CT-Guided aspiration biopsy of infected aortic graft in a patient with hypertrophic osteoarthropathy: Saline injection to improve diagnostic yield - A case report

Unilateral hypertrophic osteoarthropathy can be a diagnostic clue to chronic infection of an aortic graft and aorto-enteric fistula. In a 62-year-old woman, non-invasive diagnostic procedures failed to prove the infection. CT-guided fine needle biopsy revealed the pathogens prompting re-intervention. The biopsy result was markedly improved by injecting physiologic saline into the perigraft tissue.

[Phraseology of disk herniation: an inevitable revision renaming the posterior disk prolapse--retrolapse is better]

Etymology teaches us to use the term prolapse exclusively for describing the part of the intervertebral disk that has slipped forwards, that is, towards the anterior longitudinal ligament. Consequently, the word retrolapse has to be introduced as the corresponding term in order to designate the posterior slipped disk. The common use of matching pairs like propulsion/retropulsion or prognathism/retrognathia is another justification for the recommended revision.

Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau inversion recovery (STIR) sequences

OBJECTIVES

To compare the performance of two different MRI sequences-T(1) weighted, fat saturated, spin echo after application of contrast medium, and short tau inversion recovery (STIR) sequences-to detect spinal inflammation in patients with ankylosing spondylitis (AS).

METHODS

Both MRI sequences were performed in 38 patients with active AS and compared using the MRI activity scoring system, ASspiMRI-a. One vertebral unit (VU) was defined as the region between two virtual lines drawn through the middle of each vertebral body.

RESULTS

Intraclass correlation coefficients were excellent-0.91 and 0.86 for the Gd-DTPA and STIR sequences, respectively. The overall correlation of the single MRI scores for both sequences was also good (r = 0.84, p = 0.01). The intrarater variance was 6.71 and 9.41 and the interrater variance was 13.16 and 19.04 for the Gd-DTPA and STIR sequences, respectively. The smallest detectable distance was 4.7 and 5.6 for the Gd-DTPA and STIR sequences, respectively. The concordance rate for both sequences was 83.5% (range 80.5-87.7% in the three spinal segments). Inflammatory spinal lesions were found in 10.1% of the VUs in the STIR sequence but not in the T(1)/Gd-DTPA sequence, while the T(1)/Gd-DTPA sequence showed inflammatory lesions in 6.4% of the VUs that were found normal by STIR.

CONCLUSIONS

Both MRI techniques can evaluate active spinal lesions in patients with AS. More spinal lesions are detected by the STIR sequence, but the reliability between readings and readers is better for the Gd-DTPA sequence. The ASspiMRI-a is a reliable instrument for evaluating acute spinal changes in AS.

Inflammation in ankylosing spondylitis: a systematic description of the extent and frequency of acute spinal changes using magnetic resonance imaging

BACKGROUND

Magnetic resonance imaging (MRI) is increasingly used to detect inflammation in the spine of patients with ankylosing spondylitis (AS).

OBJECTIVES

To detect differentially the presence and extent of inflammation in the three spinal segments of patients with AS by MRI.

METHODS

In 38 patients with active AS, acute spinal lesions were assessed by T(1) weighted, gadolinium enhanced, spin echo MRI (T(1)/Gd-DTPA) and short tau inversion recovery (STIR) sequences. MRI was quantified by the validated scoring system ASspiMRI-a. Acute spinal lesions were detected in the whole spine and in each spinal segment. One vertebral unit (VU) was defined as the region between two virtual lines drawn through the middle of each vertebral body.

RESULTS

A greater number of inflammatory spinal lesions were found by the STIR sequence than by Gd-DTPA: inflammation was present in 30.6% of the VUs as assessed by STIR, compared with 26.8% of the same VUs assessed by T(1)/Gd-DTPA. Inflammation was found more commonly in the thoracic spine (TS) than in the cervical (CS) or the lumbar spine (LS) with both techniques. When STIR was used, spinal inflammation in the CS, the TS, and LS was detected in 10/38 (26%), 28/38 (74%), and 9/38 (24%) patients, respectively. The VU T7/8 was found to be the VU most often affected by both techniques (27.8% by T(1)/Gd-DTPA and 34.5% by STIR).

CONCLUSIONS

Spinal inflammation is a common manifestation in patients with AS, and appears more frequently in the TS. The scoring system ASspiMRI-a can be used for evaluation of acute spinal changes in AS.

