Left ventricular longitudinal strain in professional athletes, a useful tool to detect an athletes hearts?

Background

Professional cyclists frequently present with physiological adaptations to endurance exercise with an increase in left ventricular wall thickness and mass. Global longitudinal strain (GLS) is an early and sensitive echocardiographic method to detect left ventricular dysfunction. However, it is unclear whether GLS is able to differentiate between athlete's hearts or different pathological conditions of left ventricular hypertrophy.

Methods

A total of 87 professional athletes (37 professional cyclists, 29 professional soccer players, and 21 professional handball players) were compared to 125 patients with different forms of left ventricular hypertrophy (17 hypertrophic obstructive cardiomyopathy (HOCM), 36 hypertensive heart disease (HHD), 35 severe aortic valve stenosis (AVS); 37 untrained individuals served as controls. Examinations were performed between October 2018 to October 2019. All subjects underwent echocardiographic examination, including GLS.

Results

In all 212 participants/patients included a preserved ejection fraction >50% (mean 61±7%) was detected. Left ventricular mass index (LVMI) in professional cyclists (165.5±37.1 g/m2) was increased when compared to professional soccer players (97.3±12.4 g/m2, p<0.001), professional handball players (92.2±15.8 g/m2, p<0.001) and healthy controls (94.3±20.7 g/m2, p<0.001), as well as to patients with HHD (129.2±30.0 g/m2, p<0.001), or AVS (140.1±35.4 g/m2, p=0.064), but not to patients with HOCM (159.7±39.4 g/m2, p=0.64). Professional cyclists (−21.0±3.5%) achieved higher average GLS values than professional soccer (−18.4 ± %, p=0.004) or handball players (−18.4 ± %, p=0.021), healthy controls (−19.0±3.0%, p=0.008), HOCM (−15.0±6.5%, p<0.001), HHD (−13.8±5.9%, p<0.001), and AVS (−16.0±7.0%, p<0.001) (Figure 1).

Conclusion

In professional cyclists, higher LVMI and average GLS values were detected compared to professional soccer and handball players with lower excessive endurance exercise, as well as untrained healthy controls. Average GLS can help to differentiate between athletes' hearts in professional cyclists compared to pathologic patterns in different diseases characterized by left ventricular hypertrophy with elevated LVMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Achieving a Successful Scale-Down Model and Optimized Economics through Parvovirus Filter Validation using Purified TrueSpikeTM Viruses

This article describes a four virus panel validation of EMD Millipore's (Bedford, MA) small virus-retentive filter, Viresolve® Pro, using TrueSpike(TM) viruses for a Biogen Idec process intermediate. The study was performed at Charles River Labs in King of Prussia, PA. Greater than 900 L/m(2) filter throughput was achieved with the approximately 8 g/L monoclonal antibody feed. No viruses were detected in any filtrate samples. All virus log reduction values were between ≥3.66 and ≥5.60. The use of TrueSpike(TM) at Charles River Labs allowed Biogen Idec to achieve a more representative scaled-down model and potentially reduce the cost of its virus filtration step and the overall cost of goods. The body of data presented here is an example of the benefits of following the guidance from the PDA Technical Report 47, The Preparation of Virus Spikes Used for Viral Clearance Studies.

LAY ABSTRACT

The safety of biopharmaceuticals is assured through the use of multiple steps in the purification process that are capable of virus clearance, including filtration with virus-retentive filters. The amount of virus present at the downstream stages in the process is expected to be and is typically low. The viral clearance capability of the filtration step is assessed in a validation study. The study utilizes a small version of the larger manufacturing size filter, and a large, known amount of virus is added to the feed prior to filtration. Viral assay before and after filtration allows the virus log reduction value to be quantified. The representativeness of the small-scale model is supported by comparing large-scale filter performance to small-scale filter performance. The large-scale and small-scale filtration runs are performed using the same operating conditions. If the filter performance at both scales is comparable, it supports the applicability of the virus log reduction value obtained with the small-scale filter to the large-scale manufacturing process. However, the virus preparation used to spike the feed material often contains impurities that contribute adversely to virus filter performance in the small-scale model. The added impurities from the virus spike, which are not present at manufacturing scale, compromise the scale-down model and put into question the direct applicability of the virus clearance results. Another consequence of decreased filter performance due to virus spike impurities is the unnecessary over-sizing of the manufacturing system to match the low filter capacity observed in the scale-down model. This article describes how improvements in mammalian virus spike purity ensure the validity of the log reduction value obtained with the scale-down model and support economically optimized filter usage.

Morphologic outcome of bimaxillary surgery--an anthropometric appraisal

OBJECTIVES

To adequately perform orthognathic surgery procedures, it is from basic interest to understand the morphologic changes caused by orthognathic surgery. Anthropometric analyses of standardized frontal view and profile photographs could help to investigate and understand such changes.

STUDY DESIGN

We present a pre- to postoperative evaluation of orthognathic surgery results based on anthropometric indices described by Farkas and cephalometric measurements. 30 Class III patients undergoing maxillary advancement by Le Fort I Osteotomy and mandibular setback by bilateral sagittal split osteotomy were evaluated. Preoperative as well as three and nine months postoperative lateral cephalograms as well as standardized frontal view and profile photographs were taken. On the photographs 21 anthropometric indices given by Farkas were evaluated. In cephalograms SNA and SNB angle as well as Wits appraisal were investigated.

