Man against machine reloaded: performance of a market-approved convolutional neural network in classifying a broad spectrum of skin lesions in comparison with 96 dermatologists working under less artificial conditions

BACKGROUND

Convolutional neural networks (CNNs) efficiently differentiate skin lesions by image analysis. Studies comparing a market-approved CNN in a broad range of diagnoses to dermatologists working under less artificial conditions are lacking.

MATERIALS AND METHODS

One hundred cases of pigmented/non-pigmented skin cancers and benign lesions were used for a two-level reader study in 96 dermatologists (level I: dermoscopy only; level II: clinical close-up images, dermoscopy, and textual information). Additionally, dermoscopic images were classified by a CNN approved for the European market as a medical device (Moleanalyzer Pro, FotoFinder Systems, Bad Birnbach, Germany). Primary endpoints were the sensitivity and specificity of the CNN's dichotomous classification in comparison with the dermatologists' management decisions. Secondary endpoints included the dermatologists' diagnostic decisions, their performance according to their level of experience, and the CNN's area under the curve (AUC) of receiver operating characteristics (ROC).

RESULTS

The CNN revealed a sensitivity, specificity, and ROC AUC with corresponding 95% confidence intervals (CI) of 95.0% (95% CI 83.5% to 98.6%), 76.7% (95% CI 64.6% to 85.6%), and 0.918 (95% CI 0.866-0.970), respectively. In level I, the dermatologists' management decisions showed a mean sensitivity and specificity of 89.0% (95% CI 87.4% to 90.6%) and 80.7% (95% CI 78.8% to 82.6%). With level II information, the sensitivity significantly improved to 94.1% (95% CI 93.1% to 95.1%; P < 0.001), while the specificity remained unchanged at 80.4% (95% CI 78.4% to 82.4%; P = 0.97). When fixing the CNN's specificity at the mean specificity of the dermatologists' management decision in level II (80.4%), the CNN's sensitivity was almost equal to that of human raters, at 95% (95% CI 83.5% to 98.6%) versus 94.1% (95% CI 93.1% to 95.1%); P = 0.1. In contrast, dermatologists were outperformed by the CNN in their level I management decisions and level I and II diagnostic decisions. More experienced dermatologists frequently surpassed the CNN's performance.

CONCLUSIONS

Under less artificial conditions and in a broader spectrum of diagnoses, the CNN and most dermatologists performed on the same level. Dermatologists are trained to integrate information from a range of sources rendering comparative studies that are solely based on one single case image inadequate.

Diagnostic performance of a deep learning convolutional neural network in the differentiation of combined naevi and melanomas

BACKGROUND

Deep learning convolutional neural networks (CNN) may assist physicians in the diagnosis of melanoma. The capacity of a CNN to differentiate melanomas from combined naevi, the latter representing well-known melanoma simulators, has not been investigated.

OBJECTIVE

To assess the diagnostic performance of a CNN when used to differentiate melanomas from combined naevi in comparison with dermatologists.

METHODS

In this study, a CNN with regulatory approval for the European market (Moleanalyzer-Pro, FotoFinder Systems GmbH, Bad Birnbach, Germany) was used. We attained a dichotomous classification (benign, malignant) in dermoscopic images of 36 combined naevi and 36 melanomas with a mean Breslow thickness of 1.3 mm. Primary outcome measures were the CNN's sensitivity, specificity and the diagnostic odds ratio (DOR) in comparison with 11 dermatologists with different levels of experience.

RESULTS

The CNN revealed a sensitivity, specificity and DOR of 97.1% (95% CI [82.7-99.6]), 78.8% (95% CI [62.8-89.1.3]) and 34 (95% CI [4.8-239]), respectively. Dermatologists showed a lower mean sensitivity, specificity and DOR of 90.6% (95% CI [84.1-94.7]; P = 0.092), 71.0% (95% CI [62.6-78.1]; P = 0.256) and 24 (95% CI [11.6-48.4]; P = 0.1114). Under the assumption that dermatologists use the CNN to verify their (initial) melanoma diagnosis, dermatologists achieve an increased specificity of 90.3% (95% CI [79.8-95.6]) at an almost unchanged sensitivity. The largest benefit was observed in 'beginners', who performed worst without CNN verification (DOR = 12) but best with CNN verification (DOR = 98).

CONCLUSION

The tested CNN more accurately classified combined naevi and melanomas in comparison with trained dermatologists. Their diagnostic performance could be improved if the CNN was used to confirm/overrule an initial melanoma diagnosis. Application of a CNN may therefore be of benefit to clinicians.

Changes in muscle cross-sectional area, muscle force, and jump performance during 6 weeks of progressive whole-body vibration combined with progressive, high intensity resistance training

OBJECTIVES

We hypothesized that progressive whole-body vibration (WBV) superimposed to progressive high intensity resistance training has greater effects on muscle cross-sectional area (CSA), muscle force of leg muscles, and jump performance than progressive high intensity resistance training alone.

METHODS

Two groups of healthy male subjects performed either 6 weeks of Resistive Vibration Exercise (RVE, squats and heel raises with WBV, n=13) or Resistive Exercise (RE, squats and heel raises without WBV, n=13). Squats under RVE required indispensable weight loading on the forefoot to damp harmful vibrations to the head. Time, intervention, and interaction effects were analyzed.