Magnetic resonance spectroscopy in clinical oncology

The combination of magnetic resonance spectroscopy (MRS) and imaging (MRI) has led to mapping metabolites from normal and neoplastic tissue within the time limits of a routine study. MRSI (magnetic resonance spectroscopy imaging) detects metabolites that contain protons, phosphorus, fluorine, or other nuclei. The uniqueness of the information available in vivo and in a non-invasive manner encouraged radiologists and oncologists to apply MRSI in research and clinical practice. Both (1)H- and (31)P-MRS have revealed significant disturbances in amino acids, lipids, and phosphorus-containing metabolites within tumors. Phosphocreatine is often diminished in neoplasms compared to their primary host or surrounding tissues. However, the reduction of the compound does not appear to be closely correlated to the degree of malignancy. Moreover, abnormalities in (31)P spectra from neoplasms are shared by other disorders. Changes in high-energy phosphate levels almost invariably occur with radio- and chemotherapy of tumors. The spectroscopic alterations are often seen before any variations in tumor size and shape can be detected. However, opposite responses can be associated with the same clinical outcome. (1)H-MRS has been successfully used to quantify the extent of neuronal cell loss imposed on the brain during radiotherapy. Recently, MRSI was successfully integrated into radiotherapy planning in prostate cancer patients. (19)F-MRS opens access to artificially induced fluorocompounds such as 5-fluorouracil and its metabolites.

Analysing chronic spinal changes in ankylosing spondylitis: a systematic comparison of conventional x rays with magnetic resonance imaging using established and new scoring systems

OBJECTIVES

To compare conventional radiography and magnetic resonance imaging (MRI) for detection of chronic changes in the spine of patients with ankylosing spondylitis (AS).

METHODS

Assessment of chronic lesions in conventional x rays and T1 weighted MRI turbo spin echo sequences was performed with the established x ray scores BASRI and SASSS, the new Berlin score, and the MRI scoring system ASspiMRI-c All images were read twice and "blindly" by two readers. One vertebral unit (VU) was defined as the region between two virtual lines drawn through the middle of each vertebra. Definite involvement was defined as a score > or =2 in a spinal segment.

RESULTS

Thirty nine patients with AS were examined (25 (64%) male, mean age 40.9 years, 33/36 (92%) HLA-B27 positive). The Berlin score correlated with the BASRI (r = 0.73, p = 0.01). The ASspiMRI-c correlated well with the BASRI and the Berlin score (r = 0.66 and r = 0.51, respectively, p = 0.01). The Berlin x ray score showed that 12/35 (34.3%), 13/35 (37.1%), and 12/28 (31.6%) patients had definite involvement of the cervical spine (CS), thoracic spine (TS), and lumbar spine (LS), respectively. The ASspiMRI-c showed that 10/36 (27.8%), 21/36 (58.3%), and 9/35 (25.7%) patients had definite involvement of the CS, TS, and LS, respectively. Syndesmophytes were found in 14.4% of all VUs with 90% agreement between the SASSS and Berlin score.

CONCLUSIONS

T1 weighted MRI can detect chronic lesions in AS. The two new scoring systems proved valid in comparison with established scoring systems and based on aspects of the OMERACT filter. The thoracic spine is most commonly affected in AS. This part of the spine is best assessed by MRI.

[Organ dose and conversion coefficients applied to gonads and uterus in enteroclysis with double contrast technique]

PURPOSE

Conversion coefficients are commonly used to estimate the radiation dose in projectional radiography from the dose-area product (DAP). This study investigates whether conversion coefficients can also be used for dosimetry in fluoroscopic procedures.

MATERIALS AND METHODS

Thermoluminescence dosimeters (TLD) were placed into an anthropomorphic phantom (Alderson Rando Phantom) to measure the dose absorbed by the gonads and uterus. A standardized enteroclysis in double contrast technique (Sellink/Herlinger) was simulated and the DAP was measured. Three examinations with 70, 80 and 90 kV were carried out with a fluoroscopy time of 15 minutes each. The relations between the DAP and the organ dose were analyzed and a linear regression was performed to determine the conversion coefficients [mSv/cGycm (2)].

RESULTS

The DAP and the organ dose measured by TLD were strongly correlated (r > 0.95) for all examined organs.

CONCLUSION

The strong correlations between TLD-measured organ doses and DAP recommend the use of conversion coefficients for the dosimetry of fluoroscopic procedures.

Long-term efficacy and safety of infliximab in the treatment of ankylosing spondylitis: an open, observational, extension study of a three-month, randomized, placebo-controlled trial

OBJECTIVE

Treatment of ankylosing spondylitis (AS) with infliximab, an anti-tumor necrosis factor alpha monoclonal antibody, was shown to be efficacious in patients with active disease during a 3-month treatment period. The purpose of this study was to evaluate the efficacy and safety of infliximab treatment of AS for a 1-year period.

METHODS

This study was an open, observational, extension study of a 3-month, randomized, placebo-controlled trial. All patients who had tolerated infliximab (infliximab/infliximab group) or placebo (placebo/infliximab 12-week crossover group) therapy for 3 months entered the open extension trial (n = 65). Infliximab was administered at a dosage of 5 mg/kg every 6 weeks after the induction phase (weeks 0, 2, and 6). The primary end point was a 50% improvement in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).