RESULTS

The investigated anthropometric indices showed a significant increase of the vertical height of the upper lip without changing the relation of the upper vermilion to the cutaneous upper lip. The lower vermilion height increased relatively to the cutaneous lower lip without vertical changes in the lower lip. Due to maxillary advancement the upper face height increased meanwhile the lower face height decreased due to mandibular setback. SNA and SNB angle and Wits appraisal showed typical changes related to surgery.

CONCLUSIONS

The investigated photo-assisted anthropometric measurements presented reproducible results related to bimaxillary surgery.

Posttraumatic edema of the lower extremities: evaluation of the lymphatic vessels with magnetic resonance lymphangiography

OBJECTIVE

To assess for the first time the morphology of the lymphatic system in patients with posttraumatic edema of the lower extremities by magnetic resonance (MR) imaging using the interstitial lymphangiography technique

MATERIALS AND METHODS

Six patients with posttraumatic edema in eight of their 12 lower extremities were examined by MR lymphangiography. Eighteen mL of gadoteridol and one mL of mepivacainhydrochloride 1% were subdivided into 10 portions and injected intracutaneously. MR imaging was performed with a 1.5-T system equipped with high-performance gradients. For MR lymphangiography, a 3D-spoiled gradient-echo sequence was used.

RESULTS

In five of the eight (63%) traumatized lower extremities, enlarged lymphatic vessels were detected, with the largest diameter measuring 5 mm. Additionally, a fast lymphatic outflow was observed in seven of the eight (88%) traumatized legs with enhancement of the inguinal lymph nodes already in the first image acquisition 15 minutes after contrast material injection. In two of the eight (25%) traumatized lower extremities, an extensive network of collateral lymphatic vessels was detected at the level of the calf. In both extremities, lymphatic collateralization involved not only the epifascial but also the subfascial lymphatic system. In one patient, who sustained a trauma of the left lower leg with tibial fracture, a small aneurysmatic widening of 7 mm could be detected at the middle level of the calf.

CONCLUSION

MR lymphangiography is a safe and accurate minimal-invasive imaging modality for the evaluation of the lymphatic circulation in patients with posttraumatic edema of the lower extremities. If the extent of lymphatic damage is unclear at the initial clinical examination or requires a better definition for optimal therapeutic planning, MR lymphangiography is able to identify the anatomic and physiological derangements and to establish an objective baseline.

Impact of digital impression techniques on the adaption of ceramic partial crowns in vitro

OBJECTIVES

To investigate the effects, digital impression procedures can have on the three-dimensional fit of ceramic partial crowns in vitro.

METHODS

An acrylic model of a mandibular first molar was prepared to receive a partial coverage all-ceramic crown (mesio-occlusal-distal inlay preparation with reduction of all cusps and rounded shoulder finish line of buccal wall). Digital impressions were taken using iTero (ITE), cara TRIOS (TRI), CEREC AC with Bluecam (CBC), and Lava COS (COS) systems, before restorations were designed and machined from lithium disilicate blanks. Both the preparation and the restorations were digitised using an optical reference-scanner. Data were entered into quality inspection software, which superimposed the records (best-fit-algorithm), calculated fit-discrepancies for every pixel, and colour-coded the results to aid visualisation. Furthermore, mean quadratic deviations (RMS) were computed and analysed statistically with a one-way ANOVA. Scheffé's procedure was applied for multiple comparisons (n=5, α=0.05).

RESULTS

Mean marginal (internal) discrepancies were: ITE 90 (92) μm, TRI 128 (106) μm, CBC 146 (84) μm, and COS 109 (93) μm. Differences among impression systems were statistically significant at p<0.001 (p=0.039). Qualitatively, partial crowns were undersized especially around cusp tips or the occluso-approximal isthmus. By contrast, potential high-spots could be detected along the preparation finishline and at central occlusal boxes.

CONCLUSIONS

Marginal and internal fit of milled lithium disilicate partial crowns depended on the employed digital impression technique.

CLINICAL SIGNIFICANCE

The investigated digital impression procedures demonstrated significant fit discrepancies. However, all fabricated restorations showed acceptable marginal and internal gap sizes, when considering clinically relevant thresholds reported in the literature.

Oral prophylaxis and its effects on halitosis-associated and inflammatory parameters in patients with chronic periodontitis

OBJECTIVE

A controlled clinical trial was conducted to evaluate the effects of oral prophylaxis on halitosis-associated, immunological and microbiological parameters.

METHODS

Thirty subjects were included in this controlled clinical trial (patients with generalized chronic periodontitis and controls without clinical attachment loss; each n = 15). Before oral prophylaxis and 14 days after (including tongue cleaning) volatile sulphur compounds (VSC), organoleptic scores and a tongue coating index were evaluated. The levels of IL-1β, IL-8, IL-10 and MMP-8 were measured in GCF, and also major periodontal pathogens were detected. Data were statistically analysed using anova and paired t-test.

RESULTS

Supragingival plaque and calculus removal with combined tongue cleaning was able to reduce significantly (P < 0.05) the VSC values in both groups (no significant differences between both groups). Two weeks after periodontal debridement, the VSC values were observed in the periodontitis group, but not in the control group, similar to the baseline values. The difference between the groups was statistically significant (P < 0.05). Only a repeated prophylaxis session in the periodontitis group was able to reduce VSC values significantly in comparison with baseline (P < 0.05). Organoleptic scores (10 and 30 cm) were significantly different (P < 0.05) between both groups before and after the treatment. Periodontal pathogens and host-derived markers were not significantly affected by a single prophylaxis session.

