Salivary cortisone as potential predictor of occupational exposure to noise and related stress

Salivary cortisone strongly correlates with serum cortisol, and since it is less invasive to measure salivary cortisone than serum cortisol and easier than to measure cortisol in saliva, as its concentrations are much lower, we wanted to compare salivary cortisone and cortisol levels as markers of noise-induced stress reaction. The study included 104 participants aged 19-30 years, 50 of whom were exposed to occupational noise ≥85 dB(A) and 54 non-exposed, control students. All participants took samples of their saliva with Salivette® Cortisol synthetic swabs on three consecutive working days first thing in the morning. Salivary cortisone and cortisol levels were determined with high-performance liquid chromatography. In addition, they completed a 10-item Perceived Stress Scale (PSS-10) questionnaire, and occupationally noise-exposed participants also completed the Health and Safety Executive (HSE) questionnaire on occupational psychosocial risks. The exposed participants had significantly higher cortisone (P<0.001) and cortisol (P<0.001) levels than controls, and the correlation between cortisone and cortisol levels in the exposed participants was strong (ϱ =0.692, P<0.001), which suggests that salivary cortisone can replace cortisol measurements in saliva as a more reliable method than salivary cortisol and less invasive than serum cortisol. However, the level of perceived stress scored on PSS-10 in the exposed participants did not differ significantly from stress reported by controls, but correlated negatively with cortisone levels, which is contrary to our expectations and raises questions as to why.

Impact of Intraoperative Findings on Hearing in Revision Ear Surgery

Introduction

Hearing results after chronic ear surgery encompass recurrence, localization and extent of cholesteatoma, type of surgery, ossiculoplasty methods, but rarely interpret intraoperative findings. This study aimed to analyze the impact of intraoperative findings in revision tympanomastoidectomy in predicting postoperative hearing.

Materials and Methods

This was a retrospective non-randomized cohort of 101 patients treated for recurrent chronic otitis media by tympanomastoidectomy. The patients' demographics, localizations of disease recurrence and perioperative hearing results were analyzed.

Results

Logistic regression showed that presence of tympanic perforation (p=0.036), ossicular chain damage (p=0.006), were negatively associated with improved hearing postoperatively. Attic cholesteatoma was associated with better postoperative hearing (p=0.045). Presence of tympanic perforation (p=0.050), alongside perifacial localization of imflammation (p=0.021) and ossicle destruction (p=0.013) were associated with worse postoperative hearing results. Multivariate analysis confirmed that tympanic perforation (p=0.040, F=4.401), and ossicular chain involvement (p=0.025, F=5.249), were consistent negative predictors of hearing improvement, while postoperative deterioration of hearing was associated with tympanic perforation (p=0.038, F=4.465) and facial nerve dehiscence (p=0.045, F=4.160).

Conclusions

Comparison of postoperative revision tympanomastoidectomy hearing outcomes revealed significant positive reductions in air-bone gap values, primarily at low and mid frequencies. Postoperative hearing results at high frequencies are not affected by revision surgery.

Surgical Considerations in Addressing Cholesterol Granuloma of the Petrous Apex through an Infracochlear Approach

Cholesterol granuloma of the petrous bone is a foreign body giant cell reaction to cholesterol deposits with symptoms including hearing loss, vestibular dysfunction, and cranial nerve deficit as a result of cystic mass compression. Surgical treatment is often difficult to plan due to limited access to the lesion and possible injury to surrounding structures. We report on a case of petrous apex cholesterol granuloma drainage through an infracochlear approach. A 27-year-old female patient presented with acute diplopia due to left-sided abducens paralysis. Multislice computed tomography (MSCT) and magnetic resonance (MR) imaging described a 3.5-cm well-marginated lesion in petrous bone apex, compressing the left abducens nerve at the point of entry into the cavernous sinus, corresponding to cholesterol granuloma. The patients was surgically treated through a transcanal infracochlear approach, since preserving the external and middle ear conduction mechanisms was paramount for the patient. The patient was discharged on the second postoperative day and diplopia resolved within 5 days postoperatively. Six months after the surgery, her hearing on the left side is normal, and she remains symptom-free. This case underpins the value of preoperative planning when approaching the petrous apex, an anatomically complex area due to abundance of important neurovascular structures crowded in a narrow and confined region.

Impact of preoperative antibiotic use in preventing complications of cochlear implantation surgery

OBJECTIVE

To examine the impact of preoperative antibiotic prophylaxis on the occurrence of postoperative complications.

MATERIALS AND METHODS

Data of 491 patients undergoing cochlear implantation were included in a non-randomized retrospective comparative cohort study. Demographic data, cochlear implant and surgical details, use of preoperative antibiotics and occurrence of postoperative complications were analyzed using a binary logistic regression model.

RESULTS

There were 317 patients (64.56%) who did not receive preoperative antibiotic prophylaxis and 174 (35.44%) patients who received preoperative antibiotic prophylaxis with ceftriaxone. The overall rate of complications requiring surgical treatment was 2.85%. Younger patient age was identified as a positive predictive factor for administering preoperative antibiotic prophylaxis (p<0.001, OR 1.05 CI 95% 1.0124-1.0826). No difference in complication rate was observed between the two groups. No correlation between sex, age, manufacturer, surgeon and postoperative complications were noted (p=0.45).

CONCLUSION

There is insufficient evidence to inform decision making regarding preoperative intravenous ceftriaxone use for prevention of infection after cochlear implantation surgery, with data failing to show that administration of preoperative antibiotics leads to a decrease in complication rate. Considering a very low overall complication rate, with few complications related to infection, routine use of preoperative antibiotic prophylaxis should be analyzed further.