RESULTS

At week 54, a total of 54 of the 69 patients (78%) continued to take infliximab. The intent-to-treat primary efficacy analysis at week 54 showed that 47% of patients in the infliximab/infliximab group (95% confidence interval 31-63) and 51% of the patients in the placebo/infliximab group (95% confidence interval 36-67) achieved 50% improvement in BASDAI scores. In the analysis of those who completed the study, the mean BASDAI scores improved between weeks 0 and 54 in both treatment groups: from 6.6 to 2.4 in the infliximab/infliximab group and from 6.3 to 2.6 in the placebo/infliximab group. The dosage of nonsteroidal antiinflammatory drugs was reduced in approximately 70% of the patients. There were significant improvements in measures of functioning, metrologic parameters, and quality of life. Between weeks 12 and 54, a total of 4 patients had serious adverse events that were possibly related to infliximab and resulted in their discontinuing the study.

CONCLUSION

Infliximab therapy in AS patients resulted in a rapid and significant improvement in BASDAI scores (>50% improvement) and a durable response for 1 year. The safety profile of infliximab in AS was comparable to that observed in the postmarketing experience for the approved indications.

Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system

OBJECTIVE

To evaluate a magnetic resonance imaging (MRI) scoring system for the assessment of spinal inflammation in patients with ankylosing spondylitis (AS) who participated in a randomized, placebo-controlled trial of infliximab, and to examine whether infliximab is also effective for the reduction of MRI-proven spinal inflammation.

METHODS

Twenty patients with AS (9 women and 11 men, mean age 40.9 years) were examined at baseline and after 3 months. Nine patients had received infusions of infliximab (5 mg/kg body weight) at weeks 0, 2, and 6, and 11 patients had received placebo. Three MRI sequences and 2 scoring systems were used. Chronic lesions were evaluated by T1-weighted turbo spin-echo (TSE) sequences and were assigned a chronicity score. Active lesions were evaluated either by repetition of T1-weighted TSE sequences after infusion of gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) or by short tau inversion recovery (STIR) sequences, and were assigned an activity score. The 40 images were evaluated twice by 2 readers who were blinded to the names of the patients and the dates of the examinations, and were analyzed in relation to the clinical results.

RESULTS

Active spinal lesions were detected in 15 of 20 patients (75%); the frequency as determined by STIR was equal in the 2 groups. At baseline, the total MRI scores determined using Gd-DTPA, STIR, and T1 were 112.5, 156, and 253.5, respectively. The interrater variance and intrarater variance were, respectively, 6.4 and 7.7 for the active lesion score as determined by Gd-DTPA, 15.7 and 5.3 for the active lesion score as determined by STIR sequence, and 167.3 and 75.5 for the chronic lesion score as determined by T1 sequence. Based on the means of the scores assigned by the 2 readers, the active lesion score as determined by Gd-DTPA improved by 40% in the infliximab group compared with 6% in the placebo group, the active lesion score as determined by STIR improved by 60% in the infliximab group but deteriorated by 21% in the placebo group, and the chronic lesion score as determined by T1 improved by 7% in the infliximab group but worsened by 35% in the placebo group. Five patients in the infliximab group and 2 in the placebo group were clinical responders. The acute MRI changes correlated with clinical improvement as assessed by the Bath Ankylosing Spondylitis Disease Activity Index.

CONCLUSION

This novel MRI scoring system performed well in assessing acute inflammation by using STIR and post-Gd-DTPA sequences. In correlation with clinical improvement in patients with active AS who were treated with infliximab, significant regression of spinal inflammation was shown by using the MRI activity scores.

[Recycling and reuse of disposable products in radiology]

Legitimacy and appropriateness of recycling and reuse of single-use disposable medical devices is a common issue in many areas of medicine. Advocates of reprocessing claim economic savings and environmental benefits. From the manufacturers' point of view, the single use is a characteristic property of their products. Moreover, they warn that using of recycled instruments makes the procedure more difficult and increases the rate of adverse events. As comparative tests demonstrate, reused products are sometimes inferior to the genuine ones with respect to mechanical properties, but these differences may have relatively little consequence for the performance of the products and the success rate of the interventions. With rigorous cleaning and sterilizing of the instruments, patients do not run an increased risk of infection. Sterile single-use products are subject to the German Medical Products Act (1994) and the German Medical Devices Ordinance (1998). New legal provisions (in force since January 1st 2002) have restricted professional recycling of used devices further. Companies reprocessing medical products for the original users are free from certification liability. CE can no longer be issued for devices newly placed on the market. Lawyers controversially discuss whether patients must be informed about the use of recycled products. In view of the otherwise strict regulations concerning the information given to patients, it seems imperative to obtain a written informed consent when reprocessed devices are used. This might interfere with the confidential relationship of patients and physicians. The combination of increased risk, strict legal regulations, ethical concern and adverse publicity demand to refrain from reprocessing and reusing disposable equipment in diagnostic and interventional radiology.