RESULTS

After 6 weeks of training, knee extensor CSA, isometric knee extension force, and counter movement jump height increased equally in both groups (time effect, P⟨0.001, P≤0.02, and P≤0.03, respectively), whereas only in RVE ankle plantar flexor CSA and isometric ankle plantar flexion force reached significance or a tendency, respectively, (time effect, P=0.015 and P=0.069, respectively; intervention effect also for the latter, P=0.006). Drop jump contact time did significantly more improve in RVE (interaction effect, P=0.042).

CONCLUSIONS

RVE showed better training effects than RE only in plantar flexor muscles. RVE seems to be suitable in professional sports with a special focus on calf muscles.

Blast Injuries

Blast injuries cause specific lesions with which the radiologist should be familiar. The mechanism of injury and the pathophysiology of this form of trauma are discussed. The clinical effects as well as the radiologic observations in various organs are presented. Most dramatic effects are observed in the thorax.

Melanoma thickness: the role of patients' characteristics, risk indicators and patterns of diagnosis

BACKGROUND

Factors associated with early vs. late diagnosis of cutaneous melanoma remain poorly understood.

OBJECTIVE

To identify factors with a significant impact on melanoma thickness.

METHODS

Patients with previous melanoma (n = 347, median age at diagnosis: 56.5 years, 44.7% female, 55.3% male) were recruited for this monocentre, non-randomized, observational study between April 2012 and March 2013. All patients were assessed by means of a structured interview and systematic clinical and dermoscopic full-body examination. Melanoma thickness in association with patients' characteristics, risk indicators and patterns of diagnosis was submitted to statistical analyses.

RESULTS

Univariate analyses revealed associations between a statistically significant lower Breslow thickness and participation in specialized dermoscopic screening programs, personal history of more than one previous melanoma, diagnostic examination with a dermatoscope, diagnostic examination by board certified dermatologist, high number of common and/or atypical nevi, younger age at time of diagnosis, higher level of education, or superficial spreading or lentigo maligna melanoma subtype (all P ≤ 0.01). In a multivariate regression analysis only three of these criteria: (i) participation in specialized screening programs (P < 0.0001); (ii) melanoma subtype (P < 0.0001); and (iii) diagnostic examination with a dermatoscope (P = 0.040) and one interaction term ('younger age' x 'female sex', P < 0.0001) showed an independent influence on a significantly lower melanoma thickness.

CONCLUSIONS

The screening of patients in specialized surveillance programs resulted in melanoma detection at significantly earlier stages. The use of dermoscopy, SSM or LMM histotype and younger age in connection with female sex were also characteristics that were independently associated with significantly thinner melanomas in multivariate analyses.

Randomized controlled study on resistive vibration exercise (EVE study): protocol, implementation and feasibility

OBJECTIVES

A training intervention comparing resistance exercise with or without whole-body vibration (WBV) was conducted to compare acute and chronic effects on functional and molecular parameters.

METHODS

A six-week training intervention was performed including 26 healthy males (26 years, SD=4). Two groups were analyzed in a parallel design performing either resistive exercise (RE, n=13) or resistive vibration exercise (RVE, n=13) training with weekly increasing vibration frequencies (20-40Hz). Resting and exercising blood pressure and heart rate were measured before and after the 6-week intervention.

RESULTS

Both training interventions decreased resting systolic blood pressure (P=0.003). Resting diastolic blood pressure was significantly decreased only in the RVE group (P=0.01). Exercising diastolic blood pressure was significantly decreased during the final training (P<0.001) with no additional effect of superimposed vibrations. Resistance exercise with superimposed vibrations evoked back pain to a higher degree than resistance exercise alone when training at frequencies above 30Hz (P<0.01).

CONCLUSIONS

These data suggest positive effects of resistance exercise upon cardiovascular health and vascular responsiveness and a further beneficial effect of superimposed vibrations in decreasing resting diastolic blood pressure. Finally, development of back pain may be fostered by superimposed vibrations to high training loads, particularly at higher frequencies.

Validation of three BRCA1/2 mutation-carrier probability models Myriad, BRCAPRO and BOADICEA in a population-based series of 183 German families

Many studies have evaluated the performance of risk assessment models for BRCA1/2 mutation carrier probabilities in different populations, but to our knowledge very few studies have been conducted in the German population so far. In the recent study, we validated the performance of three risk calculation models by names BRCAPRO, Myriad and BOADICEA in 183 German families who had undergone molecular testing of mutations in BRCA1 and BRCA2 with an indication based on clinical criteria regarding their family history of cancer. The sensitivity and specificity at the conventional threshold of 10% as well as for a threshold of 20% were evaluated. The ability to discriminate between carriers and non-carriers was judged by the area under the receiver operating characteristics curve. We further focused on the performance characteristic of these models in patients carrying large genomic rearrangements as a subtype of mutations which is currently gaining increasing importance. BRCAPRO and BOADICEA performed almost equally well in our patient population, but we found a lack of agreement to Myriad. The results obtained from this study were consistent with previously published results from other population and racial/ethnic groups. We suggest using model specific decision thresholds instead of the recommended universal value of 10%. We further suggest integrating the CaGene5 software package, which includes BRCAPRO and Myriad, in the genetic counselling of German families with suspected inherited breast and ovarian cancer because of the good performance of BRCAPRO and the substantial ease of use of this software.

Thrombophilia in patients with chronic venous leg ulcers-a study on patients with or without post-thrombotic syndrome

BACKGROUND

Chronic venous leg ulcers (CVU) cause considerable burden of disease for the patients as well as enormous costs for health care systems. The pathophysiology of CVU is complex and not entirely understood. So far reliable pathogenic and/or prognostic parameters have not been identified.

OBJECTIVES

We studied the role of thrombophilia in patients referred to a University dermatology department for treatment of CVU.