CONCLUSIONS

Oral prophylaxis may result in a significant decrease in VSC values. However, in periodontal diseases, a more complex treatment seems to be necessary.

Soft tissue outcome after mandibular advancement--an anthropometric evaluation of 171 consecutive patients

OBJECTIVES

There is an ongoing discussion in the literature about preoperative planning and postoperative evaluation of orthognathic surgery and its impact on facial appearance and aesthetics.

MATERIALS AND METHODS

We present an anthropometric and cephalometric evaluation of orthognathic surgery results based on reference anthropometric data. In 171 Class II patients, mandibular advancement by bilateral sagittal split osteotomy was performed. Preoperative as well as 3 and 9 months postoperative standardized frontal view and profile photographs and lateral cephalograms were evaluated in a standardized manner by use of 21 anthropometric indices. In cephalograms, SNA and SNB angle as well as Wits appraisal were investigated. Results of anthropometric and cephalometric measurements were correlated.

RESULTS

Lower vermilion contour, vermilion and cutaneous total lower lip height, nose-lower face height, nose-face height, upper face-face height, upper lip- and chin-mandible height index showed significant pre- to postoperative changes as well as SNB angle and Wits appraisal. Furthermore, medial-lateral cutaneous upper lip height, vermilion and cutaneous total lower lip height and philtrum-mouth width index presented significant correlations to cephalometric measurements.

CONCLUSIONS

The investigated anthropometric indices and cephalometric measurements presented reproducible results related to surgery. The correlation of cephalometric to anthropometric measurements has been proven useful for preoperative planning and postoperative evaluation of orthognathic surgery patients.

CLINICAL RELEVANCE

The presented anthropometric measurements and their observed correlation to cephalometric measurements could lead to a better prediction and optimized planning of the soft tissue result in orthognathic surgery patients and thereby improve the aesthetic outcome.

A norovirus outbreak triggered by copper intoxication on a coach trip from the Netherlands to Germany, April 2010

We report an unusual outbreak of norovirus infection on a coach trip. Overall, 30 of 40 people (including drivers and crew) developed nausea, vomiting and/or diarrhoea, 11 of them on the first day of the trip. The incidence epidemic curve showed a first peak on Day 1 and a second on Day 4. Nine passengers were hospitalised with gastrointestinal symptoms. Norovirus was found in stool samples from two patients, but the infection could not explain the first peak in the epidemic curve only a few hours after departure. Interviews with the passengers and an inspection of the coach and its water supply implicated the water used for coffee and tea as the potential source. Microbiological investigations of the water were negative, but chemical analysis showed a toxic concentration of copper. Blood copper levels as well as renal and liver function were determined in 28 of the 32 passengers who had been exposed to the water. One passenger who did not have gastrointestinal symptoms had an elevated copper level of 25.9 μmol/L, without loss of liver or renal function. It is likely that the spread of norovirus was enhanced because of vomiting of one of the passengers due to copper intoxication.

A norovirus outbreak triggered by copper intoxication on a coach trip from the Netherlands to Germany, April 2010

We report an unusual outbreak of norovirus infection on a coach trip. Overall, 30 of 40 people (including drivers and crew) developed nausea, vomiting and/or diarrhoea, 11 of them on the first day of the trip. The incidence epidemic curve showed a first peak on Day 1 and a second on Day 4. Nine passengers were hospitalised with gastrointestinal symptoms. Norovirus was found in stool samples from two patients, but the infection could not explain the first peak in the epidemic curve only a few hours after departure. Interviews with the passengers and an inspection of the coach and its water supply implicated the water used for coffee and tea as the potential source. Microbiological investigations of the water were negative, but chemical analysis showed a toxic concentration of copper. Blood copper levels as well as renal and liver function were determined in 28 of the 32 passengers who had been exposed to the water. One passenger who did not have gastrointestinal symptoms had an elevated copper level of 25.9 µmol/L, without loss of liver or renal function. It is likely that the spread of norovirus was enhanced because of vomiting of one of the passengers due to copper intoxication.

Systematic comparison of sporadic and syndromic pancreatic islet cell tumors

Pancreatic islet cell tumors (ICTs) occur as sporadic neoplasias or as a manifestation of multiple endocrine neoplasia type 1 (MEN1) and von Hippel-Lindau disease (VHL). Molecular classification of ICTs is mandatory for timely diagnosis and surveillance. Systematic comparison of VHL-ICTs and sporadic ICTs has been lacking. Our registry-based approaches used the German NET-Registry with 259 patients with neuroendocrine tumors (NETs), who were primarily diagnosed with NETs, and the German VHL-Registry with 485 molecular genetically confirmed patients who had undergone magnetic resonance imaging or computed tomography of the abdomen. All patients provided blood DNA for testing of the MEN1 and VHL genes for intragenic mutations and large deletions. In the NET-Registry, 9/101 patients (8.9%) with ICTs had germline mutations, 8 in MEN1 and 1 in VHL. In the VHL-Registry, prevalence of NETs was 52/487 (10.6%), and all were ICTs. Interestingly, of those with VHL p.R167W, 47% developed ICTs, compared to 2% of those with p.Y98H. In total, there were 92 truly sporadic, i.e. mutation-negative ICT patients. Comparing these with the 53 VHL-ICT patients, the statistically significant differences were predominance of female gender (P=0.01), multifocal ICTs (P=0.0029), and lower malignancy rate (P<0.001) in VHL-ICTs compared to sporadic cases. VHL was prevalent in <0.5% of NETs, while NETs occur in ∼10% of VHL, virtually exclusively as ICTs, which are rarely the first presentation. Patients with NETs should not be subjected to genetic testing of the VHL gene, unless they have multifocal ICTs, other VHL-associated tumors, and/or a family history for VHL.