Expression and localization of FGFR1, FGFR2 and CTGF during normal human lung development

Aim of our study was to provide insight into the temporal and spatial expression of FGFR1, FGFR2 and CTGF during normal human lung development which may have an important impact on understanding occurrence of developmental lung anomalies. Morphological parameters were analysed using double immunofluorescence on human embryonal (6th and 7th developmental week-dw) and foetal (8th, 9th and 16th developmental week) human lung samples. FGFR1 and FGFR2 was positive during all the dw in both the epithelium and mesenchyme. The highest number of FGFR1 positive cells was observed during the 6th dw (112/mm²) and 9th dw (87/mm²) in the epithelium compared to the 7th, 8th and 16th dw (Kruskal-Wallis test, p < 0.001, p < 0.0001). The highest number of FGFR1 positive cells in the mesenchyme was observed during the 8th dw (19/mm²) and 16th dw (13/mm²) compared to the 6th, 7th, and 9th dw (Kruskal-Wallis test, p < 0.001, p < 0.0001). The number of FGFR1 positive cells in the epithelium was higher for FGFR2 compared to number of positive cells (Mann-Whitney test, p < 0.0001). FGFR2 showed the highest number in the epithelium during the 7th dw (111/mm²) and 9th dw (87/mm²) compared to 6th, 8th and 16th dw (Kruskal-Wallis test, p < 0.001, p < 0.0001, p < 0.01 respectively). The highest number of FGFR2 positive cells in the mesenchyme was observed during the 9th dw (26/mm²), compared to the 6th, 7th,8th and 16th dw (Kruskal-Wallis test, p < 0.0001), while the number of FGFR2 positive cells in the epithelium was significantly higher than in the mesenchyme (Mann-Whitney test, p < 0.0001). CTGF was negative in both epithelium and mesenchyme during all except the 16th dw in the mesenchyme where it co-localized with FGFR2. FGFR1 and FGFR2 might be essential for epithelial-mesenchymal interactions that determine epithelial branching and mesenchymal growth during early lung development. Sudden increase in FGF1 in the epithelium and FGF2 in the mesenchyme in the foetus at 9th dw could be associated with the onset of foetal breathing movements. CTGF first appear during the foetal lung development.

Quantitative investigation of dose accumulation errors from intra-fraction motion in MRgRT for prostate cancer

Accurate spatial dose delivery in radiotherapy is frequently complicated due to changes in the patient's internal anatomy during and in-between therapy segments. The recent introduction of hybrid MRI radiotherapy systems allows unequaled soft-tissue visualization during radiation delivery and can be used for dose reconstruction to quantify the impact of motion. To this end, knowledge of anatomical deformations obtained from continuous monitoring during treatment has to be combined with information on the spatio-temporal dose delivery to perform motion-compensated dose accumulation (MCDA). Here, the influence of the choice of deformable image registration algorithm, dose warping strategy, and magnetic resonance image resolution and signal-to-noise-ratio on the resulting MCDA is investigated. For a quantitative investigation, four 4D MRI-datasets representing typical patient observed motion patterns are generated using finite element modeling and serve as a gold standard. Energy delivery is simulated intra-fractionally in the deformed image space and, subsequently, MCDA-processed. Finally, the results are substantiated by comparing MCDA strategies on clinically acquired patient data. It is shown that MCDA is needed for correct quantitative dose reconstruction. For prostate treatments, using the energy per mass transfer dose warping strategy has the largest influence on decreasing dose estimation errors.

Deep correction of breathing-related artifacts in real-time MR-thermometry

Real-time MR-imaging has been clinically adapted for monitoring thermal therapies since it can provide on-the-fly temperature maps simultaneously with anatomical information. However, proton resonance frequency based thermometry of moving targets remains challenging since temperature artifacts are induced by the respiratory as well as physiological motion. If left uncorrected, these artifacts lead to severe errors in temperature estimates and impair therapy guidance. In this study, we evaluated deep learning for on-line correction of motion related errors in abdominal MR-thermometry. For this, a convolutional neural network (CNN) was designed to learn the apparent temperature perturbation from images acquired during a preparative learning stage prior to hyperthermia. The input of the designed CNN is the most recent magnitude image and no surrogate of motion is needed. During the subsequent hyperthermia procedure, the recent magnitude image is used as an input for the CNN-model in order to generate an on-line correction for the current temperature map. The method's artifact suppression performance was evaluated on 12 free breathing volunteers and was found robust and artifact-free in all examined cases. Furthermore, thermometric precision and accuracy was assessed for in vivo ablation using high intensity focused ultrasound. All calculations involved at the different stages of the proposed workflow were designed to be compatible with the clinical time constraints of a therapeutic procedure.

The usefulness of wideband absorbance in the diagnosis of otosclerosis

Objective: To compare wideband absorbance (WBA) patterns between ears with otosclerosis and normal hearing ears and to investigate if WBA findings could be useful in the diagnosis of otosclerosis.Design: WBA was obtained at 107 frequency samples ranging from 0.226 to 8 kHz (24 per octave). A T-test was performed to compare between WBA in ears with otosclerosis and in normal hearing ears. The ability of WBA to discriminate between the patients with otosclerosis from the normal hearing participants was tested with a receiver operating characteristics (ROC) curve analysis.Study sample: Thirty-five patients with otosclerosis (age 31-64) and thirty-five normal hearing volunteers (age 32-64).Results: In frequency range 0.432-1.059 kHz, mean WBA in otosclerosis was significantly lower than mean WBA in normal hearing ears and in frequency range 4.238-8 kHz mean WBA in otosclerosis was significantly higher than mean WBA in normal hearing ears. The ROC analysis revealed that ears with otosclerosis and normal hearing ears could be distinguished based on mean WBA in frequency range >0.5 ≤ 1 kHz (AUC = 0.673) and based on mean WBA in frequency range >4 ≤ 8 kHz (AUC = 0.769).Conclusion: Our results suggest that WBA findings in ears with otosclerosis differ from WBA findings in normal hearing ears.