PATIENTS AND METHODS

A cohort of 310 patients with active chronic venous leg ulcers (CEAP 6) was stratified into two comparably large groups according to the presence or absence of post-thrombotic syndrome (PTS+; PTS-) as determined using duplex scan and/or phlebography. In addition, several thrombophilia parameters were assessed.

RESULTS

The prevalence of protein S deficiency and factor V Leiden mutation was significantly higher in PTS+ patients compared with the PTS- group. However, patients in both subgroups revealed high prevalences of thrombophilia (antithrombin deficiency, protein C deficiency, protein S deficiency, activated protein C resistance, factor V mutation or elevated homocysteine).

CONCLUSION

Based on these data, it is conceivable that thrombophilia contributes to the pathogenesis of CVU, possibly through induction of microcirculatory dysregulations.

Significant association of a M129V independent polymorphism in the 5' UTR of the PRNP gene with sporadic Creutzfeldt-Jakob disease in a large German case-control study

BACKGROUND

A single nucleotide polymorphism (SNP) in the coding region of the prion protein gene (PRNP) at codon 129 has been repeatedly shown to be an associated factor to sporadic Creutzfeldt-Jakob disease (sCJD), but additional major predisposing DNA variants for sCJD are still unknown. Several previous studies focused on the characterisation of polymorphisms in PRNP and the prion-like doppel gene (PRND), generating contradictory results on relatively small sample sets. Thus, extensive studies are required for validation of the polymorphisms in PRNP and PRND.

METHODS

We evaluated a set of nine SNPs of PRNP and one SNP of PRND in 593 German sCJD patients and 748 German healthy controls. Genotyping was performed using MALDI-TOF mass spectrometry.

RESULTS

In addition to PRNP 129, we detected a significant association between sCJD and allele frequencies of six further PRNP SNPs. No significant association of PRND T174M with sCJD was shown. We observed strong linkage disequilibrium within eight adjacent PRNP SNPs, including PRNP 129. However, the association of sCJD with PRNP 1368 and PRNP 34296 appeared to be independent on the genotype of PRNP 129. We additionally identified the most common haplotypes of PRNP to be over-represented or under-represented in our cohort of patients with sCJD.

CONCLUSION

Our study evaluated previous findings of the association of SNPs in the PRNP and PRND genes in the largest cohorts for association study in sCJD to date, and extends previous findings by defining for the first time the haplotypes associated with sCJD in a large population of the German CJD surveillance study.

[Acute effects on the health of children after accidental exposure to epichlorohydrine]

PURPOSE

In September 2002, two freight trains collided at Bad Muender, Germany. The inhabitants were potentially exposed to combustion products and to the human carcinogen epichlorohydrine (ECH). We aimed to describe the geographical distribution of and potential risk factors for acute symptoms among children residing in Bad Muender.

METHODS

The parents of a random sample of children were invited to answer a mail-in questionnaire (response rate 63%). The main outcome measures were self-reported acute symptoms potentially associated with combustion products (e. g., irritation of the eyes, nose, or throat) and stress-related unspecific symptoms (e. g., gastrointestinal complaints, sleep problems, headaches). The main location during the first 26 hours after the train accident served as exposure proxy measure. In addition, potential predictors for the symptoms under study were assessed.

RESULTS

The prevalence of symptoms associated with combustion products was 5.9%. Unspecific symptoms were reported for 6.3% of the children. Main location and prevalence of symptoms were not significantly associated. Physician-diagnosed asthma and nasal allergies were the main predictors of symptoms.

CONCLUSION

The prevalence of acute symptoms was relatively high in a random sample of children living close to the incident. However, associations between exposure to the accident and symptoms could not be established conclusively.

Effects of socio-demographic variables on health-related quality of life determined by the quality of life index--German version

STUDY OBJECTIVE

The purpose of this study was to determine subjective health-related quality of life (HRQoL) in a sample of the Austrian population over 14 years of age in order to evaluate the effect of socio-demographic variables on HRQoL.

DESIGN/SETTING

HRQoL was determined by means of the quality of life index-German version (QLI-Ge). The influence of socio-demographic variables on HRQoL was assessed by statistical analysis using the Kruskal-Wallis test and an analysis of variance.

PARTICIPANTS

A random-quota procedure was used to get balanced representation from regions and demographic groups of the Austrian population. The sample consisted of 1049 participants, 493 men and 556 women.

MAIN RESULTS

Age was found to influence the QLI-Ge total score (index score) and most individual items, with increasing age resulting in a decrease in HRQoL. Differences between the sexes were observed in three dimensions: males scored higher in 'physical well-being', 'psychological well-being' and 'occupational functioning'. Marital status impacted most items with married persons showing better values than divorced persons or singles. Profession had only a minor effect on HRQoL, the level of education showed no influence at all.

CONCLUSIONS

The socio-demographic variables age, sex and objective living conditions had a major influence on subjectively rated HRQoL, whereas profession and education were found to play a minor role in this context. It is recommended that in the interpretation of studies assessing HRQoL the above-mentioned objective factors be considered. This will be of particular importance when determining the effect of a pharmacotherapy on HRQoL in patients.

Modeling and dissection of longitudinal blood pressure and hypertension phenotypes in genetic epidemiological studies

We discuss analyses of the Genetic Analysis Workshop 13 data from the Framingham Heart Study and simulations based on this study. We summarize analyses that investigated measures of systolic blood pressure or hypertension as the main phenotype, with the main focus being the modeling of this complex longitudinal phenotype. The approaches include familial aggregation methods and one-stage and two-stage linkage methods. For one-stage linkage methods, phenotype modeling is carried out jointly with the linkage analysis or incorporated in the analysis design. For two-stage linkage methods, phenotypes are first modeled in order to develop summary measures that are then analyzed in a subsequent linkage analysis. Results depend on phenotype selection and on how analyses account for longitudinality, treatment effects, and heterodasticity.