[The economic challenges of polytrauma care]

Following the introduction of DRGs ("diagnosis-related groups") in Germany, reimbursements changed from a per diem rate to a flat charge per patient. DRGs are defined by the German Institute for the Hospital Remuneration System (InEK, Institut für das Entgeltsystem im Krankenhaus) along with the respective reimbursement. The revenues are set according to the diagnoses and procedures. In complex cases like serious injury this applies for the average diagnoses and procedures. As a result, several groups reported costs of polytrauma care as high as 70,000 euro with losses as high as 20,000 euro. In the USA, a similar constellation has lead to the closure of trauma centers. The main reasons for the financial deficit are heterogeneity of polytrauma patients and contingency costs. Both are difficult to transfer to a case-based compensation system. Since the German DRG system was designed to learn during introduction, there were adjustments to reimbursements for polytrauma care in the initial phase. However, in recent years, no further improvements in the care of severely injured patients have been seen. The deficit per seriously injured patient currently runs at approx. 5000 euro. A renewed joint effort is required in order to avoid an economy-related reduction in quality of care.

[Outlier cases in surgical disciplines. Micro-economic and macro-economic problems]

Postoperative complications will always occur and the negative impact puts strain on patients, relatives and the attending physicians. The conversion to a remuneration system based on flat rates (diagnosis-related groups) presents additional economic problems for hospitals in some resource-intensive treatments. This particularly pertains to extremely cost-intensive cases in which costs succeed revenue by the factor of 2 and are often surgical procedures. Here the economic risk increases with the number of interventions performed. Despite improvements in the remuneration system this problem persists. An improved payment for these treatments is desirable. To achieve this it is necessary to systematically analyze the extremely cost-intensive cases by experts of different medical disciplines to create a data basis for a proposal of a cost-covering payment.

Continuously moving table MRI with sliding multislice for rectal cancer staging: image quality and lesion detection

PURPOSE

To determine image quality and lesion detection of sliding multislice (SMS), a recently developed moving table MRI technique, in patients with rectal cancer.

MATERIALS AND METHODS

Twenty-seven paired SMS (Avanto, Siemens Medical Solutions) and MDCT (Sensation 64, Siemens Medical Solutions) examinations of abdomen and pelvis were performed in patients with rectal cancer and compared for detection of liver, lymph node and bone metastases by two independent observers. A contrast-enhanced, fat saturated 2D gradient echo sequence (TE, 2.0 ms; TR, 102 ms; slice, 5 mm) was acquired with SMS and a standard contrast-enhanced protocol (100 ml @ 2.5 ml/s; slice, 5 mm) was used for abdominal MDCT. Standard of reference consisted of a consensus evaluation of SMS, MDCT, and all available follow-up examinations after a period of 6 months. Artifact burden and image quality of SMS was assessed in comparison to stationary gradient echo sequences obtained in an age-matched group of 27 patients.

RESULTS

Whereas SMS achieved a mean quality score of 3.65 (scale, 0-4) for the liver, representing very good diagnostic properties, strong breathing artifacts in the intestinal region were observed in 19 cases by both observers. The retroperitoneum still achieved a mean quality score of 3.52, although breathing artifacts were noted in 12 and 15 cases (observers 1 and 2, respectively). The sensitivities of SMS to detect hepatic metastases were 91.2% and 94.1% for both observers, respectively, compared to 98.5%/98.5% for MDCT. The sensitivities for lymph node metastases were 87.5%/81.3% for SMS compared to 78.1%/81.3% for MDCT. The sensitivities for bone metastases were 91.7%/100% for SMS compared to 8.3%/16.7% for MDCT.

CONCLUSION

With slightly reduced image quality in the intestinal region, SMS exhibits equal detection of lymph node and liver metastases compared to MDCT. SMS MRI proved to be superior to MDCT in detection of bone metastases.

Sliding multislice MRI for abdominal staging of rectal gastrointestinal stromal tumours

Anorectal gastrointestinal stromal tumours (GISTs) are uncommon mesenchymal neoplasms. The objective of this report was to demonstrate the value of sliding multislice (SMS) as an upcoming method of continuously moving table MRI, providing detailed abdominal staging of rectal GISTs. Integration of SMS into a high-resolution pelvic MR imaging protocol allows for both detailed assessment of rectal GISTs and depiction of the entire abdomen with high image quality. The staging of liver, malignant lymph nodes and bone metastases is now possible, prolonging pelvic MRI for only one minute.

State of the art 3D MR-cholangiopancreatography for tumor detection

With the use of current multislice techniques for MR cholangiopancreatography various upper abdominal pathologies including pancreatic carcinoma, Klatskin tumor and metastatic spread can be non invasively depicted. Respiratory gating allows free breathing of the patient, which increases patient comfort, while excellent image quality can be achieved. In this concise pictorial report, state of the art MRCP images of various cancer entities including sequence descriptons are presented.