Generation of intense and coherent sub-femtosecond X-ray pulses in electron storage rings

Temporally short X-ray pulses are an indispensable tool for the study of electron transitions close to the Fermi energy and structural changes in molecules undergoing chemical reactions which take place on a time-scale of hundreds of femtoseconds. The time resolution of experiments at 3^rd generation light sources which produce intense synchrotron radiation is limited fundamentally by the electron-bunch length in the range of tens of picoseconds. Here we propose a new scheme for the generation of intense and coherent sub-femtoseconds soft X-ray pulses in storage rings by applying the Echo-Enabled Harmonic Generation (EEHG) method. Many issues for obtaining the EEHG structure such as two modulators and a radiator are solved by a paradigm shift in an achromatic storage ring cell. Numerical demonstration of the feasibility of the scheme for the BESSY II beam parameters is presented.

Patch-based field-of-view matching in multi-modal images for electroporation-based ablations

Various multi-modal imaging sensors are currently involved at different steps of an interventional therapeutic work-flow. Cone beam computed tomography (CBCT), computed tomography (CT) or Magnetic Resonance (MR) images thereby provides complementary functional and/or structural information of the targeted region and organs at risk. Merging this information relies on a correct spatial alignment of the observed anatomy between the acquired images. This can be achieved by the means of multi-modal deformable image registration (DIR), demonstrated to be capable of estimating dense and elastic deformations between images acquired by multiple imaging devices. However, due to the typically different field-of-view (FOV) sampled across the various imaging modalities, such algorithms may severely fail in finding a satisfactory solution. In the current study we propose a new fast method to align the FOV in multi-modal 3D medical images. To this end, a patch-based approach is introduced and combined with a state-of-the-art multi-modal image similarity metric in order to cope with multi-modal medical images. The occurrence of estimated patch shifts is computed for each spatial direction and the shift value with maximum occurrence is selected and used to adjust the image field-of-view. The performance of the proposed method - in terms of both registration accuracy and computational needs - is analyzed in the practical case of on-line irreversible electroporation procedures. In total, 30 pairs of pre-/per-operative IRE images are considered to illustrate the efficiency of our algorithm. We show that a regional registration approach using voxel patches provides a good structural compromise between the voxel-wise and "global shifts" approaches. The method was thereby beneficial for CT to CBCT and MRI to CBCT registration tasks, especially when highly different image FOVs are involved. Besides, the benefit of the method for CT to CBCT and MRI to CBCT image registration is analyzed, including the impact of artifacts generated by percutaneous needle insertions. Additionally, the computational needs using commodity hardware are demonstrated to be compatible with clinical constraints in the practical case of on-line procedures. The proposed patch-based workflow thus represents an attractive asset for DIR at different stages of an interventional procedure.

Recovery From Sudden Sensorineural Hearing Loss May Be Linked to Chronic Stress Levels and Steroid Treatment Resistance

Purpose This article investigates the possible connections between the level of chronic stress and success of steroid therapy in patients with sudden sensorineural hearing loss (SSNHL). Method A single-center, retrospective, longitudinal cohort study on 55 patients in a tertiary referral otology center was examined. Patients diagnosed with SSNHL between 2014 and 2017 were asked to complete a Measure of Perceived Stress (Brajac, Tkalcic, Dragojević, & Gruber, 2003 ) questionnaire. Inclusion criteria were patients > 18 years of age, SSNHL diagnosed within 4 previous weeks, completed steroid treatment, and complete documentation. Results There were 30 patients (55%) that showed significant improvement in their pure-tone audiogram (PTA) hearing threshold average (≥ 15 dB) after steroid treatment. Two-step cluster analysis identified 3 clusters based on average PTA hearing threshold recovery and average Measure of Perceived Stress scores. The difference between pretreatment and posttreatment hearing levels was significantly higher in the cluster with moderate stress compared to clusters with mild and high stress levels (Kruskal-Wallis test, Friedman test, p < .001). There were no significant differences in average PTA hearing threshold recovery after steroid therapy between groups of patients with mild and severe stress. Conclusion Patients with moderate stress levels show significantly better results after steroid treatment for SSNHL than patients with low or high stress levels.

ACTIVE MIDDLE EAR VIBRANT SOUNDBRIDGE SOUND IMPLANT

The Vibrant Soundbridge represents a new approach to hearing improvement in the form of active implantable middle ear hearing device. Unlike conventional acoustic hearing aids, which increase the volume of sound that goes to the eardrum, the Vibrant Soundbridge bypasses the ear canal and eardrum by directly vibrating the small bones in the middle ear. Because of its design, no portion of the device is placed in the ear canal itself. The Vibrant Soundbridge has been approved by the FDA as a safe and effective treatment option for adults with moderate to severe sensorineural, conductive or mixed hearing losses who desire an alternative to the acoustic hearing aids, for better hearing. The paper presents a review of the active middle ear implant Vibrant Soundbridge, which has been also implanted at the Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Center, which is the Referral Center for Cochlear Implantation and Surgery of Hearing Impairment and Deafness of the Ministry of Health, Republic of Croatia.

Hypertrophic recurring lichen planus of the external auditory canal

INTRODUCTION

We report a case of unilateral progressive primary hypertrophic lichen planus of the external auditory canal requiring several surgical interventions to deal with constant pruritus, otorrhoea, stenosis and conductive hearing loss.

