Efficacy of Video-Based Forearm Anatomy Model Instruction for a Virtual Education Environment.

INTRODUCTION: As virtual education becomes more widespread, particularly considering the recent COVID-19 pandemic, studies that assess the impact of online teaching strategies are vital. Current anatomy curriculum at Paul L. Foster School of Medicine consists of self-taught PowerPoint material, clinical vignette-centered team-based learning (dry lab), and prosection-based instruction (wet lab). This study examined the impact of video-based muscle model (VBMM) instruction using a student-designed forearm muscle model on anatomy quiz scores and student perceptions of its effectiveness with regards to learning outcomes. METHODS: Students divided into Group 1 (54 students) and Group 2 (53 students) were assessed prior to and following a 3.5-minute video on anterior forearm compartment musculature using the muscle model. Group 1 began by completing a pretest, then received VBMM instruction, and then completed a posttest prior to participating in the standard dry lab and 1 hour wet lab. Group 2 completed the wet lab, then received the pretest, VBMM instruction, and posttest prior to participating in the dry lab. Both groups took an identical five-question quiz covering locations and functions of various anterior forearm muscles each time. RESULTS: Mean scores were higher than no formal intervention with exposure to VBMM instruction alone (0.73 points, P = .01), wet lab alone (0.88 points, P = .002), and wet lab plus VBMM instruction (1.35 points, P= <.001). No significant difference in scores was found between instruction with VBMM versus wet lab alone (P = 1.00), or between either instruction method alone compared to a combination of the two methods (P = .34, .09). Student survey opinions on the VBMM instruction method were positive. CONCLUSION: VBMM instruction is comparable to prosection-based lab with regards to score outcomes and was well received by students as both an independent learning tool and as a supplement to cadaveric lab. When compared to either instruction method alone, the supplementation of VBMM with cadaveric prosection instruction was best. VBMM instruction may be valuable for institutions without access to cadaveric specimens, or those looking to supplement their current anatomy curriculum.

Visual systemizing preference in children with autism: A randomized controlled trial of intranasal oxytocin.

Several studies have suggested that the neuropeptide oxytocin may enhance aspects of social communication in autism. Little is known, however, about its effects on nonsocial manifestations, such as restricted interests and repetitive behaviors. In the empathizing-systemizing theory of autism, social deficits are described along the continuum of empathizing ability, whereas nonsocial aspects are characterized in terms of an increased preference for patterned or rule-based systems, called systemizing. We therefore developed an automated eye-tracking task to test whether children and adolescents with autism spectrum disorder (ASD) compared to matched controls display a visual preference for more highly organized and structured (systemized) real-life images. Then, as part of a randomized, double-blind, placebo-controlled crossover study, we examined the effect of intranasal oxytocin on systemizing preferences in 16 male children with ASD, compared with 16 matched controls. Participants viewed 14 slides, each containing four related pictures (e.g., of people, animals, scenes, or objects) that differed primarily on the degree of systemizing. Visual systemizing preference was defined in terms of the fixation time and count for each image. Unlike control subjects who showed no gaze preference, individuals with ASD preferred to fixate on more highly systemized pictures. Intranasal oxytocin eliminated this preference in ASD participants, who now showed a similar response to control subjects on placebo. In contrast, control participants increased their visual preference for more systemized images after receiving oxytocin versus placebo. These results suggest that, in addition to its effects on social communication, oxytocin may play a role in some of the nonsocial manifestations of autism.

Subclinical Partial Attritional Rupture of the Flexor Digitorum Profundus as an Etiology of Atraumatic Trigger Finger.