Pharmacokinetics and systemic endocrine effects of the phyto-oestrogen 8-prenylnaringenin after single oral doses to postmenopausal women

AIMS

Pre-clinical data suggest that the racemic phyto-oestrogen 8-prenylnaringenin (8-PN) may have beneficial effects in postmenopausal women and may become an alternative to classical hormone replacement therapy (HRT) treatment regimes. The aim of this study was to investigate the pharmacokinetics, endocrine effects and tolerability of chemically synthesized 8-PN in postmenopausal women.

METHODS

The study was performed using a randomized, double-blind, placebo-controlled, dose-escalation design with three groups of eight healthy postmenopausal women. In each group six subjects received 8-PN and two subjects placebo. 8-PN was given orally in doses of 50, 250 or 750 mg. Drug concentrations in serum, urine and faeces were measured up to 48 h and follicle-stimulating hormone/luteinizing hormone (LH) concentrations up to 24 h.

RESULTS

All treatments were well tolerated and associated with a low incidence of (drug unrelated) adverse events. Serum concentrations of free 8-PN showed rapid drug absorption and secondary peaks suggestive of marked enterohepatic recirculation. Independent of the treatment group, approximately 30% of the dose was recovered in excreta as free compound or conjugates over the 48-h observation period. The first C(max) and AUC(0-48 h) showed dose linearity with ratios of 1 : 4.5 : 13.6 (C(max)) and 1 : 5.2 : 17.1 (AUC). The750- mg dose decreased LH concentrations by 16.7% (95% confidence interval 0.5, 30.2).

CONCLUSION

Single oral doses of up to 750 mg 8-PN were well tolerated by postmenopausal women. The pharmacokinetic profile of 8-PN was characterized by rapid and probably complete enteral absorption, high metabolic stability, pronounced enterohepatic recirculation and tight dose linearity. The decrease in LH serum concentrations found after the highest dose demonstrates the ability of 8-PN to exert systemic endocrine effects in postmenopausal women.

Detection of recurrent rectal cancer with CT, MRI and PET/CT

Computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) all have the potential to directly visualize local and distant relapse of colorectal cancer (CRC). Nevertheless, the role of diagnostic imaging for routine follow-up of CRC patients remains controversial. Although MRI and PET have advantages over CT in the detection of local recurrence, until now only a few surveillance programs recommend the use of annual CT for routine follow-up. The objective of this review is to elucidate the current status of diagnostic imaging for the detection of recurrent rectal cancer based on the recent literature and our own experience. Furthermore, an insight into contemporary surveillance programs and an outlook concerning a novel technical approach to moving-table MRI at 1.5 Tesla for staging purposes are given.

Diagnostik entzündlicher und tumoröser Erkrankungen des Kolons

The detection of inflammatory and tumorous conditions of the colon is one of the main topics in current abdominal radiology. The barium enema was introduced first in 1923 by Fischer, and has represented the workhorse of intestinal diagnostics for decades. The widespread use of endoscopy and the ongoing technical improvements in CT and MRI, however, have led to an inevitable displacement of this technique. Nevertheless, radiographs and enema are frequently employed in the initial work-up of patients with suspected colonic disease. This article provides an overview of the most important entities of inflammatory and tumorous changes of the colon.

Fluorine-18 DOPA PET imaging of paraganglioma syndrome

A 12-year-old boy was admitted after recently having had a resection performed of an extraadrenal retroperitoneal paraganglioma and left adrenalectomy for pheochromocytoma. Despite these procedures, the blood pressure and urinary noradrenalin were elevated. Screening with fluorine-18 DOPA PET demonstrated increased tracer uptake in the right adrenal gland, in a second abdominal lesion, which was prevertebral, and 2 cervical hot spots near the carotid bifurcation, one on each side of the neck. The patient carries a mutation of the gene Succinate dehydrogenasis subunits D (SDHD) and is thus classified with the paraganglioma syndrome type 1.

Serial high-resolution computed tomography imaging in patients with Wegener granulomatosis: differentiation between active inflammatory and chronic fibrotic lesions

PURPOSE

To evaluate pulmonary pathologies in Wegener granulomatosis with sequential computed tomography (CT) in order to differentiate active inflammatory lesions from chronic fibrotic lesions.

MATERIAL AND METHODS

Serial CT findings in 38 patients with Wegener granulomatosis were retrospectively analyzed (mean follow-up period, 21 months). The presence, extension, and distribution of the following findings were evaluated with CT: parenchymal nodules, masses, ground-glass attenuation, airspace consolidation, bronchial wall-thickening, bronchiectasis, linear areas of attenuation, pleural irregularities, pleural effusions, hilar and mediastinal lymphadenopathy.

RESULTS

Observed in 92% of patients, nodules were the most common CT pathology. Areas of ground-glass attenuation, consolidation, masses of linear attenuation, and tracheal/bronchial wall-thickening were detected in 24%, 26%, 32%, 39%, and 68% of patients. At follow-up, the clearance of lesions was most consistent for areas of ground-glass attenuation (89%), masses (87%), and cavitated nodules (85%). In the follow-up scan, 58% of all nodules, 47% of pulmonary consolidations, and 66% of bronchial wall-thickening were completely resolved. Areas of bronchiectasis and septal/non-septal lines remained stable in 70% and 71% of patients.