Results of a surveillance programme for patients at high risk of malignant melanoma using digital and conventional dermoscopy

Patients with a high number of atypical naevi and a personal and/or family history of melanoma are at high risk of malignant melanoma. The objective of this study was to design a special documentation and surveillance programme using epiluminescence microscopy (ELM) and digital epiluminescence microscopy (DELM) to improve the surveillance of these patients. High-risk patients (n=212) were categorized by the number and phenotype of their naevi and their personal and family history of melanoma. Then patients were screened by the unaided eye, conventional photography, ELM and, in selected cases of atypia, DELM. Median follow-up was 18 months, and 2939 pigmented lesions were followed by DELM. Examination on the first visit identified 17 cutaneous melanomas. During the following observation period, another 17 melanomas were identified. Fifteen of these follow-up melanomas were exclusively identified based upon DELM. In these cases, subtle lesional changes occurred over time, and ELM diagnostic algorithms for differentiating benign melanocytic lesions from melanoma did not score a suspicion of melanoma. All melanomas, either pre-existing or developing during follow-up, were identified in an early, curable phase of tumour growth. We conclude that DELM follow-up for patients at high risk allows the early detection of melanomas that have not yet acquired melanoma-typical ELM features.

Retrospektive Untersuchung von Patienten mit malignem Melanom unter einer Misteltherapie

OBJECTIVE

The aim of the present investigation was to analyze survival time and survival rate of all patients with malignant melanoma who had been counseled at the Tumorambulanz Herdecke of the Community Hospital Herdecke.

PATIENTS AND METHODS

284 melanoma patients were included in a retrospective questionnaire study. Only those patients were considered for analysis in whom the prognostic factors histology, tumor localization, and Clark level were known. The data of the study population were compared with patient data obtained from the literature.

RESULTS

94 patients were included in the analysis. 66 of whom had received and 7 had not received mistletoe treatment, in the remaining 21 patients there was no information whether or not mistletoe treatment had been given. Thus, we did our study without a clearly defined internal control group. The median survival time among patients treated with mistletoe had been 14.1 years. The 5- and 10-year survival rates were 80 and 68% for the mistletoe-treated patients, respectively.

DISCUSSION

The 5-year survival rate of the mistletoe-treated patients is comparable to that of patients without mistletoe therapy while the 10-year survival rate is a little bit lower. This may be due to the fact that, in contrast to the patients from the relevant literature, 33.3% of the patients suffered from lymph node and/or distant metastases already before counseling the Tumorambulanz Herdecke. Moreover, 50% of our patients had melanoma of Clark level IV in contrast to 22.2% or 31% in the relevant literature.

CONCLUSIONS

In spite of the theoretical reservations against mistletoe treatment in melanoma patients, our retrospective analysis did not show any clues about disadvantages of mistletoe treatment in melanoma patients. A controlled prospective study therefore should prove the efficacy of a mistletoe therapy in patients with malignant melanoma.

[Methods in evidence-based medicine consensus findings--a case study in trauma surgery]

The methods and processes of a guideline development programme including a structured consensus conference for the employment of Diagnostic Imaging in Trauma Surgery are presented and critically reviewed. International standards and methodical concepts described in the Guideline Manual by the Agency for Quality in Medicine (AQuMed) and the Association of the Scientific Medical Societies in Germany (AWMF) have been implemented. Experiences with this project reveal that even a small multidisciplinary panel group is potentially able to cope with the comprehensive panel work if they are methodologically supported. The establishment of an internal quality management proved to be a useful tool for the production of high-quality results in the face of limited project resources. As expected, for most sub-questions knowledge of evidence and medical experience correlated well. However, the lack of a method for ensuring that consensus recommendations finally obtained by panel work and discussions during the conference were always based on evidence was the weak spot of this evidence-based consensus conference.

[Childhood diseases, infectious diseases, and fever as potential risk factors for cancer?]

OBJECTIVE

We investigated the assertion that past childhood diseases, acute and febrile infections as well as allergies have a preventive effect on cancer. Former studies on this topic show controversial results and methodical deficits. PATIENTS AND METHODS The investigation was conducted as a retrospective case control study with 111 cancer patients and a group of 109 control persons from 3 hospitals in Berlin.

RESULTS

A significant change in the risk of developing cancer could only be observed for mumps (OR = 2.6; increased risk), whooping cough (OR = 2.7; increased risk), and colds in the recent past (OR = 0.7; decreased risk). Fever within the last 5 years showed no association with the development of malign tumors.

CONCLUSION

We could not confirm the results of former studies which assumed a preventive effect of childhood diseases and fever on the cancer risk. On the contrary, on the basis of this investigation one might postulate a 2- to 3-fold rise of the cancer risk by mumps or whooping cough. Because of divergent study results, deficits in the study designs, and a low evidence of the present findings no final statement on the association between childhood diseases or fever and cancer should be made.

Validation of questionnaires from several medical fields regarding the constitution of patients

INTRODUCTION

To consider or determine an individual's 'warm and cold' constitution is common part of traditional Chinese medicine (TCM), Indian medicine (Ayurveda), anthroposophic medicine and classical natural medicine.

OBJECTIVE

Common psychometric characteristics of 4 questionnaires should be examined.