[Absorption of L-lysine diatrizoate from the gastrointestinal tract: the influence of surgery, inflammation and neoplasia]

PURPOSE

To ascertain whether the absorption of L-lysine diatrizoate, a sodium-free salt of the contrast-giving diatrizoic acid, from the gastrointestinal tract is increased by surgery, inflammation or neoplasia.

MATERIAL AND METHODS

Using contrast medium containing L-lysine diatrizoate for intestinal opacification, this prospective study compared 32 radiographic examinations of the upper gastrointestinal tract with 52 radiographic examination of the lower gastrointestinal tract. In blood samples taken from the patients immediately after the radiographic examinations, the concentration of diatrizoic acid was determined by high pressure liquid chromatography. The results were correlated with sex, age, surgical history and any evidence of inflammatory or neoplastic diseases.

RESULTS

The serum diatrizoic acid concentration in patients after oral administration was 3.62 (95% CI, 2.86 - 10.17) microg/ml. The titer was lower in patients who had undergone abdominal surgery than in patients without surgery. Serum diatrizoic acid concentration in patients after rectal administration was 0.30 (95% CI, 0.13 - 0.60) microg/ml. The titer was significantly higher (p < 0.05) in patients suffering from inflammatory conditions or neoplasms than in the other patients.

CONCLUSION

The L-lysine salt of diatrizoic acid is absorbed in larger amounts from the upper than from the lower gastrointestinal tract. Absorption is not increased after abdominal surgery. However, inflammatory conditions and neoplasms of the large bowel increase the uptake of contrast medium from the intestine.

Imaging and scoring in ankylosing spondylitis

Ankylosing spondylitis (AS), the prototype of the spondyloarthritides (SpA), is a disease subset but also a possible outcome of the SpA. Early diagnosis of sacroiliitis, the most frequent clinical symptom often accompanied by inflammatory back pain, and other inflammatory lesions of the spine such as spondylitis and spondylodiscitis, can be visualized early by magnetic resonance imaging (MRI). Chronic changes such as syndesmophytes are well detected by conventional x-rays of the spine, mostly lateral, in the lumbar spine also a.p. Active spinal inflammation can be demonstrated by MRI by using either the fat saturating STIR technique or by application of the contrast agent gadolinium-DTPA. This is especially useful in early and active disease, in young women and in children, and for the differential diagnosis of septic sacroilitis. Because of the efficacy of the novel biologic agents directed against TNFalpha such as infliximab and etanercept in SpA there is a need for spinal imaging techniques that are more sensitive than conventional x-rays. The available scoring tools are limited in their sensitivity to change. Novel approaches using MRI have been recently proposed.

Use of contrast enhanced magnetic resonance imaging to detect spinal inflammation in patients with spondyloarthritides

Inflammation of spinal structures is a characteristic feature of the spondyloarthritides (SpA). The term SpA covers patients with inflammatory back pain and/or peripheral arthritis who can be further categorized. Ankylosing spondylitis (AS), the prototype of the SpA, the most frequent inflammatory spinal disease in adults, usually starts in the sacroiliac joints. Pathologic spinal changes occurring in AS are spondylitis, spondylodiscitis and inflammation and ankylosis also at other sites in the axial skeleton. In the later stages of AS such changes can be well recognized by spinal x-rays. In the early disease stages it has been more difficult to analyze the exact anatomic localization of spinal inflammation to date, because conventional imaging systems have only a limited capacity to demonstrate such changes early. There is some evidence that magnetic resonance imaging (MRI) with fat saturation and contrast enhanced MRI are useful to visualize early and late inflammatory changes in the sacroiliac joints. In this paper we report that MRI is also useful to localize the site of inflammation to distinct regions of the spine in AS and other SpA.

Temporary unilateral microembolization of the lung-a new approach to regional chemotherapy for pulmonary metastases

BACKGROUND

Except in patients with resectable disease, treatment of pulmonary metastases is still disappointing. Regional chemotherapy may be a suitable method for delivering more effective doses to regionally confined tumors while minimizing systemic toxicity. We propose an unilateral chemoembolization of the lung applicable by endovascular method.

MATERIALS AND METHODS

An unilateral microembolization of the lung with degradable starch microspheres (DSM) alone (group 1) and combined with carboplatin (group 2) was performed on Sprague-Dawley rats (n = 12). Microcirculatory parameters were studied by in vivo videomicroscopy and radiological pattern on pulmonary angiogram.