CASE SUMMARY

A 58-year-old woman was initially treated with meatoplasty for suspected chronic obliterating otitis externa. She remained symptom-free for 5 years, before the disease recurred, affecting other body surfaces as well. Otorrhoea, conductive hearing loss and pruritus worsened, and a canal wall down tympanomastoidectomy was performed, removing the skin of the external auditory canal and the tympanic membrane completely. Lichen planus was confirmed histopathologically.

DISCUSSION

Very few surgical results have been published on stenosis of the external auditory canal caused by lichen planus. Complete medial external auditory canal skin elevation and removal with postoperative split-skin grafting is advised for initial treatment. We discuss treatment options and surgical outcome after initial surgical failure.

Transverse resonance island buckets for synchrotron-radiation based electron time-of-flight spectroscopy

At the Metrology Light Source (MLS), the compact electron storage ring of the Physikalisch-Technische Bundesanstalt (PTB) with a circumference of 48 m, a specific operation mode with two stable closed orbits for stored electrons was realized by transverse resonance island buckets. One of these orbits is closing only after three turns. In combination with single-bunch operation, the new mode was applied for electron time-of-flight spectroscopy with an interval of the synchrotron radiation pulses which is three times the revolution period at the MLS of 160 ns. The achievement is of significant importance for PTB's future programs of angular-resolved electron spectroscopy with synchrotron radiation and similar projects at other compact electron storage rings. The scheme applied here for selecting the photons originating from a particular orbit by optical imaging has been used before in fs slicing applications and may be relevant for the BESSY VSR project of the Helmholtz-Zentrum Berlin.

Anatomically plausible models and quality assurance criteria for online mono- and multi-modal medical image registration

Medical imaging is currently employed in the diagnosis, planning, delivery and response monitoring of cancer treatments. Due to physiological motion and/or treatment response, the shape and location of the pathology and organs-at-risk may change over time. Establishing their location within the acquired images is therefore paramount for an accurate treatment delivery and monitoring. A feasible solution for tracking anatomical changes during an image-guided cancer treatment is provided by image registration algorithms. Such methods are, however, often built upon elements originating from the computer vision/graphics domain. Since the original design of such elements did not take into consideration the material properties of particular biological tissues, the anatomical plausibility of the estimated deformations may not be guaranteed. In the current work we adapt two existing variational registration algorithms, namely Horn-Schunck and EVolution, to online soft tissue tracking. This is achieved by enforcing an incompressibility constraint on the estimated deformations during the registration process. The existing and the modified registration methods were comparatively tested against several quality assurance criteria on abdominal in vivo MR and CT data. These criteria included: the Dice similarity coefficient (DSC), the Jaccard index, the target registration error (TRE) and three additional criteria evaluating the anatomical plausibility of the estimated deformations. Results demonstrated that both the original and the modified registration methods have similar registration capabilities in high-contrast areas, with DSC and Jaccard index values predominantly in the 0.8-0.9 range and an average TRE of 1.6-2.0 mm. In contrast-devoid regions of the liver and kidneys, however, the three additional quality assurance criteria have indicated a considerable improvement of the anatomical plausibility of the deformations estimated by the incompressibility-constrained methods. Moreover, the proposed registration models maintain the potential of the original methods for online image-based guidance of cancer treatments.

Thrombolysis in Newborns and Infants

This review analyses literature reports from 1970 to 1998 assessing the use of streptokinase (SK), urokinase (UK) or recombinant tissuetype plasminogen activator (rt-PA) for thrombolytic therapy in neonates and infants. From 1970 to 1998 182 infants were reported to have received SK (n = 54; 29.5%), UK (n = 41; 22.5%) or rt-PA (n = 87; 48%). During thrombolytic therapy no concomitant heparin administration or low dose heparin therapy (5 U/kg/h) were recorded. To perform reocclusion prophylactics heparin was reinitiated at the end of thrombolytic therapy usually in the recommended dosage of 20 U/kg/h. The overall thrombolytic patency rate in neonates varied from 39% to 86%. Besides bleeding from local puncture sites or recent catheterisation sites (10.4%), pulmonary embolism was reported in 1.1% of the 182 infants. Major bleeding complications, i.e. pulmonary bleeding (0.6%), gastrointestinal bleeding (0.6%) or intraventricular haemorrhage (IVH 2.7%) are rarely reported side effects and only 2 thrombolysis related deaths due to haemorrhage were mentioned. Bleedings reported in the central nervous system (n = 4) mainly occurred in preterm infants (n = 3). In conclusion, data of this preliminary analysis suggest that there is no big difference (p = 0.09; χ2-test) in the efficacy rate between the 3 thrombolytic agents used in the first year of life. In each case an assessment must be made with respect to the relative benefit conferred by thrombolytic therapy in preventing organ or limb damage versus the potential side effects, costs and inconvenience for the childhood patient. Controlled prospective multicentre studies on thrombolytic therapy in neonates and infants are recommended to evaluate patency rates and adverse effects for the different thrombolytic agents used.

Hyperbaric Oxygen Therapy as Salvage Therapy for Sudden Sensorineural Hearing Loss

OBJECTIVE

To measure the effect of hyperbaric oxygen (HBO) therapy as salvage therapy after the failure of steroid therapy for sudden sensorineural hearing loss (SSNHL).

MATERIALS AND METHODS

Ninety-three patients with SSNHL were unsuccessfully treated with systemic steroid therapy. Following steroid therapy, 43 patients received additional HBO therapy while 50 did not. Hearing levels at 0.25, 0.5, 1, 2, 4, and 8 kHz before and after therapy were measured.

RESULTS

A significant difference in hearing thresholds after HBO therapy was found at all frequencies in patients with a hearing loss of >61 dB. The group of patients with a hearing threshold of ≤60 dB had a significant improvement only at 250 and 500 Hz, while group of patients without additional therapy control group showed no hearing improvement.