BACKGROUND: Trigger finger is a relatively common clinical entity. The etiology is most often attributable to stenosing tenosynovitis though traumatic cases have been described. When trigger finger is associated with an underlying flexor tendon rupture, previous cases have reported a clear association with overt laceration or previous trauma. METHODS: We present the case of a 23-year-old male active duty military service member who presented with a characteristic history and clinical exam consistent with trigger finger. The symptomatic onset was gradual, with no history of inciting trauma. RESULTS: Given symptomatic persistent triggering following failure of conservative management to include cortisone injections, the patient was taken for open A1 pulley release. Intraoperatively, the triggering was found to be attributable to a partial attritional rupture of the small finger flexor digitorum profundus tendon. Tendon debridement, tubularization, and A1 and partial A2 pulley releases were performed with subsequent resolution of triggering. CONCLUSION: We present the rare case of subclinical atraumatic attritional rupture of the FDP tendon to the small finger as a cause of clinically apparent trigger finger. This is an important consideration as the hand surgeon must be prepared to address more atypical pathologies.

Effects of cue modality and emotional category on recognition of nonverbal emotional signals in schizophrenia.

BACKGROUND: Impaired interpretation of nonverbal emotional cues in patients with schizophrenia has been reported in several studies and a clinical relevance of these deficits for social functioning has been assumed. However, it is unclear to what extent the impairments depend on specific emotions or specific channels of nonverbal communication. METHODS: Here, the effect of cue modality and emotional categories on accuracy of emotion recognition was evaluated in 21 patients with schizophrenia and compared to a healthy control group (n = 21). To this end, dynamic stimuli comprising speakers of both genders in three different sensory modalities (auditory, visual and audiovisual) and five emotional categories (happy, alluring, neutral, angry and disgusted) were used. RESULTS: Patients with schizophrenia were found to be impaired in emotion recognition in comparison to the control group across all stimuli. Considering specific emotions more severe deficits were revealed in the recognition of alluring stimuli and less severe deficits in the recognition of disgusted stimuli as compared to all other emotions. Regarding cue modality the extent of the impairment in emotional recognition did not significantly differ between auditory and visual cues across all emotional categories. However, patients with schizophrenia showed significantly more severe disturbances for vocal as compared to facial cues when sexual interest is expressed (alluring stimuli), whereas more severe disturbances for facial as compared to vocal cues were observed when happiness or anger is expressed. CONCLUSION: Our results confirmed that perceptual impairments can be observed for vocal as well as facial cues conveying various social and emotional connotations. The observed differences in severity of impairments with most severe deficits for alluring expressions might be related to specific difficulties in recognizing the complex social emotional information of interpersonal intentions as compared to "basic" emotional states. Therefore, future studies evaluating perception of nonverbal cues should consider a broader range of social and emotional signals beyond basic emotions including attitudes and interpersonal intentions. Identifying specific domains of social perception particularly prone for misunderstandings in patients with schizophrenia might allow for a refinement of interventions aiming at improving social functioning.

[Complex pacemaker dysfunction. Sometimes a problem does not come alone...]. / Komplexe Schrittmacherdysfunktion. Manchmal kommt ein Problem nicht allein...

The electrocardiogram of a multimorbid patient with a pacemaker is discussed. At first sight, it clearly shows dysfunction of an implanted pacemaker. However, this case illustrates that sometimes a second careful look is essential to reveal further hidden problems.

Systemic and local cytokine kinetics after total hip replacement surgery.

BACKGROUND: Trauma induces local and subsequent systemic inflammatory reactions. Aberrant reactions can lead to a systemic inflammatory response syndrome, with a potentially lethal outcome. Our aim was to investigate the early local cytokine kinetic compared to systemic changes in a standardized surgical trauma. METHODS: In 7 patients with total hip replacement, drained blood samples and venous blood samples were taken 3 times within the first day after the operation. Interleukin (IL) release was assessed by a multiplex antibody bead kit and compared to pre-operative values. RESULTS: The major findings were significant increases in systemic levels of IL-6 and in local levels of IL-6, IL-8 and IL-1 receptor antagonist (IL-1Ra), and that the local levels of these cytokines were significantly higher than the systemic ones after surgery. Besides, there were only modest changes in local and systemic levels of tumour necrosis factor alpha, IL-1 beta, IL-2, IL-2Ra, IL-4, IL-5, IL-7, IL-10, IL-12, IL-13, IL-15 and IL-17. CONCLUSIONS: The acute sterile inflammation after major orthopaedic surgery is principally characterized by significantly increased local and systemic levels of IL-6 and significantly increased local levels of IL-8 and IL-1Ra. Furthermore, the concentrations are higher at the local site of injury. Hence, we conclude that systemic cytokine levels might not reflect local reactions.