RESULTS

After injection of DSM, mean embolization time in subpleural capillaries was 7.1 +/- 2.3 min, followed by a mean flow retardation of 14.3 +/- 4.6 min; 21.4 +/- 4.7 min after embolization, original flow of erythrocytes was observed demonstrating reperfusion and reversibility of microembolization. After reperfusion relative fluorescence measured in subpleural alveoli was 0.13 +/- 0.049 in group 1, 0.105 +/- 0.016 in group 2, and 0.11 +/- 0.036 in control group (NS). Alveolar septal diameter was 17.3 +/- 1.13 microm in group 1, 16.8 +/- 1.25 microm in group 2, and 16.6 +/- 1.08 microm in control group (NS), demonstrating neither altered permeability nor pulmonary edema. Pulmonary angiogram confirmed patency of the central pulmonary artery.

CONCLUSION

For the first time unilateral microembolization of the lung could be established in an experimental model. By injection of DSM, reversible embolization on arteriolar and capillary level could be demonstrated without occlusion of the main branches of the pulmonary arteries. Alveolar-capillary membrane disorder as symptom of early toxicity could not be detected even with additional application of carboplatin.

Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial

BACKGROUND Treatment options for patients with ankylosing spondylitis are few. We aimed to assess the effectiveness of infliximab, an antibody to tumour necrosis factor (TNF)-alpha, in treatment of such patients.

METHODS

In this 12-week placebo-controlled multicentre study, we randomly assigned 35 patients with active ankylosing spondylitis to intravenous infliximab (5 mg/kg) and 35 to placebo at weeks 0, 2, and 6. One patient in the infliximab group was withdrawn from the study. Our primary outcome was regression of disease activity of at least 50%. To assess response, we used validated clinical criteria from the ankylosing spondylitis assessment working group, including disease activity (BASDAI), functional indices (BASFI), metrology (BASMI), and quality of life (short form 36). Analyses were done by intention to treat.

FINDINGS

18 (53%) of 34 patients on infliximab had a regression of disease activity at week 12 of at least 50% compared with three (9%) of 35 on placebo (difference 44% [95% CI 23-61], p<0.0001). Function and quality of life also improved significantly on infliximab but not on placebo (p<0.0001 and p<0.0001, respectively). Treatment with infliximab was generally well tolerated, but three patients had to stop treatment because of systemic tuberculosis, allergic granulomatosis of the lung, or mild leucopenia.

INTERPRETATION

Our results show that treatment with infliximab is effective in patients with active ankylosing spondylitis. Since there are some potentially serious adverse effects, we recommend that this treatment mainly be used in co-operation with rheumatological centres.

Functional magnetic resonance imaging - basics and applications in oncology

Functional MR imaging (F-MRI) permits to visualize active processes evolving in the human brain. The shifts in blood oxygenation following local neuronal activation are used for generating an MR signal. Specific procedural problems have to be solved when using F-MRI in patients with brain neoplasms. The relationship between perirolandic tumors and the adjacent motor areas has been studied most intensively. When the resection of tumors in the motor area is considered, functional imaging can help the surgeon to avoid or at least to minimize postoperative functional deficits. Overall, F-MRI study results are useful in at least one crucial preoperative decision step for about 90% of brain tumor patients. Experience with functional imaging in radiotherapy of brain neoplasms is still limited. Presently, F-MRI cannot yet replace intraoperative brain mapping.

Magnetic resonance measurements of the deviation of the angle of force generated by contraction of the quadriceps muscle in dogs with congenital patellar luxation

OBJECTIVE

To measure the quadriceps angle (Q-angle) in dogs with congenital patellar luxation using magnetic resonance (MR) methods.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Thirty-eight client-owned dogs.

METHODS

Thirty-eight dogs were examined and placed into the following groups based on the degree of patellar instability: normal, grade I, grade II, and grade III. MR images of 37 pelvic limbs without patellar instability, 33 pelvic limbs with patellar luxation, and 6 limbs with cranial cruciate ligament (CrCL) rupture were made. The Q-angle was calculated using trigonometric methods based on MR images. Limbs with patellar luxation were compared with normal stifles and stifle with other disorders.

RESULTS

The average Q-angle of the normal group was 10.5 degrees (24.9 degrees to -2.0 degrees ). The grade I group had an average Q-angle of 12.2 degrees (28.8 degrees to 2 degrees ), the grade II group 24.3 degrees (44.6 degrees to 7.7 degrees ), and the grade III group 36.6 degrees (51.4 degrees to 15.6 degrees ). The average Q-angle of limbs with an isolated CrCL rupture was 19.3 degrees (34.7 degrees to 3.9 degrees ).

CONCLUSION

MR images can be used to make exact calculations of the Q-angle.

CLINICAL RELEVANCE

MR images can be used to quantify the degree of patellar luxation.