METHODS

110 cancer patients and 110 non-cancer patients were asked to answer these questionnaires twice 4 weeks apart. Subsequent validation of the questionnaires included psychometrical qualities of item acceptability, sensitivity to change, construct validity (homogeneity), re-test reliability and group comparison.

RESULTS

The Ayurveda questionnaire was considered suitable after reducing the questions from 22 to 8 (internal construct validity kappa = 0.64). The TCM questionnaire was considered unsuitable in our model because of the absence of construct validity. The questionnaire on anthroposophic medicine was considered a suitable and reliable tool with alpha = 0.57 (Cronbach's alpha) and r = 0.61 (re-test reliability) after reducing the questions from 6 to 4. The questionnaire on sensitivity to temperatures based on classical natural medicine was considered suitable after reducing the questions from 10 to 8 (alpha = 0.58; r = 0.73). Cancer and non-cancer patients differ in only one item, i.e. in their sensitivities to cold.

CONCLUSION

The questionnaires for anthroposophic medicine, Ayurveda medicine and sensitivity to temperatures are in part suitable and reliable for determining individual constitutions according to their medical philosophy. The questionnaire based on traditional Chinese medicine failed these criteria. A difference between patients with or without malignant disease was only observed for sensitivity to temperatures. The anthroposophic hypothesis that cancer either changes an individual's thermic constitution or is caused by such a change could not be confirmed in this study.

Sleeping habits in the Austrian population

OBJECTIVES

To gain reliable data on sleeping habits and sleep disturbances of the Austrian population.

BACKGROUND

Exact data on sleeping habits are of interest in relation to assessment of sleep disturbance-related illnesses and general social processes.

METHODS

A prospective, cross-sectional study was performed with recruitment of a representative sample of 1049 Austrians (aged 15-82 years), according to the Federal Statistics population characteristics. Interviews were conducted in the households of the participants by specially trained interviewers of an institute for empirical research.

RESULTS

Men consider their quality of sleep to be significantly better than women (P=0.00234), and younger persons consider their quality of sleep to be significantly better than older persons (P=0.00001). In comparison, women and people over the age of 50 report worse subjective sleep quality, worse sleep efficiency, more difficulty in falling asleep and sleep maintenance, more apneic events, more pathologic limb movements, more daytime dysfunction, and more intake of sleeping medication. Other sociodemographic factors influence sleep reports to a lesser extent.

CONCLUSIONS

Subjectively disturbed sleep (prevalence in the total population 24.9%), excessive hypnotic drug intake (prevalence 13.0%), and daytime dysfunction (prevalence 17.4%) are a widespread problem, especially in women and older people. With increasing life expectancy in Western societies, the prevalence of sleep disturbances will increase.

Noninvasive detection of coronary lesions by multislice computed tomography: results of the New Age pilot trial

The reliable noninvasive assessment of coronary artery disease would constitute an important step forward in clinical cardiology. The aim of the New Age pilot trial was to evaluate the diagnostic accuracy of multislice computed tomography (MSCT) in determining coronary lesions. As a gold standard for in vivo plaque detection, intracoronary ultrasound (ICUS) was used. Forty plaques were detected by ICUS in 15 target vessels (LAD, n = 8; RCA, n = 7) in patients assigned for ICUS-guided PTCA. Preinterventional MSCT was performed in all patients and the results were compared to ICUS with regard to lesion detection and quantification. According to ICUS results, the 40 plaques were divided into three groups: group I, mild lesions < 50% (n = 14; 44.36% +/- 5.77%); group II, intermediate lesions 50%-75% (n = 12; 59.18% +/- 9.39%); and group III, severe lesions > 75% (n = 14; 91.47% +/- 3.68%). All MSCT scans showed sufficient image quality for analysis. Thirty of 40 (75%) plaques were detected by MSCT in a first blinded session. After unblinding the ICUS results, the remaining 10 (25%) plaques could be identified. Lesion severity was classified correctly in 34 of 40 (85%) plaques. Plaque calcifications were diagnosed correctly in 16 of 19 (84.2%) plaques. Quantification of vessel size revealed a good correlation to the ICUS results (r(2) 0.68; P = 0.004). Noninvasive MSCT angiography showed good diagnostic accuracy with regard to lesion detection and quantification of vessel size. The overall good image quality, makes this new technology a promising modality, which might become an alternative diagnostic approach in patients with known or suspected coronary artery disease. Cathet Cardiovasc Intervent 2001;53:352-358.

Locking a microsphere whispering-gallery mode to a laser

We have locked a whispering-gallery resonance of a fused-silica microsphere to a frequency-scanning laser. The resonance frequency is modulated by axial compression of the microsphere, and phase-sensitive detection of the fiber-coupled optical throughput is used for locking. Using a laser wavelength of either 1570 nm or 830 nm, we demonstrate a locked tracking range exceeding 30 GHz for a microsphere of 120 GHz free spectral range. This performance has been enabled by an improved compression tuner design that allows coarse tuning over 1 THz and piezoelectric tuning over 80 GHz. Compression modulation rates of up to 13 kHz have also been achieved with this tuner.