CONCLUSION

The majority of the lesions decreased or resolved completely with or without areas of linear attenuation. Ground-glass attenuation, cavitated nodules and masses appear to represent active inflammatory lesions. In most probability, areas of bronchiectasis and septal/non-septal lines more often represent chronic fibrotic changes rather than active inflammatory changes. In combination with clinical evaluation and bronchoscopy, CT assists in the assessment of disease activity.

Differentiation of perianal fistulas with digital subtraction magnetic resonance fistulography

BACKGROUND

Pelvic magnetic resonance imaging (MRI) is accurate in identifying perianal fistulas. The exact visualization of fistulous tracts and concomitant abscesses determine the type of treatment. To improve the detection of perianal fistulas, we studied digital subtraction MR-fistulography for tissue differentiation based on signal intensity measurements.

METHODS

This study included 75 patients with the clinical diagnosis of perianal fistula. All patients were analyzed by a thin-slice, high-resolution, fast low-angle shot 3-dimensional sequence in the axial plane before and after intravenous injection of gadobenate dimeglumine, followed by image subtraction. Operator-defined regions of interest were used to calculate signal intensities of the inflamed fibrous walls of fistulas, the common femoral artery, the internal and external sphincter muscles, and the gluteus muscle. The fistulas were classified according to Parks classification.

RESULTS

Based on signal intensity measurements in 75 patients with perianal fistulas, diagnosed by digital subtraction MR-fistulography, a significant differentiation between fistulous tracts and anatomic structures was possible. MRI identified 116 perianal fistulas (34 intersphincteric, 33 transsphincteric, 10 suprasphincteric, and 39 extrasphincteric) and 35 abscesses.

CONCLUSIONS

Digital subtraction MR-fistulography is a new, promising, noninvasive imaging technique for the detection of perianal fistulas and abscesses.

Endovascular treatment of superficial femoral artery occlusive disease with stents coated with diamond-like carbon

A major consideration in the reduction of early stent thrombosis and in-stent restenosis is the improvement of biocompatibility of the devices. Diamond-like carbon is a novel material for coating stent surfaces in order to increase biocompatibility. The authors report on the endovascular treatment of two individuals with superficial femoral artery occlusions, using stents coated with diamond-like carbon. Technical and clinical success was achieved in both cases, with primary patency rates of 100% 12 months after intervention.

Diagnosenverschlüsselung durch Medizinische Dokumentationsassistentin oder Stationsarzt

BACKGROUND AND OBJECTIVE

Starting in 2004 the patient budget in Germany will be calculated according to the Diagnosis Related Group (DRG) system, by which system the monetary reward of a unit will be directly related to the quality of documentation e. g. diagnosis and procedures. The aim of this study was to compare the quality of documentation by a medical documentation assistant (MDA) with the usual practice of documentation by the ward physician (WP). Additionally, the effect of introducing a completely changed organizational process was tested.

METHODS

In a prospective study on the ward of a gastroenterology unit two different approaches of medical documentation were compared. In a first six-month period diagnosis and procedures were encoded by WP. In the following six months an MDA was introduced and involved in the encoding process.

RESULTS

In the first six months 221 patients (mean age 55 +/- 16,2 years, 55,7 % males) were evaluated, whereas in the following six months 305 patients (mean age 53 +/- 15,4 years, 59,9 % males) were included. The introduction of an MDA improved medical documentation and economical reference numbers: with an increase of diagnosis per case to 7,43 (in first six months 5,53), patient complexity and comorbidity level (PCCL) to 2,5 (in first six months 2,13), case-mix index to 1,04 (in first six months 0,98). Additionally the medial hospitalization time decreased from 11,2 to 8,1 days. The average daily reimbursement increased in the MDA group from 423 Euro to 603 Euro. This was calculated on the basis of a basic case factor of 2900 Euro.

CONCLUSION

Introduction of an MDA in a gastroenterology ward increases the quality of documentation and results in an improved presentation of DRG-relevant efforts with a better reimbursement of medical costs.

Assessment of anal fistulas with high-resolution subtraction MR-fistulography: comparison with surgical findings

PURPOSE

To investigate a new MR-imaging protocol defined as subtraction MR-fistulography for the detection of fistula-in-ano.

MATERIALS AND METHODS

A total of 36 patients (18 men, 18 women) with the clinical diagnosis of anal fistula or abscess who were scheduled for surgical exploration were preoperatively imaged at 1.5 T in the supine position; coronal STIR sequences and axial T1-weighted three-dimensional FLASH sequences before and after intravenous injection of gadobenate dimeglumine (Gd-BOPTA) were obtained. Image subtraction was routinely used. The image findings were compared with the findings at surgical exploration according to a uniform classification system.

RESULTS

A total of 46 fistulas were seen on subtraction MR-fistulography, whereas surgery described 41 fistulas. MRI and surgery concordantly depicted a total number of 40 fistulas, six fistulas were only described by MRI, and one fistula was only seen during surgery. A total of 27 abscesses were detected with MRI, compared to 22 during surgery. A total of 22 abscesses were concordantly diagnosed. Complete agreement between subtraction MR-fistulography and surgery occurred in 32 (89%) of the 36 patients. The four patients in whom both procedures disagreed had complex anal sepsis with multiple fistulas and/or abscesses due to Crohn disease.

CONCLUSION

High-resolution subtraction MR-fistulography is an important complement to surgical exploration and especially suitable for investigating complex anal sepsis.