CONCLUSION

Hyperbaric oxygen therapy therapy as salvage therapy for SSNHL showed some benefits in hearing improvement. Better results could be expected in patients with severe hearing loss, while in patients with mild-or-moderate hearing loss, recovery should be expected only at low frequencies.

Primary Ameloblastoma of the Temporal Bone

Ameloblastoma is a locally aggressive tumor derived from odontogenic epithelium. Although benign, its clinical behavior can often exhibit malignant characteristics. It is marked by slow and persistent growth with infiltration of adjacent tissues. Almost 70% occur in the mandible in patients older than 30 years. Recurrence of ameloblastoma from inadequate treatment is frequent. Because of its slow growth, recurrences can present decades after primary surgery. A primary ameloblastoma in an area outside the mandibular, maxillary, and infratemporal fossa regions has not been described in detail to date, with only 1 possible case mentioned in the literature. The authors present a case of primary temporal bone ameloblastoma in a 17-year-old boy. The tumor originated in the left mastoid, infiltrated the lateral semicircular canal, facial nerve, and cochlea, and adhered to the sigmoid sinus and posterior cranial fossa dura. Although invasion of multiple structures in the infratemporal fossa and temporal bone leads to variable disease presentation, this case is unique because the first symptom of disease was sudden and recurring unilateral sensorineural hearing loss. Surgery required transection of the facial nerve. Histopathology confirmed primary temporal bone ameloblastoma. The difficulties in achieving wide surgical margins, diagnostics, and further management are addressed.

An improved optical flow tracking technique for real-time MR-guided beam therapies in moving organs

Magnetic resonance (MR) guided high intensity focused ultrasound and external beam radiotherapy interventions, which we shall refer to as beam therapies/interventions, are promising techniques for the non-invasive ablation of tumours in abdominal organs. However, therapeutic energy delivery in these areas becomes challenging due to the continuous displacement of the organs with respiration. Previous studies have addressed this problem by coupling high-framerate MR-imaging with a tracking technique based on the algorithm proposed by Horn and Schunck (H and S), which was chosen due to its fast convergence rate and highly parallelisable numerical scheme. Such characteristics were shown to be indispensable for the real-time guidance of beam therapies. In its original form, however, the algorithm is sensitive to local grey-level intensity variations not attributed to motion such as those that occur, for example, in the proximity of pulsating arteries.In this study, an improved motion estimation strategy which reduces the impact of such effects is proposed. Displacements are estimated through the minimisation of a variation of the H and S functional for which the quadratic data fidelity term was replaced with a term based on the linear L(1)norm, resulting in what we have called an L(2)-L(1) functional.The proposed method was tested in the livers and kidneys of two healthy volunteers under free-breathing conditions, on a data set comprising 3000 images equally divided between the volunteers. The results show that, compared to the existing approaches, our method demonstrates a greater robustness to local grey-level intensity variations introduced by arterial pulsations. Additionally, the computational time required by our implementation make it compatible with the work-flow of real-time MR-guided beam interventions.To the best of our knowledge this study was the first to analyse the behaviour of an L(1)-based optical flow functional in an applicative context: real-time MR-guidance of beam therapies in moving organs.

Clinical and audiological findings in children with acute otitis media

CONCLUSION

It is recommended to perform follow-up tympanometry and if necessary tonal audiometry in children who have normal plain otoscopy findings after recovering from acute otitis media (AOM). Children with Type B tympanogram, 3 months following the onset of AOM, are very likely to have a conductive hearing loss. Type B tympanogram is a much better indicator of effusion in the middle ear compared to plain otoscopy.

OBJECTIVE

This study was undertaken to investigate the frequency and duration of middle ear effusion in children following an episode of acute otitis media, to track changes in tonal audiometry and tympanometry findings in the post-AOM period, and recognize the optimal timing for performing both tests.

METHODS

In this study, 125 children aged 5-7 years with bilateral AOM were randomly selected and separately followed up for 3 months. The children underwent six ear, nose, and throat (ENT 1-6) examinations, six tympanometries (TM 1-6), and three tonal audiometries (TA 1-3). Evaluation of nasopharynx was done at the ENT 1 examination. Children who received ventilation tubes were followed for 21 month altogether.

RESULTS

At the first otoscopy, pathological findings were recorded in 250 ears/125 children (100.0%). The number of pathological otoscopy findings decreased at each subsequent examination. At ENT 6 all children had normal otoscopy findings. Type B tympanogram was detected in 49/250 (19.6%) ears at TM 6, performed 3 months following the onset of the disease. At the TA 1 conductive hearing impairment was recorded in 158/250 (63.2%) ears, at TA 2 in 66/250 (26.4%), and at TA 3 in 39/250 (15.6%). Most of them were associated with Type B tympanogram.

[Nora's Lesion: A Rare Differential Diagnosis for Benign Peripheral Bone Tumours]

We report on a bizarre parosteal osteochondromatous proliferation (BPOP), also known as Nora's lesion, in a 43-year-old female patient.

Nasopharyngeal bacterial flora in healthy preschool children during winter-spring months

The paper aimed to determine the incidence of colonization of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae type b and Neisseria meningitidis in the nasopharynges of healthy children in two preschool institutions during winter and spring months, without using antimicrobial treatment or serotyping of these bacteria. In addition to colonization of the above bacteria, the research that continued for 3 months monitored the length of their persistence in and disappearance from children's nasopharynges, children's health statuses, and provision of adequate medical interventions in children demonstrating clinical signs of disease. The ultimate aim of the paper was based on contributing to clearer and more accurate determination of a medical procedure in case of a positive result for bacteria intended to be found in the nasopharynx of a healthy child who spends time in a preschool institution.