N-CPAP rejecters--a specific group of noncompliant patients with obstructive sleep apnea syndrome

A large number of studies have been focused on patients with severe obstructive sleep apnea syndrome (OSAS) being non-compliant with N-CPAP therapy, but data concerning patients who reject N-CPAP therapy from the very start, without a day of N-CPAP home therapy, do not exist. The purpose of the study was to determine differences, if any, in the quality of life (QoL) between patients rejecting N-CPAP therapy from the start, untreated patients with severe OSAS waiting for N-CPAP titration, and controls. Qol was measured in terms of life satisfaction on the basis of the Munich life quality dimension list (MLDL), an instrument for cognitive assessment of elementary components (physical condition, psyche, social life, everyday life) of QoL. Untreated patients (n = 16) with severe OSAS have a significantly worse QoL in the dimension of psyche (p = 0.00022), social life (p = 0.00582) and everyday life (p = 0.01633) than do rejecters of therapy (n = 19). In the dimension of physical condition, no significant difference was seen (p = 0.47138). Compared with controls (n = 113), rejecters of therapy have a significantly lower QoL score in regard of physical condition (p = 0.00014) but not in terms of psyche, social life and everyday life. We conclude that a good QoL and the absence of the stress of suffering is one reason why patients with severe OSAS reject N-CPAP therapy in spite of physical impairment.

Sleep and quality of life in the Austrian population

PURPOSE

To compare the self-reported estimation of sleep quality evaluated by the Pittsburgh Sleep Quality Index (PSQI) and life quality assessed by the Quality of Life Index (QLI).

BACKGROUND

The PSQI comprised 19 questions and assessed a wide variety of factors relating to sleep quality. The QLI consisted of 10 items for self assessment of different dimensions of life quality.

SUBJECTS

A representative Austrian sample (n = 1049) aged above 15 years.

PROCEDURE

Interviews in the homes of the participants.

RESULTS

32.1% could be classified as poor sleepers (37% females, 26.5% males). Sleep quality decreased with increasing age, especially in women. Overall quality of life was highest in younger (15-29 years) and lowest in elderly subjects (over 50 years). Life quality decreased with increasing age. Between subjective sleep quality and quality of life a moderate, significant correlation was found (r2= 0.6721).

CONCLUSIONS

Complaints about a bad quality of sleep could be used as a screening method in the exploration of patients' quality of life (QoL).

[Mistletoe extracts in the therapy of malignant, hematological and lymphatic diseases--a monocentric, retrospective analysis over 16 years]

OBJECTIVE

The aim of the present investigation was to investigate potentials risks of treatment with mistletoe extracts in patients with malignant haematological and lymphatic diseases consulting the Tumour Ambulance of the Community Hospital Herdecke and to evaluate the therapeutic experiences with this treatment.

PATIENTS AND METHODS

All 700 patients with these diseases who had been counselled at the Tumour Ambulance of Community Hospital Herdecke since the foundation of the unit were included in a retrospective questionnaire study to collect information on the course of the disease and the survival time. Therapy with mistletoe extracts had been recommended to all patients. The treatment was carried out by the patient's physician outside the hospital. For inclusion into further analysis, information on survival time and mistletoe treatment had to be available. Survival times of patients who had actually received the recommended mistletoe treatment and of patients who had not received the recommended mistletoe treatment were compared (internal comparison). Furthermore, the results were compared to those of conventionally treated patients obtained from the literature (literature comparison).

RESULTS

Of 237 patients for whom sufficient data was available, 14 had not been treated with a mistletoe extract. The median survival time was 9.18 years among patients who had received mistletoe compared to 7.54 years among those without. Before a statistical test was carried out, the equivalent distribution of diagnosis in the 2 groups was tested. Regarding this criterion, only 205 patients treated with mistletoe extract and 9 patients not treated with mistletoe extract could be included into the statistical tests of the median survival time. The median survival time was 11.4 years (mistletoe patients) and 8.6 years (patients without mistletoe therapy). The difference was not significant. There were no cases in which mistletoe treatment was associated with deterioration. The comparison with data from the literature yielded very similar survival times among patients not treated with mistletoe extract and those included in our study.

CONCLUSION

No indications to risks of a mistletoe therapy on progress of the disease and the survival time could be found. Therefore, no ethical reservations should be opposed to future prospective investigations of mistletoe therapy in patients with malignant haematological diseases.

Localization and cellular distribution of a unique hyaluronidase in stallion spermatozoa during epididymidal transit

Three protein bands with hyaluronidase activity and molecular masses of 87, 48 and 43 kDa were isolated from purified equine sperm plasma membranes. Indirect immunofluorescence was used to assess sperm labelling patterns using a polyclonal antibody to sperm hyaluronidase. In ejaculated spermatozoa, surface-associated hyaluronidase was localized to the posterior head region of 98 +/- 2% of spermatozoa (n=10). Epididymides were isolated from mature stallions (n=5) and divided into caput, corpus and cauda epididymides in separate Petri dishes. The epididymidal tubules were dissected and washed using Dulbecco's PBS on ice and spermatozoa were collected from each region in the separate Petri dishes. After fixation and washing, the cells were labelled using indirect immunofluorescence. Spermatozoa from the caput epididymidis displayed > 90% sperm head fluorescence over the anterior head region overlying the acrosome, whereas spermatozoa from the cauda epididymidis displayed fluorescence over the posterior head region only, which is similar to ejaculated spermatozoa. Spermatozoa from the corpus epididymidis displayed sperm head fluorescence similar to that of spermatozoa from the caput epididymidis. These data indicate that surface-associated hyaluronidase is redistributed during epididymidal transit and that this maturation-associated redistribution occurs during late transit. The results indicate that epididymidal sperm maturation is a dynamic event and that hyaluronidase could potentially be used as a novel marker for epididymal dysfunction in stallions.