Differentiation of Anal Sphincters With High-Resolution Magnetic Resonance Imaging Using Contrast-Enhanced Fast Low-Angle Shot 3-Dimensional Sequences

OBJECTIVE

The imaging of the anal apparatus is becoming more and more important in the management of patients who suffer from anorectal disease. The exact differentiation of the sphincter muscles is a major requirement for the detection of disorders of the anal canal. The purpose of this study was to evaluate a new magnetic resonance (MR) imaging protocol using contrast-enhanced, high-resolution, fast low-angle shot, 3-dimensional (3D) sequences and image subtraction regarding the visualization and differentiation of the internal and external sphincter muscles.

METHODS

High-resolution pelvic MR imaging (1.5 T) was performed in 85 patients (42 male, 43 female; age range: 12-81 years) with a phased-array body coil. For an anatomic overview of the pelvic region, a short tau inversion recovery sequence in the coronal plane was carried out, followed by a 3D, high-resolution, fat-saturated, T1-weighted, gradient echo sequence before and after intravenous administration of a contrast agent (gadobenic acid, 0.15 mmol/kg). To optimize the visualization of the sphincter muscles, subtraction of the unenhanced from the contrast-enhanced sequences was routinely performed. The signal intensities of the internal and external sphincter muscles were measured in the axial plane on the subtracted images.

RESULTS

The distribution of the mean signal intensities of the internal and external sphincter muscles as well as the difference between both revealed a normal deviation. The confidence interval on a 95% significance level ranged between 1.6941 and 1.9393, with a mean of 1.81. In the whole study group, the signal intensity of the internal sphincter muscle was significantly higher than that of the external sphincter, thus facilitating the identification and differentiation of the 2 components of the anal sphincter complex.

CONCLUSION

The presented MR imaging protocol is robust, provides a high image quality, and is well accepted by patients because of its noninvasiveness.

When to look for Von Hippel-Lindau disease in gastroenteropancreatic neuroendocrine tumors?

Von Hippel-Lindau (VHL) disease is a progressive autosomal dominant multisystem disorder that is associated with a germ line mutation of the VHL gene on the short arm of chromosome 3. A variety of benign and malignant diseases, including eye and CNS hemangioblastomas, renal cell carcinoma and pheochromocytoma are the major components. Gastroenteropancreatic neuroendocrine tumors are also listed among the typical complications, although these occur seldom. Virtually all such tumors are pancreatic islet cell tumors. VHL-associated islet cell tumors are mostly hormone-inactive. They can be detected during screening investigations according to the multidisciplinary disorder or by workup of space-occupying lesions. There are no specific predictors for malignancy in VHL-associated islet cell neoplasias, but tumors smaller than 3 cm in diameter are believed to be always benign. Gadolinium-enhanced MRI is currently the imaging method of choice, but contrast-enhanced CT is also a diagnostic option. The spectrum of manifestations is illustrated by selected cases.

CT-guided radiofrequency heat ablation of malignant lung tumors

BACKGROUND

Radiofrequency heat ablation (RFA) is an advanced minimal-invasive technique for the treatment of primary and secondary malignancies in several organs. This article presents the successful percutaneous computed tomography (CT)-guided radiofrequency heat ablation of a peripheral bronchiogenic carcinoma and four lung metastases in three patients.

MATERIAL/METHODS

Pain relief in a palliative care situation was the indication for RFA treatment in two patients. A primary curative tumor treatment with RFA was intended in one patient, who refused surgery. All procedures were performed under conscious sedation and local anesthesia.

RESULTS

RFA treatment was carried out without major complications in these patients. No signs of infection or significant bleeding were observed. One patient developed a pneumothorax two days after the procedure, which was drained sufficiently. All patients had elevated temperatures, up to 38.5 degrees C for three days after RFA, due to tumor lysis. Pain relief was possible. Control CT scans three months after percutaneous RFA revealed shrinkage of the treated tumor nodules.

CONCLUSIONS

Percutaneous RFA was successfully performed in three patients. CT-guided percutaneous RFA of non-resectable lung neoplasms may be a complement to chemotherapy and radiation therapy. Further clinical experience and prospective studies are needed to determine the long-term efficacy and safety of RFA in the treatment of lung tumors.

Comparison of the Detectability of High- and Low-Contrast Details on a TFT Screen and a CRT Screen Designed for Radiologic Diagnosis

RATIONALE AND OBJECTIVES

To evaluate the detection rate of fine details of a new thin-film transistor (TFT) grayscale monitor designed for radiologic diagnosis, compared with a type of cathode ray tube (CRT) screen used routinely for diagnostic radiology.

METHODS

Fifteen radiographs of a statistical phantom presenting low- and high-contrast details were obtained and read out with an Agfa ADC compact storage phosphor system. Each radiograph presented 60 high-density (high-contrast) and 60 low-density (low-contrast) test bodies. Approximately half the test bodies contained holes with different diameters. Observers were asked to detect the presence or absence of a hole in the test body on a 5-point confidence range. The total of 1800 test bodies was reviewed by 5 radiologists on the TFT monitor (20.8 inches; 1536 x 2048 pixels; maximum luminance, 650 cd/m2; contrast, 600:1) and the CRT monitor (21 inches; P45 Phosphor; 2048 x 2560 pixels operated at 1728 x 2304 pixels; maximum luminance, 600 cd/m2; contrast, 300:1). The data were analyzed by receiver-operator characteristic analysis.