Hidradenoma of the external auditory canal: clinical presentation and surgical treatment

The aim of this article is to present clinical features, diagnostic procedures and surgical treatment of a rare ear tumor. We report a case of 78 year old female with hidradenoma of the external auditory canal. Patient had a sensation of pain and fullness with permanent ottorhea from the right ear for one year Temporal bone computed tomography showed a tumor of the external ear, 6 centimeters in diameter, without bone, temporomandibular joint or intracranial invasion; the tumor was limited medially by the tympanic membrane. Biopsy was performed and pathohistology finding was: hydradenoma nodulare atypicum. Surgical intervention and wide tumor removal in general endotracheal anesthesia was performed. One year after the surgery there was no sign of tumor recurrence. Hidradenoma is rare ear tumor arising from the epithelial cells of sweat glands of the external auditory canal. Radiological evaluation and pathohistology confirmation of hidradenoma is necessary and wide excision of the tumor is the treatment of choice.

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation of liver tumours

Recent decades have seen a paradigm shift in the treatment of liver tumours from invasive surgical procedures to minimally invasive image-guided ablation techniques. Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is a novel, completely non-invasive ablation technique that has the potential to change the field of liver tumour ablation. The image guidance, using MR imaging and MR temperature mapping, provides excellent planning images and real-time temperature information during the ablation procedure. However, before clinical implementation of MR-HIFU for liver tumour ablation is feasible, several organ-specific challenges have to be addressed. In this review we discuss the MR-HIFU ablation technique, the liver-specific challenges for MR-HIFU tumour ablation, and the proposed solutions for clinical translation.

Long-term functional outcomes after 10 years of bilateral cochlear implantat use

The aims were to determine the benefit of bilateral cochlear implantation in a 20 years old patient implanted in Croatia on hearing and speech development. The male patient, after 10 years of deafness, got cochlear implants Med-EL Combi 40+ on both sides in one-stage surgery. The etiology of his deafness was posttraumatic meningitis. Auditory capacity and speech recognition tests were performed for both ears separately and together Average hearing level on the right ear with right cochlear implant switched on started at 62 dB 1 month after the cochlear implantation and was on 55 dB after 10 years. Average hearing level on the left ear with left cochlear implant switched on started at 55 dB 1 month after the cochlear implantation and was on 32 dB after 10 years. Average hearing level on the both ears with 2 cochlear implants switched on started at 35 dB 1 month after the cochlear implantation and was on 27 dB after 10 years. Long-term functional outcomes with bilateral cochlear implantation provides advantages over unilateral implantation including improved hearing level, speech perception in noise and improved sound localization.

Towards optimized MR thermometry of the human heart at 3T

Catheter ablation using radio frequency (RF) has been used increasingly for the treatment of cardiac arrhythmias and may be combined with proton resonance frequency shift (PRFS) -based MR thermometry to determine the therapy endpoint. We evaluated the suitability of two different MR thermometry sequences (TFE and TFE-EPI) and three blood suppression techniques. Experiments were performed without heating, using an optimized imaging protocol including navigator respiratory compensation, cardiac triggering, and image processing for the compensation of motion and susceptibility artefacts. Blood suppression performance and its effect on temperature stability were evaluated in the ventricular septum of eight healthy volunteers using multislice double inversion recovery (MDIR), motion sensitized driven equilibrium (MSDE), and inflow saturation by saturation slabs (IS). It was shown that blood suppression during MR thermometry improves the contrast-to-noise ratio (CNR), the robustness of the applied motion correction algorithm as well as the temperature stability. A gradient echo sequence accelerated by an EPI readout and parallel imaging (SENSE) and using inflow saturation blood suppression was shown to achieve the best results. Temperature stabilities of 2 °C or better in the ventricular septum with a spatial resolution of 3.5 × 3.5 × 8mm(3) and a temporal resolution corresponding to the heart rate of the volunteer, were observed. Our results indicate that blood suppression improves the temperature stability when performing cardiac MR thermometry. The proposed MR thermometry protocol, which optimizes temperature stability in the ventricular septum, represents a step towards PRFS-based MR thermometry of the heart at 3 T.

Local tissue properties of human osteoarthritic cartilage correlate with magnetic resonance T(1) rho relaxation times

The objective of this study is to examine the local relationship between T(1ρ) relaxation times and the mechanical behavior of human osteoarthritic articular cartilage using high-resolution magnetic resonance imaging (MRI) and local in situ microindentation. Seven human tibial plateaus were obtained from patients who underwent total knee arthroplasty due to severe osteoarthritis (OA). Three to six sites were selected from each sample for visual classification using the ICRS Outerbridge scale (a total of 36 sites). Samples were imaged by MR, and the local distribution of T(1ρ) relaxation times were obtained at these selected sites. The elastic and viscoelastic characteristics of the tissue were quantified nondestructively using dynamic microindentation to measure peak dynamic modulus, energy dissipation, and phase angle. Measured Outerbridge scores, MR T(1ρ) relaxation times, and mechanical properties were highly heterogeneous across each cartilage surface. Site-specific measures of T(1ρ) relaxation times correlated significantly with the phase angle (p < 0.001; R = 0.908), a viscoelastic mechanical behavior of the cartilage. The novel combination of high-resolution MR imaging and microindentation allows the investigation of the local relationship between quantitative MRI and biomechanical properties in highly heterogeneous OA cartilage. These findings suggest that MRI T(1ρ) can provide a functional assessment of articular cartilage.

Enzyme replacement therapy with agalsidase alfa in patients with Fabry's disease: an analysis of registry data

BACKGROUND

We analysed 5-year treatment with agalsidase alfa enzyme replacement therapy in patients with Fabry's disease who were enrolled in the Fabry Outcome Survey observational database (FOS).