[Development of lymphocyte subsets in tumor patients after subcutaneous administration of mistletoe extracts]

OBJECTIVE

In order to exclude the possibility that mistletoe therapy may result in immunosuppression, as indicated by a significant reduction of defined lymphocyte subsets,

PATIENTS AND METHODS

peripheral blood cells of 23 tumour patients were treated subcutaneously with increasing concentrations of aqueous mistletoe extracts (Helixor(R)).

RESULTS AND CONCLUSIONS

Within an observation period of 7 months, the relative amount of lymphocytes and the number of natural killer (NK) cells increased while the number of lymphocyte subsets (i. e. CD19+ B cells, CD4+ T helper cells, CD8+ CD28- suppressor cells, CD8+ CD28+ cytotoxic cells) and the proportion of CD25+ (activated) cells within T cells showed a statistically remarkable trend; due to the multiple test problem of statistical evaluation this trend is not allowed to be termed significant. The leucocytes decreased insignificantly within the observation period. However, we were unable to verify a suggested increase of defined lymphocyte subsets within 2-3 months after the onset of mistletoe treatment. Nevertheless, for the parameters CD19+ B cells, CD4+ T helper cells, CD8+ cells, CD8+ CD28+ cytotoxic cells and CD16+/CD56+ NK cells we observed statistically remarkable peaks within die 2nd and 3rd month of therapy, confirming the hypothesis. The responses to the extracts were obviously interindividually different; the immune responses especially of patients with a lower number of peripheral T cells were less significant as compared to those of patients with adequate T cell numbers. Surprisingly, even an increase of the drug concentration >3 ng mistletoe lectin (as determined within the whole plant extract) per kg body weight enhanced the number of CD4+ T helper cells. A decreased immunological reaction on mistletoe extracts was shown especially for patients with a reduced number of peripheral T cells, whereas patients with normal T-cell number were more reactive.

Self-reported prevalence of venous diseases in the general population of Austria--results of the SERMO (Self-Reported Morbidity) Study

Venous diseases are common in Western societies, their causes, however, have remained largely unknown. The prevalence of venous diseases in the general population of Austria was assessed, and information on the background morbidity of venous diseases obtained from the data base of the SERMO study (Self-Reported Morbidity Study). The SERMO study consists of 9 representative population surveys conducted between December 1994 and December 1995; the study aimed at describing and monitoring the characteristics of background morbidity in the Austrian population. 5.9% of the sample reported to suffer from venous diseases (vein varicosis, phlebitis, vein thrombosis) in 1995; the point prevalence was 4.1%. The prevalence rate of chronic vascular disorders of the lower extremities was 5.9%. The prevalence of venous diseases is much higher among women than men. Advanced age is as much a risk factor for venous diseases as is low education. This study has shown that persons suffering from venous diseases, especially those advanced in age, suffer more often from concomitant diseases and disorders than others. In addition to clinical and mortality data, self-reported morbidity data provide important information on the health of a general population. Persons above 60 years of age are expected to constitute one third of the entire Austrian population by the year 2030. With this anticipated demographic development in view, the need for long-term prevention plans of chronic venous diseases appears to be of particular importance.

[Acute generalized exanthematous pustulosis, induced by nystatin]

Despite its widespread use, the antimycotic nystatin rarely causes allergic reactions. We observed a case of acute generalized pustular exanthem with arthralgia and fever, after the oral administration of nystatin. A causal relationship was demonstrated by positive Intracutaneous testing of the drug. Immunohistology revealed positive staining for C3 in the test area, whereas circulating immune complexes could not be identified. These findings are compatible with a type-II allergic reaction. Systemic prednisolone treatment led to a complete remission of the clinical symptoms within 11 days. In two test subjects who had never received nystatin intracutaneous testing was initially negative. After 3 weeks, both developed itching erythematous papules at the injection sites. Therefore, intracutaneous testing of nystatin involves the risk of sensitization.

Impact of nasal continuous positive airway pressure treatment on quality of life in patients with obstructive sleep apnoea

Quality-of-life (QoL) issues have become increasingly important in health care practice and research. Obstructive sleep apnoea syndrome (OSAS) results in an especially serious reduction in QoL. The purpose of this study was to measure the QoL (life satisfaction) of OSAS patients treated with nasal continuous positive airway pressure (nCPAP). We aimed to determine whether and to what extent the QoL of OSAS patients using nCPAP differs from that of randomly selected subjects without this disorder. The QoL of 67 patients treated for at least 3 months with nCPAP, 21 OSAS patients at the time of OSAS diagnosis, and 113 randomly selected persons visiting the hospital (controls) was investigated with the help of the Munich life-quality dimension list (MLDL), an instrument for cognitive assessment of elementary components (physical condition, psyche, social life, everyday life) of QoL. It was found that QoL of OSAS patients treated with nCPAP did not significantly differ from that of control subjects with regard to elementary components. The 21 untreated OSAS patients showed significantly lower scores in all four subcategories: physical condition (p<0.0005), psyche (p<0.01), social life (p<0.0005) and everyday life (p<0.007). Thus, it may be concluded that nasal continuous positive airway pressure therapy has an important impact on the quality of life of obstructive sleep apnoea syndrome patients, and signifies a further advantage in addition to clinical aspects. Treated patients are as satisfied or dissatisfied with their life as persons without this illness.

Arterial dissections associated with pregnancy

Two cases of spontaneous arterial dissection occurring in young, multiparous women shortly after delivery of uncomplicated pregnancies are described. Histologic analysis of arterial tissue samples obtained in both cases at points near and remote from the dissection sites shows evidence of significant arterial degeneration and loss of integrity, with changes similar to those observed in pregnant women, women using oral contraceptives, and animals given female sex hormones. The types of arterial lesions associated with pregnancy and their sites of predilection and the etiologic roles of the hemodynamic stresses of pregnancy and hormones are discussed.