Investigation of lipopolysaccharide receptor expression on human monocytes after major orthopaedic surgery.

BACKGROUND: The innate immune system is suppressed after major orthopaedic surgery, implicating a risk of septic complications. Whole-blood ex vivo testing with lipopolysaccharide (LPS) has shown a depression of the tumour necrosis factor alpha (TNF-alpha) production until 12 days postoperatively. As part of the innate immune system, the Toll-like receptors TLR2 and TLR4 recognize antigens from Gram-positive and Gram-negative bacteria, respectively. The receptors CD14 and CD11b are involved in the LPS receptor complex, whereas human lymphocyte antigen (HLA)-DR binds endotoxin peptides. It is still uncertain whether the expression of all these receptors changes after major surgery. METHODS: In 6 patients undergoing hip arthroplasty, we investigated three times the display of TLR4, TLR2, CD14, CD11b, and HLA-DR on monocytes by fluorescence-activated cell sorting and white blood cell counts during 12 days postoperatively. At the same time, the plasma levels of interleukin (IL)-1beta, IL-4, IL-6, IL-10, IL-13, and TNF-alpha were measured. RESULTS: There was no significant change in the expression of TLR4, CD14, CD11b, HLA-DR, and TLR2. Monocyte count and cytokine analysis did not differ from the ones pre-operatively taken. CONCLUSIONS: After aseptic orthopaedic surgery, there is no change in the display of the LPS receptor complex on monocytes. Other mechanisms have to be investigated to gain insight into the decrease of the TNF-alpha production capacity postoperatively.

Immune modulation after total hip surgery. A prospective ex vivo study.

BACKGROUND: Major trauma affects the immune system, and immunosuppression may render the patients susceptible to septic complications. The purpose of this study was to investigate lipopolysaccharide (LPS)-induced releases of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in whole blood in patients undergoing total hip replacement. METHODS: Seven patients (6 females) who underwent elective total hip replacement were included. Ex vivo LPS-induced releases of TNF-alpha and IL-6 were measured in a whole blood assay at days 1, 6, 9 and 12 postoperatively, using low- and high-dose LPS incubation. At the same time, white blood cell counts were analyzed. RESULTS: The amount of TNF-alpha release was significantly reduced at days 6 and 12. Compared to monocyte counts, TNF-alpha release was significantly decreased also at day 9 in low- and high-dose LPS stimulation. IL-6 in plasma was significantly increased at day 1 and normalized thereafter. There were no differences in LPS-induced IL-6 levels compared to the levels before surgery. CONCLUSION: This in vivo/ex vivo study shows a reduced capacity of whole blood to release LPS-induced TNF-alpha at day 6 through to day 12 after major orthopedic surgery. Attenuated TNF-alpha release may contribute to an increased postoperative susceptibility to gram-negative sepsis.

[Cemented versus cementless revision femoral stems using morselized allograft--a prospective, randomized study with 5 years follow-up]. / Zementierte versus unzementierte Revisions-Hüftarthroplastik mit verdichtetem Knochenallograft--Prospektiv randomisierte Vergleichsstudie mit Jahres-Follow-up.