Positron emission tomography and lymphoma therapy

FDG-PET is both able to provide information of lymphomatous organ involvement not available by conventional imaging techniques (US, CT, MRI) and to give reliable data otherwise obtainable only by using invasive procedures. As a whole body-screening technique, PET reduces diagnostic requirements and potential complications. Nevertheless the conventional imaging techniques are essential for the exact localisation and correct interpretation of PET findings. A number of factors that may produce false-positive results have to be taken into consideration, including post-treatment inflammatory changes and the sensitivity of the method in the setting of minimal residual disease. Despite its potential of a screening method being performed prior to other imaging procedures, PET is not yet established as a routine element for the primary staging of Hodgkin's disease and non-Hodgkin's lymphoma. Its value for re-staging is less doubtful due to the frequency of stage migration and possible changes in therapy related to the use of PET. Detailed cost-effectiveness studies are needed to assess the economic implications of an expanded use of PET in lymphoma therapy.

[Body structure and radiation exposure in dynamic X-ray studies. A contribution to determining national reference values]

PURPOSE

To contribute data on radiation exposure in dynamic X-ray procedures and to compare them with anthropometric parameters.

METHODS

50 venographies of the lower extremity, 51 abdominal arteriographies, and 121 double contrast examinations of the small bowel were carried out and the dose-area product (DAP) measured for each of the procedures. Additionally, fluoroscopy time, number of shots, body height, body weight, and the sagittal diameter of the examined region were recorded. Dose measurements were statistically evaluated and the following data determined: Frequency distribution, mean, median, 25%- and 75 percentiles as well as correlations with sex, body weight, and diameters.

RESULTS

Median DAP was 587 (men: 540; women: 636) cGycm2 with venography of the lower extremities. DAP/min was better correlated with body weight (r = 0.663) than with diameters of the thigh (r = 0.611). Mean DAP was 14,869 (18,070; 10,980) cGycm2 with abdominal arteriography. DAP/min was badly correlated both with body weight (r = 0.285) and diameters of the abdomen (r = 0.249). Mean DAP was 4527 (5096; 4114) cGycm2 with enteroclysis. DAP/min was well correlated with both body weight (r = 0.621) and diameters of the abdomen (r = 0.628).

CONCLUSION

DAP of venography of the lower extremity and enteroclysis is greatly influenced by the constitution of the patient. The differences between men and women are, however, not as striking as with static X-ray procedures. By contrast, in abdominal arteriography body weight and diameter play a limited role for radiation exposure.

[Body build and radiation exposure in static roentgen studies (I): A contribution for determining a national reference dose value. Promoted by the Federal Office for Radiation Protection (St.Sch 4163)]

PURPOSE

To contribute data on radiation exposure in static x-ray procedures and to compare them with anthropometric parameters.

METHOD

121 chest x-rays and 100 lumbar spine examinations were carried out and the dose-area product (DAP) measured for each of the projections. Additionally, body height, body weight and the sagittal and transversal diameters of the examined regions were recorded. Dose measurements were statistically evaluated and the following data determined: Frequency distribution, median, 25%- and 75%-percentiles as well as correlations with sex, body weight and diameters.

RESULTS

Median DAP was 13 (men: 16; women: 11) resp. 50 (62; 37) cGycm2 with pa resp lateral chest x-ray. Values were closely correlated with body weight (r = 0.704/0.659) and diameter of the chest (r = 0.657/0.579). Median DAP was 175 (239; 126) resp 531 (670; 361) cGycm2 with ap resp lateral lumbar spine examinations. Values were closely correlated with body weight (r = 0.678/0.666) and diameter of the abdomen (r = 0.664/0.658).

CONCLUSIONS

DAP of chest x-rays and lumbar spine examinations is strongly influenced by the constitution of the patients. Men are nearly twice as largely exposed to radiation as women.

[Non-neoplastic hypertrophic osteoarthropathy due to infected aortic prosthesis. Diagnostic imaging aspects]

Secondary hypertrophic osteoarthropathy of the legs is a rare complication of arterial graft surgery. The syndrome is composed of arthralgias, clubbing of the toes and periostosis of the long bones and is usually associated with an infected aortic prosthesis. Often a CT-guided biopsy is performed in order to identify the graft as the primary focus. In addition to the lamellar periostosis demonstrable by conventional radiographs, a vast edema of the bone marrow and surrounding soft tissue is disclosed by MRI. Imaging promotes the early surgical reintervention.

The correlation of canine patellar luxation and the anteversion angle as measured using magnetic resonance images

Measurements from magnetic resonance (MR) images can be used to examine the anteversion angle (AT-angle) and its influence on the lateromedial or mediolateral luxating forces on the patella. The AT-angle of the femoral neck was measured with the aid of MR imaging in 45 pelvic limbs without patellar instability, in 33 limbs with patellar luxation and in 6 limbs with rupture of the cranial cruciate ligament. The limbs with medial patellar luxation were divided into three groups based on clinical examination. The mean (range) AT-angle was 7.6 degrees (0 degrees to 24 degrees) in the "normal" group, 8.6 degrees (-10 degrees to 29 degrees) in the group "grade II," and -0.4 degrees in the group "grade III" (-28 degrees to 12 degrees). A mean (range) AT-angle of 4.8 (-4 degrees to 11 degrees) was measured in the pelvic limbs with rupture of the cranial cruciate ligament. Compared to literature that described AT-angles based on radiographs of normal limbs, reduced AT-angles were found in this study due to different lines of measurement of the femoral neck. This study documents that the AT-angle of the femoral neck does not influence patellar instability. This study also demonstrates that MR images can be used to make exact measurements of the canine AT-angle that represent the true anatomy of the femoral neck.