The value of ultrasound in Schoenlein-Henoch purpura

We report the results of ultrasound studies on 11 children with Schoenlein-Henoch purpura. In 8 children the ultrasound examination was normal. In two of three patients with macroscopic haematuria, haemorrhagic cystitis, a previously undescribed finding in Schoenlein-Henoch purpura, was found. In one case the gall bladder wall and the wall of several adjacent loops of bowel were markedly thickened. Follow up examinations after clinical recovery demonstrated complete resolution of these abnormalities. Our observations demonstrate that diagnostic ultrasound may have an important role before more expensive and invasive procedures are employed in patients with Schoenlein-Henoch purpura.

Palmar hyperhidrosis CT guided chemical percutaneous thoracic sympathectomy

Palmar hyperhidrosis or excessive sweating of the hands causes, to those affected, emotional and physical disturbance and impediment in professional and social life. The cause is unknown. Sweat glands are innervated by the sympathetic chain of the autonomous nervous system. The center of sympathetic regulation of the upper extremities is located between the segments of D.2-D.9 of the spinal cord. Accepted treatment consists of surgery aimed to excise the third thoracic sympathetic ganglion. Besides the surgical procedure as such, and its complications, there are complications inherent to the excision of the ganglion. These are Horner's syndrome, compensatory sweating in other parts of the body, and recurrence of sweating. CT guided chemical percutaneous thoracic sympathectomy presents an alternative, which in the event of failure does not prevent ensuing surgery. The preliminary experience with this procedure in 50 patients is presented and discussed.

Potentiation of natural killer cell activity and tumor immunity by diacetylputrescine

The objective of the present investigation was to evaluate the immunomodulating properties of tetramethylenebisacetamide (N,N' 1-diacetylputrescine, DAP), a known inducer of cellular differentiation. We examined the effect of DAP administration in vivo on splenic and nonadherent peritoneal natural killer (NK) cell activity. A single i.p. injection of DAP (100 mg/kg) enhanced cytolytic activity directed against YAC-1 and MCA-38 tumor target cells 2- to 3-fold. Cytolytic activity peaked 3 days following DAP injection. DAP treatment increased the frequency of asialo-GM1-positive splenocytes to 15% compared with 5% for vehicle treated controls. Furthermore, cytolytic activity could be eliminated by treatment with anti-asialo-GM1 antibodies and complement. Lysis of NK-resistant P815 and EL4 tumor target cells was not observed in leukocytes from DAP-treated mice. DAP treatment of mice given injections i.p. of MCA-38 tumor cells increased survival time of the mice by 37%, curing 10% of the animals of the tumor. DAP treatment of mice given injections intrasplenically of MCA-38 tumor cells reduced both the number and the size of the hepatic metastases. The antitumor effect of DAP in vivo could be eliminated by pretreating mice with anti-asialo-GM1 antibodies or utilizing NK cell deficient beige (bg/bg) mice. These results indicate that the observed anti-tumor activity of DAP is mediated, at least in part, by NK cells.

Intracorporeal calcifications after self-injection of papaverine

Penile indurations were found at follow-up examination in six of 120 patients with erectile dysfunction who practice intracavernosal self-injection of papaverine-phentolamine. In four of these six, cavernosal calcifications were demonstrated by means of ultrasound (US) and radiography. Most of the calcifications were close to the site of injection, but some were more distant. Cavernosal calcifications must be considered a possible complication of self-injection of papaverine-phentolamine. Baseline US and radiographic studies of the penis are advisable before starting treatment.

Nonocclusive ischaemic bowel disease in patients on chronic haemodialysis

Six patients with chronic renal failure on longstanding haemodialysis are presented, in whom nonocclusive bowel ischaemia occurred as a rare complication of their underlying disorder. Factors implicated in the development of bowel ischaemia in these patients are chronic constipation resulting in increased intraluminal pressure on the bowel wall, premature and progressive arterial disease and bouts of hypotension accompanying the haemodialysis procedure. Contrast studies of the bowel and computed tomography examination can suggest the diagnosis, but angiography alone provides the exact answer in demonstrating nonocclusive mesenteric ischaemia. In patients with chronic renal failure and longstanding dialysis presenting with abdominal symptoms this diagnosis should be considered.

Reevaluation of transthoracic fine needle aspiration biopsy in diagnosing superior vena cava syndrome

Superior vena cava syndrome has various aetiologies but in the majority of cases it is caused by a malignant mass. Assessment of the underlying pathology as rapidly and reliably as possible is very important for proper therapy management. Dynamic computed tomography examination of the chest can differentiate patients in whom superior vena cava obstruction is caused by a mass, from those with a vascular aetiology. In patients with a mass, fine needle aspiration biopsy guided by the computed tomographic examination may provide cytological diagnosis in a fast and well tolerated manner.

Intraoperative ultrasonography in cystic brain lesions

Four neurosurgical patients were operated on under real-time ultrasonographic guidance. Two had cystic tumors which were drained through the unincised dura. In one patient a brain abscess was located intraoperatively by ultrasound after a small craniotomy. In a fourth patient with multiple abscesses, one abscess was drained under ultrasonographic guidance through a previous craniotomy. Using intraoperative ultrasonography the length of the operation can be shortened and normal brain tissue spared. Intraoperative ultrasonography is of special value in cystic lesions which can be drained under ultrasonographic guidance.