BACKGROUND: There are only few studies on hip revision using the impaction grafting technique. Furthermore, data on cementless femoral stems as compared to cemented and polished femoral stems are lacking. We wanted to determine whether cementless femoral stems were equally good in preserving bone mineral density around the femoral stem and in functional outcome. METHOD: Consecutively 14 patients needing hip revisions for aseptic loosening in the stem with bone stock deficiency Paparowsky grade II were randomized into two groups intraoperatively. Morselized fresh-frozen bone allografts were impacted in both groups. The cemented group received polished Landos Fjord-CrCo stems and the uncemented group received the hydroxyapatite-coated Landos Corail-Titan stems. The dual energy X-ray absorptiometry was used to measure bone mineral density around the femoral stem according to Gruen zones. Function was measured by Merle d'Aubigné score. Patients were controlled at 0.5, 3, 6, 9, 12, 18, 24, 36 and 60 months postoperatively. RESULTS: There was no statistical difference between the BMD loss in the cemented vs. the uncemented group. The BMD loss was between 0-10 % in distal Gruen zones and was between 10-20 % in proximal Gruen zones. Functional scores were similar and reached a plateau of 16 in the Merle d'Aubigné score after 6 months. CONCLUSIONS: Cemented technique in hip revisions using morselized bone allograft is as good as uncemented technique in preserving BMD measured by the DEXA method and restoring function in a 5 years follow-up.

[Recurrent hemoptysis as initial symptom of a thoracic angiomatosis in an adult patient]. / Rezidivierende Hämoptysen als Erstsymptom einer thorakalen Angiomatose beim Erwachsenen.

HISTORY: A 24-year-old man presented with recurrent hemoptysis and decreased exercise capacity. DIAGNOSTIC FINDINGS: The chest radiograph demonstrated multiple disseminated pulmonary nodules. In addition the patient developed a hematopericardium with tamponade. The further diagnostic approach revealed an extensive thoracic angiomatosis affecting the lung and the heart. TREATMENT AND COURSE: Tumor resection could not be performed. A therapy with Interferon alpha-2a was initiated. After 3 month a significant regression of the pulmonary angiomatosis was documented. On the other hand the cardiac tumor showed no therapeutic response. CONCLUSION: Thoracic angiomatosis should be considered in the differential diagnosis of otherwise unclear hemoptysis or hematopericardium. Diagnosis intra vitamin requires an aggressive and invasive approach. Interferon alpha-2a is effective in palliative treatment of diffuse angiomatous diseases. But not all angiomatous processes respond to that therapy.

Analysis of beta-catenin gene mutations in pancreatic tumors.

BACKGROUND/AIM: Mutations of the adenomatous polyposis coli (APC) tumor suppressor gene have been described in a subset of pancreatic carcinomas. The APC gene modulates the beta-catenin-Tcf pathway. The major player in this pathway is the beta-catenin protein encoded by the beta-catenin gene. A variety of different tumors, including colon, prostate, endometrial, and hepatocellular carcinomas, carry mutations in exon 3 of the beta-catenin gene. The aim of this study was to determine the role of the beta-catenin gene in the genesis of exocrine and endocrine tumors of the pancreas. METHODS: 78 ductal pancreatic adenocarcinomas, 14 ductal pancreatic cancer cell lines, and 33 endocrine pancreatic tumors were evaluated for mutations in exon 3 of the beta-catenin gene by single-strand conformation polymorphism analysis and direct DNA sequencing. In addition, 40 ductal pancreatic adenocarcinomas were analyzed for intracellular beta-catenin accumulation by immunohistochemistry, indicating alterations of the beta-catenin gene. RESULTS: Neither the 111 exocrine and endocrine pancreatic tumors nor the 14 pancreatic cancer cell lines carried mutations in exon 3 of the beta-catenin gene. Intracellular beta-catenin accumulation was not identified in any of the 40 pancreatic adenocarcinomas. CONCLUSION: These data suggest that the beta-catenin gene as the major player of the beta-catenin-Tcf pathway does not play an important role in the genesis of pancreatic tumors.

Higher frequency of DPC4/Smad4 alterations in pancreatic cancer cell lines than in primary pancreatic adenocarcinomas.

