the lesion, bone marrow-stimulation by microfracture or microdrilling (antegrade or retrograde), and autologous matrix-induced chondrogenesis (AMIC®) - with or without reconstruction of a subchondral bone defect or cyst by autologous cancellous bone grafting. Isolated subchondral cysts with an intact cartilage surface can be treated by retrograde drilling and possibly additional retrograde bone grafting. For larger defects or as salvage procedure, osteochondral cylinder transplantation (OATS® or Mosaicplasty®) or matrix-induced autologous chondrocyte transplantation (MACT) are recommended. Transplantation of so-called (osteochondral) mega grafts, such as autologous bone grafts or allografts, are used for very large osteochondral defects that cannot be reconstructed otherwise. Implantation of the so-called "small metal implants" - such as HemiCAP Talus® - is reserved for selected cases after failed primary reconstruction. Corrective osteotomies are indicated in accompanying axial malalignments. Conclusions: There are several different treatment strategies for OCLs, but clinical studies are rare and evidence is limited. Therefore, interventional studies, e.g. randomised controlled trials (RCTs), but also observational studies, e.g. based on data of the Cartilage Registry of the German Society of Orthopaedics and Traumatology (www.knorpelregister-dgou.de), are needed and are recommended by the authors.

Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: A guideline by the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU)

BACKGROUND

Autologous chondrocyte implantation (ACI) is an established and well-accepted procedure for the treatment of localised full-thickness cartilage defects of the knee.

METHODS

The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning therapeutic consequences of primary cartilage lesions and the suitable indication for ACI.

RESULTS

Based on best available scientific evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than three to four square centimetres; in the case of young and active sports patients at 2.5cm(2), while advanced degenerative joint disease needs to be considered as the most important contraindication.

CONCLUSION

The present review gives a concise overview on important scientific background and the results of clinical studies and discusses the advantages and disadvantages of ACI.

LEVEL OF EVIDENCE

Non-systematic Review.

The associations of physical activity with fracture risk--a 7-year prospective controlled intervention study in 3534 children

SUMMARY

This is the first study indicating an association between gradually diminished risk of fractures and years of increased physical activity. Our results could imply great benefits not only for the individual but also for the healthcare burden and cost of society.

INTRODUCTION

Physical activity (PA) in childhood is associated with high bone mass and beneficial neuromuscular function. We investigate if increased PA also is associated with fracture risk.

METHODS

We registered fractures in 3534 children aged 6 to 8 years at study start for up to 7 years; 1339 with 40 min of moderate PA every school day (intervention) and 2195 with the Swedish standard curriculum of 60 min of PA per school week (controls). In a subsample of 264 children, we measured areal bone mineral density (aBMD; g/cm(2)) with dual-energy X-ray absorptiometry (femoral neck and total spine) and muscle strength (peak torque for knee extension and flexion; Nm) with computerized dynamometer at baseline and after 7 years. We estimated annual fracture incidence rate ratios (IRR) in the intervention group compared to the control group as well as changes in bone mass and muscle strength. Data is given as mean (95% CI).

RESULTS

The IRR of fractures decreased with each year of the PA intervention (r = -0.79; p = 0.04). During the seventh year, IRR was almost halved [IRR 0.52 (0.27, 1.01)]. The intervention group had a statistically significant greater gain in total spine aBMD with a mean group difference of 0.03 (0.00, 0.05) g/cm(2) and peak flexion torque 180° with a mean group difference of 5.0 (1.5, 8.6) Nm.

CONCLUSIONS

Increased PA is associated with decreased fracture risk, probably in part due to beneficial gains in aBMD and muscle strength.

Design and development of a mobile image overlay system for needle interventions

Previously, a static and adjustable image overlay systems were proposed for aiding needle interventions. The system was either fixed to a scanner or mounted over a large articulated counterbalanced arm. Certain drawbacks associated with these systems limited the clinical translation. In order to minimize these limitations, we present the mobile image overlay system with the objective of reduced system weight, smaller dimension, and increased tracking accuracy. The design study includes optimal workspace definition, selection of display device, mirror, and laser source. The laser plane alignment, phantom design, image overlay plane calibration, and system accuracy validation methods are discussed. The virtual image is generated by a tablet device and projected into the patient by using a beamsplitter mirror. The viewbox weight (1.0 kg) was reduced by 8.2 times and image overlay plane tracking precision (0.21 mm, STD = 0.05) was improved by 5 times compared to previous system. The automatic self-calibration of the image overlay plane was achieved in two simple steps and can be done away from patient table. The fiducial registration error of the physical phantom to scanned image volume registration was 1.35 mm (STD = 0.11). The reduced system weight and increased accuracy of optical tracking should enable the system to be hand held by the physician and explore the image volume over the patient for needle interventions.

Dual-Energy Imaging of Bone Marrow Edema on a Dedicated Multi-Source Cone-Beam CT System for the Extremities

PURPOSE

Arthritis and bone trauma are often accompanied by bone marrow edema (BME). BME is challenging to detect in CT due to the overlaying trabecular structure but can be visualized using dual-energy (DE) techniques to discriminate water and fat. We investigate the feasibility of DE imaging of BME on a dedicated flat-panel detector (FPD) extremities cone-beam CT (CBCT) with a unique x-ray tube with three longitudinally mounted sources.

METHODS

Simulations involved a digital BME knee phantom imaged with a 60 kVp low-energy beam (LE) and 105 kVp high-energy beam (HE) (+0.25 mm Ag filter). Experiments were also performed on a test-bench with a Varian 4030CB FPD using the same beam energies as the simulation study. A three-source configuration was implemented with x-ray sources distributed along the longitudinal axis and DE CBCT acquisition in which the superior and inferior sources operate at HE (and collect half of the projection angles each) and the central source operates at LE. Three-source DE CBCT was compared to a double-scan, single-source orbit. Experiments were performed with a wrist phantom containing a 50 mg/ml densitometry insert submerged in alcohol (simulating fat) with drilled trabeculae down to ~1 mm to emulate the trabecular matrix. Reconstruction-based three-material decomposition of fat, soft tissue, and bone was performed.

RESULTS

For a low-dose scan (36 mAs in the HE and LE data), DE CBCT achieved combined accuracy of ~0.80 for a pattern of BME spherical lesions ranging 2.5 - 10 mm diameter in the knee phantom. The accuracy increased to ~0.90 for a 360 mAs scan. Excellent DE discrimination of the base materials was achieved in the experiments. Approximately 80% of the alcohol (fat) voxels in the trabecular phantom was properly identified both for single and 3-source acquisitions, indicating the ability to detect edemous tissue (water-equivalent plastic in the body of the densitometry insert) from the fat inside the trabecular matrix (emulating normal trabecular bone with significant fraction of yellow marrow).

CONCLUSION

Detection of BME and quantification of water and fat content were achieved in extremities DE CBCT with a longitudinal configuration of sources providing DE imaging in a single gantry rotation. The findings support the development of DE imaging capability for CBCT of the extremities in areas conventionally in the domain of MRI.