METHODS

Baseline and 5-year data were available for up to 181 adults (126 men) in FOS. Serial data for cardiac mass and function, renal function, pain, and quality of life were assessed. Safety and sensitivity analyses were done in patients with baseline and at least one relevant follow-up measurement during the 5 years (n=555 and n=475, respectively).

FINDINGS

In patients with baseline cardiac hypertrophy, treatment resulted in a sustained reduction in left ventricular mass (LVM) index after 5 years (from 71.4 [SD 22.5] g/m(2.7) to 64.1 [18.7] g/m(2.7), p=0.0111) and a significant increase in midwall fractional shortening (MFS) from 14.3% (2.3) to 16.0% (3.8) after 3 years (p=0.02). In patients without baseline hypertrophy, LVM index and MFS remained stable. Mean yearly fall in estimated glomerular filtration rate versus baseline after 5 years of enzyme replacement therapy was -3.17 mL/min per 1.73 m(2) for men and -0.89 mL/min per 1.73 m(2) for women. Average pain, measured by Brief Pain Inventory score, improved significantly, from 3.7 (2.3) at baseline to 2.5 (2.4) after 5 years (p=0.0023). Quality of life, measured by deviation scores from normal EuroQol values, improved significantly, from -0.24 (0.3) at baseline to -0.17 (0.3) after 5 years (p=0.0483). Findings were confirmed by sensitivity analysis. No unexpected safety concerns were identified.

INTERPRETATION

By comparison with historical natural history data for patients with Fabry's disease who were not treated with enzyme replacement therapy, long-term treatment with agalsidase alfa leads to substantial and sustained clinical benefits.

FUNDING

Shire Human Genetic Therapies AB.

Etiology of deafness in children cochlear implant candidates in Croatia

The aim of this study was to provide more information on the causes of sensorineural hearing loss (SNHL) in children cochlear implant candidates in Croatia. The retrospective study included 270 children candidates for cochlear implantation between January 1997 and January 2005 at our institution. The medical assessment of the candidates included the history, physical examination, radiologic evaluation of the temporal bone and audiologic assessment. A family history of SNHL had 82 (30.4%) candidates. The prematurity and/or complicated perinatal course was found in 35 (12.9%) of candidates. Computerized tomography (CT) scan analysis identified 44 (16.3%) candidates presenting with an inner ear malformation. Overall, a definite or probable cause of SNHL was identified in 58.9% of candidates and 41.1% had no obvious cause. The results of the study might give us better insight into the potential causes of SNHL and allow more timely intervention, allowing children with SNHL to reach their potential.

High-flexion, motion-guided total knee arthroplasty: who benefits the most?

A multicenter study was performed to determine which patients have the most potential to benefit from total knee arthroplasty (TKA) with a high-flexion, guided-motion design. In 201 consecutive TKAs, the mean gain in range of motion (ROM) was 14 degrees at 3 months and 24 degrees at 6 months. The gain in flexion was significant at 3 and 6 months postoperatively. No differences were found based on preoperative diagnosis, age, or sex. There was a poor correlation between body mass index and ROM. Pre- and postoperative flexion also displayed a weak correlation. Patients with the least preoperative flexion (<90 degrees) gained the most degrees of flexion (26 degrees). We conclude that the use of a high-flexion, guided-motion TKA allows a significant functional improvement in patients with preoperative stiffness and the preservation of good flexion in patients with normal preoperative flexion.

In vivo T(1rho) and T(2) mapping of articular cartilage in osteoarthritis of the knee using 3 T MRI

OBJECTIVE

Evaluation and treatment of patients with early stages of osteoarthritis (OA) is dependent upon an accurate assessment of the cartilage lesions. However, standard cartilage dedicated magnetic resonance (MR) techniques are inconclusive in quantifying early degenerative changes. The objective of this study was to determine the ability of MR T1rho (T(1rho)) and T(2) mapping to detect cartilage matrix degeneration between normal and early OA patients.

METHOD

Sixteen healthy volunteers (mean age 41.3) without clinical or radiological evidence of OA and 10 patients (mean age 55.9) with OA were scanned using a 3Tesla (3T) MR scanner. Cartilage volume and thickness, and T(1rho) and T(2) values were compared between normal and OA patients. The relationship between T(1rho) and T(2) values, and Kellgren-Lawrence scores based on plain radiographs and the cartilage lesion grading based on MR images were studied.

RESULTS

The average T(1rho) and T(2) values were significantly increased in OA patients compared with controls (52.04+/-2.97ms vs 45.53+/-3.28ms with P=0.0002 for T(1rho), and 39.63+/-2.69ms vs 34.74+/-2.48ms with P=0.001 for T(2)). Increased T(1rho) and T(2) values were correlated with increased severity in radiographic and MR grading of OA. T(1rho) has a larger range and higher effect size than T(2), 3.7 vs 3.0.

CONCLUSION

Our results suggest that both in vivo T(1rho) and T(2) relaxation times increase with the degree of cartilage degeneration. T(1rho) relaxation time may be a more sensitive indicator for early cartilage degeneration than T(2). The ability to detect early cartilage degeneration prior to morphologic changes may allow us to critically monitor the course of OA and injury progression, and to evaluate the success of treatment to patients with early stages of OA.

Myeloperoxidase predicts risk of vasculopathic events in hemizgygous males with Fabry disease

Fabry disease results in a global vasculopathy leading to early-onset stroke and renal and cardiac failure. We found that random myeloperoxidase in serum and plasma was significantly elevated in 73 consecutive male patients with Fabry disease. Random serum myeloperoxidase level in men predicted the risk of a Fabry vasculopathy-related event in subsequent years. Long-term enzyme replacement therapy did not reduce myeloperoxidase level or eliminate the risk of vasculopathic events.