The tumor suppressor gene DPC4/Smad4 at 18q21.1 is inactive in about 50% of pancreatic carcinoma xenografts and cell lines. However, the role of DPC4 in the multistep carcinogenesis of primary pancreatic adenocarcinomas remains uncertain. Therefore, we examined 45 primary human pancreatic adenocarcinomas and 12 pancreatic cancer cell lines for DPC4 alterations by single-strand conformational variant (SSCV) analysis and a PCR-based deletion assay. DPC4 was inactivated by either homozygous deletion or point mutation in 6 of 12 cell lines (50%). None of the primary pancreatic carcinomas carried a DPC4 mutation, although 66% revealed LOH of 18q21 sequences. These findings suggest that inactivation of DPC4 occurs more frequently in tumor-derived cell lines than in primary pancreatic adenocarcinomas. In addition, another, yet unidentified, tumor suppressor gene(s) may be linked with the frequent LOH of 18q21 in primary pancreatic adenocarcinomas.

Malignant fibrous histiocytoma of the pancreas: a case report with genetic analysis.

BACKGROUND: Malignant fibrous histiocytoma (MFH) is the most common type of soft tissue sarcoma in adults; it occurs frequently in the extremities, the trunk, or retroperitoneal tissues. MFH rarely is detected in digestive organs, such as the liver or stomach. METHODS: The authors report a patient with MFH of the pancreas who was treated with surgery alone. The tumor was studied for genetic alterations in the p53, p16ink4a, and DPC4 tumor suppressor genes as well as the K-ras oncogene by immunohistochemistry, single strand conformation variant (SSCV) analysis, and direct DNA sequencing. RESULTS: The authors believe that this is the 13th report of primary pancreatic MFH in the world literature and the first genetic analysis of this rare tumor. The patient is alive with no evidence of recurrence 34 months after surgery. Immunohistochemistry revealed no abnormal accumulation of the p53 protein and normal nuclear p16 expression. Mutation analysis of the p53, p16, DPC4, and K-ras genes showed only a polymorphism at codon 72 of the p53 gene and no mutations in any of the genes. CONCLUSIONS: Genotypically, MFH of the pancreas is clearly different from other malignant pancreatic tumors, which further supports the hypothesis that this tumor is a rare but distinct entity.

Mutations of the DPC4/Smad4 gene in neuroendocrine pancreatic tumors.

Tumors of the endocrine pancreas are extremely rare, and molecular mechanisms leading to their development are not well understood. A candidate tumor suppressor gene, DPC4, located at 18q21, has recently been shown to be inactivated in half of pancreatic adenocarcinoma xenografts. The close anatomical relationship of the exocrine and endocrine pancreas prompted us to determine the role of DPC4 in the tumorigenesis of 25 pancreatic islet cell tumors (11 insulinomas, nine non-functioning endocrine carcinomas, three gastrinomas, two vipomas). A mutation screening of the highly conserved COOH-terminal domain of DPC4 (exons 8-11) was performed by single-strand conformational variant (SSCP) analysis and a PCR-based deletion assay. Five of nine (55%) non-functioning endocrine pancreatic carcinomas revealed either point mutations, small intragenic deletions or homozygous deletion of DPC4 sequences compared to none of the insulinomas, gastrinomas or vipomas. These results suggest that DPC4 is an important target gene promoting tumorigenesis of non-functioning neuroendocrine pancreatic carcinomas.

K-ras oncogene mutations indicate malignancy in cystic tumors of the pancreas.