Craniosynostosis in cherubism

Cherubism is a rare autosomal dominant fibro-osseous disorder that affects almost exclusively maxilla and mandible. Extracranial skeletal involvement is rare. We report on three affected males in three generations. The youngest affected relative was examined at age 4 months. He also had craniosynostosis. His affected father and grandfather had cherubism and clubbing of the fingers. Cherubism was mapped to region 4p16. Because of the associated cranio-synostosis, we excluded the FGFR3 gene as a candidate gene for cherubism.

Primary and secondary Sjögren's syndrome in children--a comparative study

Sjögren's syndrome is a chronic inflammatory systemic autoimmune disease mainly affecting the exocrine and, particularly, the salivary and lacrimal glands. The condition usually occurs in adults. In 1994, the criteria for this syndrome were redefined in a multicenter European study. In children, Sjögren's syndrome is a rare and probably underdiagnosed disease. To date, Sjögren's syndrome in children has only been described in case reports and in the comparative presentation of various study results. So far, no study of a comparative classification into primary and secondary Sjögren's syndrome has been carried out in a patient population of any size. Sjögren's syndrome should be considered in the differential diagnosis of children with recurrent parotitis, keratoconjunctivitis sicca, or pronounced and early tooth decay associated with xerostomia. In this study of 23 children and adolescents under the age of 16 with the clinical symptoms and laboratory findings of Sjögren's syndrome, we differentiate between primary and secondary Sjögren's syndrome. The value of the individual methods of assessing the oral and the ophthalmological components and the manifestation of the underlying rheumatic condition are discussed on the basis of the EULAR criteria. The EULAR diagnostic criteria are of limited applicability in children because reliable anamnestic data are frequently lacking. Another problem in diagnosing Sjögren's syndrome is the short-term detection of serological alterations and clinical symptoms. Even if young patients do not completely fulfill the required criteria, Sjögren's syndrome can be assumed or confirmed in the presence of positive testing for oral and ocular manifestations and recurrent salivary gland enlargement.

Successful treatment of active ankylosing spondylitis with the anti-tumor necrosis factor alpha monoclonal antibody infliximab

OBJECTIVE

Tumor necrosis factor alpha (TNFalpha) has been detected in sacroiliac joint biopsy specimens from patients with spondylarthropathy. The present open pilot study was undertaken to test the efficacy of the anti-TNFalpha monoclonal antibody infliximab in the treatment of active ankylosing spondylitis (AS).

METHODS

Eleven patients with AS of short duration (median 5 years, range 0.5-13 years) that had been active for at least 3 months (range 3-72 months) were treated with 3 infusions of infliximab (at weeks 0, 2, and 6), in a dosage of 5 mg/kg. Ten of the 11 patients had elevated C-reactive protein (CRP) levels (>6 mg/liter) before treatment; these elevations were known to have had persisted > 1 year in at least 3 patients. The Bath AS Disease Activity Index (BASDAI), the Bath AS Functional Index (BASFI), pain as measured on a visual analog scale, and the Bath AS Metrology Index (BASMI) were assessed. Quality of life was assessed using the Short Form 36 instrument. Laboratory markers of disease activity, including interleukin-6 (IL-6) levels, were determined. Dynamic magnetic resonance imaging (MRI) of the spine was performed in 5 patients.

RESULTS

One patient withdrew from the study due to the occurrence of urticarial xanthoma 8 days after the first infusion. At study enrollment, 3 of 5 patients had evidence of spinal inflammation (spondylitis and spondylodiscitis) as detected by MRI; followup MRI 2-6 weeks after the third infusion revealed improvement in 2. Improvement of > or = 50% in activity, function, and pain scores was documented in 9 of 10 patients; the median improvement in the BASDAI after 4 weeks was 70% (range 41-94%). This clear-cut benefit lasted for 6 weeks after the third infusion in 8 of 10 patients. The median CRP level decreased from 15.5 mg/liter (range <6-90.8) to normal, and the median IL-6 level from 12.4 mg/liter (range 0-28.4) to normal (<5). There was improvement in all 9 SF-36 concepts; the improvement was significant for 6 concepts.

CONCLUSION

These data suggest that anti-TNFalpha therapy is very effective for several weeks in AS. Whether this therapy, in addition to its antiinflammatory effect, prevents ankylosis remains to be determined.

