[Intra-arterial and intramuscular transplantation of adult, autologous bone marrow stem cells. Novel treatment for therapy-refractory peripheral arterial occlusive disease]. / Intraarterielle und intramuskuläre Transplantation adulter, autologer Knochenmarkstammzellen -- Neue Therapie bei therapierefraktärer peripherer arterieller Verschlusskrankheit.

HISTORY AND CLINICAL FINDINGS: A 62-year-old man had limb ischemia in stage IIb (Fontaine's classification). After surgical and interventional measures the right superficial femoral artery had remained occluded for more than one year. The patient's walking distance was only 100 meters. It was therefore decided to do a combined intraarterial and intramuscular transplantation of stem cells into the right limb. INVESTIGATIONS: Before and 10 weeks after the transplantation noninvasive tests, namely walking distance, ankle-brachial index at rest and during exercise, occlusion plethysmography and capillary venous oxygen saturation were measured. The patient was also asked to fill in a questionnaire of his symptoms. THERAPY AND RESULTS: After harvesting the patient's bone marrow the mononuclear cell fraction was separated (109.8 x 10(6)). Afterwards 10 ml of the cell suspension were injected into the right superficial femoral artery and 5 ml each of the suspension was injected into 5 different locations of the quadriceps femoris and the gastrocnemius muscles. After 10 weeks" follow-up a seven-fold improvement of walking distance and an increase of tissue oxygen saturation of more then 50% were recorded. The ankle-brachial index at rest remained unchanged, but on exercise it increased by 24%. CONCLUSION: The combined intraarterial and intramuscular transplantation of human autologous bone marrow stem cells may be a novel and clinically feasible treatment for patients with severe chronic limb ischemia. The success of this approach may be the result of increased neo-angiogenesis, especially of the small muscle-supplying vessels.

Rapid serological assays for leptospirosis are of limited value in southern Vietnam.

Leptospirosis, although ubiquitous and potentially lethal, is often not diagnosed. The seroprevalence of anti-Leptospira antibodies and the utility of two rapid tests for the serodiagnosis of the disease were studied in Binh Thuan, an area in southern Vietnam with favourable conditions for Leptospira. In an initial survey, blood samples from 44 patients with undifferentiated fever and 83 healthy subjects were each examined for anti- Leptospira antibodies using three tests: an ELISA; a latex card-agglutination test (Dri Dot); and a lateral-flow assay (LeptoTek Lateral Flow). In the ELISA, samples from 35% of the healthy subjects and 40% of the febrile patients were found to have titres of anti- Leptospira IgM of at least 1:80. Only one of the 13 patients checked again, in ELISA, 3 weeks later, showed the marked increase in IgM titre that is indicative of acute leptospirosis. In the initial survey, although the positive results of the lateral-flow assay, applied to whole blood and serum, showed a good agreement with those of the ELISA (kappa = 0.743), the results of the lateral-flow assay were often indeterminate. The card-agglutination test was more specific. The overall agreement between the results of the rapid tests and those of the ELISA was generally poor. When the samples classified as 'indeterminate' in the lateral-flow assay were considered positive, the maximum kappa-value for this assay applied to whole blood was only 0.512. In conclusion, it appears that high seroprevalences of anti- Leptospira IgM and low incidences of acute leptospirosis limit the diagnostic value of the rapid tests that were investigated. The lateral-flow assay is not specific enough. The card-agglutination test is possibly better but, because of the low incidence, its sensitivity could not be evaluated adequately in the present study.

[Retroperitoneal bleeding caused by renal angiomyolipoma]. / Retroperitoneale bloeding uit een renaal angiomyolipoma.

An 81-year-old woman presented with left-flank pain, anaemia and a fast irregular pulse while using oral anticoagulation. Diagnostic investigation revealed retroperitoneal bleeding caused by a medium-sized renal angiomyolipoma. Angiomyolipoma was also found in the contralateral kidney. No tuberous sclerosis was ascertained. Bleeding stopped after discontinuation of anticoagulant therapy. Renal angiomyolipoma is an uncommon benign tumour which is frequently associated with tuberous sclerosis. Spontaneous retroperitoneal bleeding is a potentially life-threatening complication. This type of tumour is usually found incidentally on radiological examination.

[Multiorgan failure due to chronic granulomatous disease]. / Multiorganversagen bei septischer Granulomatose.