OBJECTIVE: To evaluate clinical parameters, presurgical diagnostic tests, histologic findings, and the presence of K-ras oncogene mutations in cystic tumors of the pancreas to determine which best predict malignancy. SUMMARY BACKGROUND DATA: Because presurgical, intraoperative, and final pathologic differentiation is difficult in cystic tumors of the pancreas, it would be a major benefit to identify markers that accurately predict malignancy in these rare tumors. The role of K-ras oncogene mutations as an indicator of malignancy has not been determined in these tumors. METHODS: Nineteen patients with cystic tumors of the pancreas were evaluated, including K-ras mutation analysis based on polymerase chain reaction and restriction digestion assays and direct DNA sequencing, to screen for parameters that accurately predict malignancy. RESULTS: All malignant cystic pancreatic tumors (five cystadenocarcinomas and three mucin-producing adenocarcinomas) harbored K-ras mutations at codon 12 or 13. K-ras mutations were also detected in the percutaneous fine-needle aspirates of two of these patients. In contrast, none of nine benign cystadenomas or the solid-papillary neoplasm had K-ras mutations. None of the patients with a benign tumor carrying K-ras wild-type sequences developed recurrent disease after a mean follow-up of 50 months. Seven of the 8 malignant cystic pancreatic tumors, but none of the 11 benign tumors, showed dilatation of the main pancreatic duct on computed tomography or endoscopic retrograde cholangiopancreatography. CONCLUSIONS: K-ras mutation analysis seems to be a powerful tool to determine the malignant potential of cystic pancreatic tumors before and after surgery. Dilatation of the main pancreatic duct on computed tomography or endoscopic retrograde cholangiopancreatography is highly suggestive for malignancy in these rare tumors.

Localization, malignant potential, and surgical management of gastrinomas.

Between 1987 and 1996 a total of 25 patients with proved Zollinger-Ellison syndrome (ZES) have been treated in our department. If preoperative imaging studies did not show diffuse metastatic disease, patients were scheduled for operation with a standardized surgical approach including thorough exploration and intraoperative ultrasonography (IOUS) of the pancreas and a longitudinal duodenotomy, with separate palpation of the anterior and posterior walls. Postoperatively, patients were followed up by physical examination, fasting gastrin levels, and the secretin stimulation test. Altogether 10 patients had duodenal wall gastrinoma, 14 patients pancreatic gastrinoma, and the tumor was not found in 1 patient. Only 15 tumors (60%) (2 duodenal wall and 13 pancreatic gastrinomas) could be visualized preoperatively. Intraoperatively, 24 of 25 primary gastrinomas were localized. The mean size of duodenal wall gastrinomas (9.6 mm) was significantly smaller than that of pancreatic gastrinomas (28.7 mm) (p < 0.05). At the time of surgical exploration, five duodenal and seven pancreatic gastrinomas had metastasized. The incidence of lymph node metastases was similar for both tumor sites, whereas patients with pancreatic gastrinomas more frequently had liver metastases. The presence of liver metastases was the most important determinant for survival. Four patients (40%) with duodenal and seven with pancreatic (50%) gastrinomas (mean follow-up 5.2 years) were biochemically cured by operation. Of the remaining patients, eight are still alive with recurrent disease. Our results suggest that preoperative localization of gastrinomas often fails despite all modern imaging methods. Therefore a standardized surgical exploration of the pancreas including IOUS and a duodenal exploration should be performed to achieve optimal results. Preoperative diagnostic imaging tests should include computed tomography, ultrasonography, and somatostatin receptor scintigraphy to exclude diffuse metastases. In contrast to liver metastases, lymph node metastases do not have a significant influence on survival.

[Detection of hepatic micrometastasis in ductal pancreatic carcinoma by K-ras mutation analysis and determination of clinical relevance]. / Nachweis hepatischer Mikrometastasen beim duktalen Pankreaskarzinom durch K-ras Mutationsanalyse und Bestimmung ihrer klinischen Relevanz.

In this prospective study we evaluated the presence and importance of hepatic micrometastases at the time of operation in patients with resectable pancreatic carcinoma. In 13 patients with pancreatic carcinoma and 5 patients with chronic pancreatitis Truecut-Needle biopsies of the liver were obtained during operation. K-ras mutation analysis was done by the PCR/restriction digestion assay with HphI, followed by an ultrasound of the liver in 3 monthly intervals. Four of 13 (30%) pancreatic cancer patients had K-ras gene mutations in the liver and had a mean survival of 6 months after resection. All chronic pancreatitis patients and 8 of the 9 remaining pancreatic cancer patients without K-ras mutations in the liver biopsies are alive without evidence of liver metastases after a mean follow-up of 9 months. Detection of micrometastases in the liver by K-ras mutation analysis might be a powerful tool to identify occult clinical relevant liver metastases.