RESULTS

For high-contrast details, the mean area under the curve rated 0.9336 for the TFT monitor and 0.9312 for the CRT monitor. For low-contrast details, the mean area under the curve rated 0.9189 for the TFT monitor and 0.9224 for the CRT monitor. At P <or= 0.05, no statistically significant difference could be detected between the 2 observational modalities for both (holes in high- and low-contrast disks) types of artifacts.

CONCLUSIONS

The TFT screen performs as well as CRT monitors for the detection of fine details in both high- and low-contrast environments. Further studies with images derived from clinical routine are necessary before safely using TFT monitors in clinical practice.

CT-guided radiofrequency ablation of a bronchogenic carcinoma

We report on the successful use of percutaneous CT-guided radiofrequency ablation (RFA) of a peripheral bronchogenic carcinoma in a 73-year-old patient. RFA was the favoured treatment option in this patient, who owing to comorbid factors was not a candidate for surgery. A 15 G LeVeen Needle Electrode (RadioTherapeutics, Sunnyvale, USA) with an array diameter of 3.0 cm was connected to a 200 Watt Generator (RF 3000, RadioTherapeutics, Sunnyvale, USA) and inserted into a 3.5 cm squamous cell carcinoma of the axillary subsegment of the right upper lobe. RFA resulted in complete tumour necrosis confirmed by histopathological examination. No complications such as a pneumothorax or bleeding occurred. Further clinical experience and prospective studies are necessary to determine the long-term efficacy of RFA in the treatment of lung tumours.

Background suppression using magnetization preparation for contrast-enhanced 3D MR angiography of the pelvic and lower leg arteries

PURPOSE

To develop and evaluate non-slab-selective magnetization preparation in contrast-enhanced 3D-MR angiography.

METHODS

An ultrafast spoiled mr angiography sequence (FLASH) with non-selective inversion prepulses for background suppression was implemented on a 1.5 T MR system. In 11 patients gadobenate dimeglumine-enhanced mr-angiography of the pelvic and lower leg arteries was performed using the AngioSURF device. Source data was evaluated for contrast-to-noise-ratio, image quality and the extent of background suppression.

RESULTS

Background suppression and selective vessel contrast was excellent in all vascular levels. The mr protocol was comfortable and easy-to-handle. Abandonment of precontrast-series acquisition simplified the examination procedure markedly.

CONCLUSIONS

Magnetization preparation provides efficient suppression of the background signal in contrast-enhanced 3D mr angiography of the pelvic and lower leg arteries. Since no subtraction technique is needed, moving-bed and whole body MRA-protocols can be simplified significantly.

Magnetic resonance imaging for supraspinatus muscle atrophy after cuff repair

Between 1998 to 2000, the shoulders of 17 patients with rotator cuff tears were examined using magnetic resonance imaging preoperatively, and 6 and 12 months after open surgical repair. To assess the course of the supraspinatus muscle atrophy, the easily reproducible magnetic resonance imaging parameters occupation ratio and tangent sign in the Y-shaped view of the supraspinous fossa were evaluated and compared with the clinical examination. Occupation ratio is a quantitative parameter that reflects the area ratio, expressed as a percentage of the supraspinatus muscle belly to the supraspinous fossa. The tangent sign is a qualitative parameter that represents a line connecting the coracoid process and the apex of the scapular spine. Occupation ratio and tangent sign are reliable diagnostic tools in magnetic resonance imaging assessment of supraspinatus muscle atrophy. The sensitivity of the magnetic resonance imaging parameter occupation ratio is 75% and the specificity is 85%. The imaging parameter tangent sign has a sensitivity of 100% and a specificity of 85%. There is a significant relationship between occupation ratio, tangent sign, and improvement of strength and mobility registered in the score of Constant and Murley 12 months after surgery.

Combined radiofrequency thermal ablation and percutaneous cementoplasty treatment of a pathologic fracture

Skeletal metastases commonly occur in patients with cancer and treatment is necessary to alleviate pain and prevent complications, such as mobility deficiencies and pathologic fractures. The authors present a patient with a stage IV malignant melanoma and a pathologic fracture of the left tibial plateau treated with radiofrequency heat ablation and percutaneous cementoplasty for defect filling and stabilization. The authors believe that this approach may be an alternative to the standard treatments in palliative-care situations.

Diagnosis of the hypothenar hammer syndrome by high-resolution contrast-enhanced MR angiography

Our objective was to describe the imaging features of hypothenar hammer syndrome using minimally invasive contrast-enhanced MR angiography in comparison with oscillography study. In five patients with hypothenar hammer syndrome Gd-BOPTA-enhanced elliptically reordered 3D pulse sequence MR was compared with oscillography findings and clinical symptoms focusing on angiographic appearance of vessel injury, distribution pattern of hand vasculature and joining branches between the radial and ulnar artery supply. All patients showed segmental occlusion at the site of trauma impact with varying involvement of the superficial palmar arch, common volar digital arteries. Embolic disease was present in 50% of patients and could be clearly identified with MRA. Good correspondence was found between angiographic appearance including the presence of collaterals, clinical symptoms and oscillography. Bilateral comparison was helpful in distinguishing between vessel variants and pathology. Bilateral Gd-BOPTA-enhanced MR angiography is a minimally invasive method to depict clearly the localization and extent of vessel injury in hypothenar hammer syndrome providing valuable information about distribution pattern of hand vasculature and presence of collaterals; however, no flow data can be obtained.