[Decision analysis in radiology using Markov models]

Markov models (Multistate transition models) are mathematical tools to simulate a cohort of individuals followed over time to assess the prognosis resulting from different strategies. They are applied on the assumption that persons are in one of a finite number of states of health (Markov states). Each condition is given a transition probability as well as an incremental value. Probabilities may be chosen constant or varying over time due to predefined rules. Time horizon is divided into equal increments (Markov cycles). The model calculates quality-adjusted life expectancy employing real-life units and values and summing up the length of time spent in each health state adjusted for objective outcomes and subjective appraisal. This sort of modeling prognosis for a given patient is analogous to utility in common decision trees. Markov models can be evaluated by matrix algebra, probabilistic cohort simulation and Monte Carlo simulation. They have been applied to assess the relative benefits and risks of a limited number of diagnostic and therapeutic procedures in radiology. More interventions should be submitted to Markov analyses in order to elucidate their cost-effectiveness.

Diagnostic value of sialography with both the conventional and digital subtraction techniques in children with primary and secondary Sjögren's syndrome

OBJECTIVE

The application of anamnestic data on siccative symptoms required for classifying adult Sjögren's syndrome is limited in childhood. Instrumental test procedures are therefore necessary for objectively recording the oral and ophthalmologic manifestations of the disease. The aim of this study was to clarify the sialographic changes that occur in Sjögren's syndrome in children.

STUDY DESIGN

A total of 23 sialograms were obtained with both conventional and digital subtraction techniques in 21 children with primary (10 girls and 1 boy) or secondary Sjögren's syndrome (10 girls). The films were assessed by 3 physicians and submitted for a consensus analysis if necessary.

RESULTS

The pathologic features observed in the children varied from a slightly narrowed ductal system to multiple peripheral ductal ectasias and completely destroyed parenchyma. Sialographic examinations demonstrate that, with progressing disease, regression of acinar dilatations and rarification of the ductal system occur.

CONCLUSION

The results show that the spectrum of sialographically recordable lesions in Sjögren's syndrome in children is greater than is described thus far in the literature.

[Statistical analysis of German radiologic periodicals: developmental trends in the last 10 years]

PURPOSE

To identify which statistical tests are applied in German radiological publications, to what extent their use has changed during the last decade, and which factors might be responsible for this development.

MATERIALS AND METHODS

The major articles published in "ROFO" and "DER RADIOLOGE" during 1988, 1993 and 1998 were reviewed for statistical content. The contributions were classified by principal focus and radiological subspecialty. The methods used were assigned to descriptive, basal and advanced statistics. Sample size, significance level and power were established. The use of experts' assistance was monitored. Finally, we calculated the so-called cumulative accessibility of the publications.

RESULTS

525 contributions were found to be eligible. In 1988, 87% used descriptive statistics only, 12.5% basal, and 0.5% advanced statistics. The corresponding figures in 1993 and 1998 are 62 and 49%, 32 and 41%, and 6 and 10%, respectively. Statistical techniques were most likely to be used in research on musculoskeletal imaging and articles dedicated to MRI. Six basic categories of statistical methods account for the complete statistical analysis appearing in 90% of the articles. ROC analysis is the single most common advanced technique. Authors make increasingly use of statistical experts' opinion and programs.

CONCLUSIONS

During the last decade, the use of statistical methods in German radiological journals has fundamentally improved, both quantitatively and qualitatively. Presently, advanced techniques account for 20% of the pertinent statistical tests. This development seems to be promoted by the increasing availability of statistical analysis software.

[Benefits, costs and analysis in diagnostic radiology: definitions and glossary]

Cost efficiency analyses in clinical radiology require the application of methods and techniques that are not yet part of the academic qualifications of the specialists. The procedures used are borrowed from economics, decision theory, applied social sciences, epidemiology and statistics. Many expressions hail from the angloamerican literature and are presently not yet germanized unequivocally. This survey is intended to present main terms of cost efficiency analysis in the english version as well as a german translation, to give a clear definition and, if necessary, explanatory notes, and to illustrate their application by means of concrete radiologic examples. The selection of the terms is based on the hierarchical models of health technology assessment resp. clinical outcome research by Fryback & Thornbury resp. Maisey & Hutton. In concrete terms, both the differences between benefit, outcomes, and utility and the differences between effectiveness, efficacy and efficiency and the differences between direct, indirect, intangible, and marginal costs are explained. True cost efficiency analysis is compared with cost effectiveness analysis, cost identification analysis, cost minimization analysis, and cost utility analysis. Applied social sciences are represented by the Medical Outcomes Study Short Form-36 and the QALY conception. From decision theory both the analysis of hypothetical alternatives and the Markov model are taken. Finally, sensitivity analysis and the procedures of combined statistical evaluation of comparable results (meta-analysis) are quoted.