Perforaciones gastroduodenales agudas asociadas al consumo de pasta base de cocaína / Acute gastroduodenal perforations associated to cocaine consumption

Se presenta un estudio de 13 meses en 27 pacientes operados con diagnóstico de úlcera gastroduodenal perforada. En 5 de ellos hubo estrecha relación temporal entre consumo de pasta base e inicio de la perforación, constituyendo una frecuencia del 19 porciento. La edad promedio de este grupo fue de 30 años, los restantes pacientes promediaron 46 años. Los 5 pacientes presentaron intenso dolor abdominal, taquicardia y signos de irritación peritoneal. En 3 hubo indicios de neumoperitoneo. Sólo 2 pacinetes referían historia ulcerosa, en ellos la perforación se halló en la 1a. porción del duodeno; en los restantes 3, ésta se ibicó en cara anterior del antro. Todos fueron tratados mediante sutura y epiploplastía. Se postula que el efecto vasoconstrictor esplácnico agudo de la droga lleva a isquemia tisular local y perforación. En fumadores de pasta base con abdomen agudo puede existir perforación gastroduodenal a pesar de una clínica atípica de úlcera gastroduodenal perforada

[Diagnostic localization of insulinoma. Experiences with 25 patients with solitary tumors]. / Lokalisationsdiagnostik bei Insulinomen. Erfahrungen bei 25 Patienten mit sporadischen Tumoren.

OBJECTIVE: The most effective way to localize the mostly small ( < 2 cm), benign and solitary insulinomas is still under discussion. Especially the evaluation of the different preoperative localization methods is not clarified. The aim of our study was to support the ongoing discussion in that matter. PATIENTS AND METHODS: In total 25 patients have been included in our study since 1987. All showed sporadic insulinomas and underwent surgery. The following preoperative localization methods had been used: ultrasonography (US): 25 patients, computed tomography (CT): 23 patients, somatostatin receptor scintigraphy (SRS): four patients since 1990, angiography: six patients, endosonography (ES): five patients since 1995, selective portal venous sampling (PVS): two patients, magnetic resonance imaging (MRI): four patients since 1993. All 25 patients underwent a bidigital palpation in combination with intraoperative ultrasonography (IOUS). Four of the 25 patients were reoperated and had a prior unsuccessful operation elsewhere. RESULTS: Preoperatively 19 of 25 insulinomas were localized (76%). The following sensitivity rates had been found: ultrasonography: 56%, computed tomography: 43%, endosonography: 100%, angiography: 66%, magnetic resonance imaging: 25%, selective portal venous sampling: 100%, somatostatin receptor scintigraphy: 0%. All 25 insulinomas were detected during operation, 100% by palpation in combination with intraoperative ultrasonography and 92% by palpation on its own. CONCLUSION: After an insulinoma is biochemically proven and after exclusion of a malignant metastasizing tumor by ultrasonography, all patients should be operated on. Intraoperative ultrasonography should be performed in any case. As other preoperative localization methods did not prove a convincing cost-utility-relation, one should not consider the usage of these methods before the initial operations. Before re-operations one should consider the use of costly pre-operative methods to localize insulinomas. Here endosonography and selective portal venous sampling are recommended as the first procedures of choice.

[Structural MRI study of the Achilles tendon. Correlation with microanatomy and histology]. / Etude structurale du tendon d'achille en IRM. Corrélation avec la microanatomie et l'histologie.

On T1 and T2 weighted MR Imaging, normal Achilles tendon is generally described as a homogeneous low signal structure. However, punctuate and/or short linear high signal foci are often seen, especially on the anterior part of axial sections. These images are not artifacts. The aim of this study was to correlate MR images of 20 normal Achilles tendons with micro-anatomic and histologic studies of 2 cadaver tendons. Intratendinous vessels were found in connective tissue septa called mesotenon. Foci of high signals result from this mesotenon. On T1 weighted images, a normal Achilles tendon can present high signal images without any disease process.