PCA-based magnetic field modeling: application for on-line MR temperature monitoring

Magnetic Resonance (MR) temperature mapping can be used to monitor temperature changes during minimally invasive thermal therapies. However, MR-thermometry contains artefacts caused by phase errors induced by organ motion in inhomogeneous magnetic fields. This paper proposes a novel correction strategy based on a Principal Component Analysis (PCA) to estimate magnetic field perturbation assuming a linear magnetic field variation with organ displacement. The correction method described in this paper consists of two steps: a magnetic field perturbation model is computed in a learning step; subsequently, during the intervention, this model is used to reconstruct the magnetic field perturbation corresponding to the actual organ position which in turns allow computation of motion corrected thermal maps.

A review of ceramic bearing materials in total joint arthroplasty

Bearings made of ceramics have ultra-low wear properties that make them suitable for total hip arthroplasty (THA) and total knee arthroplasty (TKA). When compared to cobalt chrome (CoCr)-on-polyethylene (PE) articulations, ceramics offer drastic reductions in bearing wear rates. Lower wear rates result in fewer wear particles produced by the articulating surfaces. In theory, this should reduce the risk of periprosthetic osteolysis and premature implant loosening, thereby contributing to the longevity of total joints. In addition to ceramics, other alternative bearing couples, such as highly cross-linked PE (XLPE) and metal-on-metal also offer less wear than CoCr-on-PE articulations in total joint arthroplasty. Alumina and zirconia ceramics are familiar to orthopaedic surgeons since both materials have been used in total joints for several decades. While not new in Europe, alumina-on-alumina ceramic total hips have only recently become available for widespread use in the United States from various orthopaedic implant manufacturers. As the search for the ideal total joint bearing material continues, composite materials of existing ceramics, metal-on-ceramic articulations, and new ceramic technologies will offer more choices to the arthroplasty surgeon. The objective of this paper is to present an overview of material properties, clinical applications, evolution, and limitations of ceramic materials that are of interest to the arthroplasty surgeon.

Neuropathic and cerebrovascular correlates of hearing loss in Fabry disease

Fabry disease, OMIM 301500, is a progressive multisystem storage disorder due to the deficiency of alpha-galactosidase A (GALA). Neurological and vascular manifestations of this disorder with regard to hearing loss have not been analysed quantitatively in large cohorts. We conducted a retrospective cross sectional analysis of hearing loss in 109 male and female patients with Fabry disease who were referred to and seen at the Clinical Center of the National Institutes of Health, Bethesda, MD, USA on natural history and enzyme replacement study protocols. There were 85 males aged 6-58 years (mean 31 years, SD 13) and 24 females aged 22-72 years (mean 42 years, SD 12). All patients underwent a comprehensive audiological evaluation. In addition, cerebral white matter lesions, peripheral neuropathy, and kidney function were quantitatively assessed. HL(95), defined as a hearing threshold above the 95th percentile for age and gender matched normal controls, was present in 56% [95% CI (42.2-67.2)] of the males. Prevalence of HL(95) was lower in the group of patients with residual GALA enzyme activity compared with those without detectable activity (33% versus 63%) HL(95) was present in the low-, mid- and high-frequency ranges for all ages. Male patients with HL(95) had a higher microvascular cerebral white matter lesion load [1.4, interquartile range (IQR) 0-30.1 +/- versus 0, IQR 0-0], more pronounced cold perception deficit [19.4 +/- 5.5 versus 13.5 +/- 5.5 of just noticeable difference (JND) units] and lower kidney function [creatinine: 1.6 +/- 1.2 versus 0.77 +/- 0.2 mg/dl; blood urea nitrogen (BUN): 20.1 +/- 14.1 versus 10.3 +/- 3.28 mg/dl] than those without HL(95) (P < 0.001). Of the females, 38% had HL(95). There was no significant association with cold perception deficit, creatinine or BUN in the females. Word recognition and acoustic reflexes analyses suggested a predominant cochlear involvement. We conclude that hearing loss involving all frequency regions significantly contributes to morbidity in patients with Fabry disease. Our quantitative analysis suggests a correlation of neuropathic and vascular damage with hearing loss in the males. Residual GALA activity appears to have a protective effect against hearing loss.

Fourier Transform Infrared Imaging of focal lesions in human osteoarthritic cartilage

Fourier Transform Infrared Imaging (FTIRI) is a new method for quantitatively assessing the spatial-chemical composition of complex materials. This technique has been applied to examine the feasibility of measuring changes in the composition and distribution of collagen and proteoglycan macromolecules in human osteoarthritic cartilage. Human cartilage was acquired post-operatively from total joint replacement patients. Samples were taken at the site of a focal lesion, adjacent to the lesion, and from relatively healthy cartilage away from the lesion. Sections were prepared for FTIRI and histochemical grading. FTIRI spectral images were acquired for the superficial, intermediate, and deep layers for each sample. Euclidean distance mapping and quantitative partial least squares analysis (PLS) were performed using reference spectra for type-II collagen and chondroitin 6-sulphate (CS6). FTIRI results were correlated to the histology-based Mankin scoring system. PLS analysis found relatively low relative concentrations of collagen (38 +/- 10%) and proteoglycan (22 +/- 9%) in osteoarthritic cartilage. Focal lesions were generally found to contain less CS6 compared to cartilage tissue adjacent to the lesion. Loss of proteoglycan content was well correlated to histological Mankin scores (r=0.69, p<0.0008). The evaluation of biological tissues with FTIRI can provide unique quantitative information on how disease can affect biochemical distribution and composition. This study has demonstrated that FTIRI is useful in quantitatively assessing pathology-related changes in the composition and distribution of primary macromolecular components of human osteoarthritic cartilage.