A 21-year-old male patient developed an acute septic clinical picture with intra-abdominal abscesses and multiorgan failure. The underlying disease was chronic granulomatous disease, an inherited disorder of granulocyte function caused by failure of intracellular superoxide production. In spite of surgical procedures and a calculated antibiotic and antimycotic therapy, the patient died within a few days from septic shock. This case report describes the typical problems of patients with a congenital immunodeficiency who grow out of the care of highly specialised pediatric-immunological departments.

Deep vein thrombosis as a presenting symptom of congenital interruption of the inferior vena cava.

Infrahepatic interruption of the inferior vena cava is a congenital anomaly, resulting in venous drainage of the lower extremities by way of a compensatory enlarged vena azygos system. We report the case of a 37-year-old male who presented with symptoms of deep vein thrombosis of the entire right lower extremity. A right-sided mediastinal mass on the chest X-ray was mistaken for a haematological malignancy but proved later to represent an enlarged azygos vein. The case illustrates that in a case of deep vein thrombosis, especially in younger patients, interruption of the inferior vena cava should be considered. A right-sided paratracheal mass on the chest X-ray may give a clue in making the correct diagnosis.

Two-step gonadotropin-releasing hormone agonist treatment of uterine leiomyomas: standard-dose therapy followed by reduced-dose therapy.

OBJECTIVE: Gonadotropin-releasing hormone agonist-induced partial pituitary suppression with low-grade estrogen production may be useful in long-term treatment of uterine leiomyomas. STUDY DESIGN: Twenty-seven women with uterine leiomyomas were treated with a standard dose of triptorelin for 8 weeks. Patients were then randomized to use 100, 20, or 5 micrograms of triptorelin until week 26. Uterine and myoma size, pituitary-ovarian function, bone metabolism, and bone mineral density were monitored. RESULTS: During standard treatment uterine size was reduced to 67.1% of baseline. During randomized treatment uterine size was further reduced to 57.8% of baseline. There were no differences in overall volume reduction among the groups. Luteinizing hormone and estradiol levels were restored in a dose-dependent way. Bone mineral density decreased significantly in the highest-dose group at week 26. CONCLUSIONS: This study shows that the beneficial effects of initial high-dose agonist treatment on uterine leiomyomas can be preserved by continued low-dose treatment. Bone mineral density does not seem to change during reduced-dose agonist treatment.

Oral magnetic particles (ferristene) as a contrast medium in abdominal magnetic resonance imaging.

RATIONALE AND OBJECTIVES: In this phase III study, we evaluated the efficacy and safety of a negative contrast medium, ferristene (oral magnetic particles), among 277 patients undergoing magnetic resonance (MR) imaging of the abdomen. METHODS: Enhanced (800 ml ferristene) MR images were compared with unenhanced MR images in an intraindividual-patient control design. Adverse events were recorded. The examinations were performed on 1.5-T MR systems (T1- and T2-weighted sequences). RESULTS: Ferristene increased the diagnostic information in 50.9% of the patients, particularly in those with abdominal masses, lymphoma, or pancreatic disease. Distribution of ferristene in the stomach, duodenum, jejunum, and ileum was complete or sufficient in 70.5-85% of the studies. In 64% of the patients, we were confident in the MR findings after the use of ferristene, and ferristene disclosed additional findings in 22% of the patients. The incidence of adverse events was 9.0%, but only 3.6% of all patients experienced ferristene-related adverse events (e.g., nausea, vomiting). Most events were mild or moderate in intensity. CONCLUSION: Ferristene was well tolerated, and for 50% of the patients it added useful diagnostic information.

Computed tomography and granulocyte scintigraphy in active inflammatory bowel disease. Comparison with endoscopy and operative findings.

The accuracy of computed tomography (CT) and [99mTc]HMPAO granulocyte scintigraphy (GS) for detection of bowel localization, inflammatory activity, and complications in acute inflammatory bowel disease (IBD) was prospectively studied in 32 patients. Of each bowel segment, findings on CT and GS were scored by one blinded observer. Findings on operation or endoscopy served as the gold standard. In Crohn's disease (CD, 17 patients), CT detected bowel pathology (sensitivity 71%, specificity 98%), abscesses (sensitivity and specificity 100%), and fistulas (sensitivity 80%, specificity 100%). In CD, GS had a sensitive of 79% and a specificity of 98% for detection of inflammatory activity. The detection of complications with GS was poor. Segmental inflammatory activity correlated with endoscopy-operative findings for CT (r = 0/86, P < 0.0001) and GS (r = 0.86, P < 0.0001). In ulcerative colitis (UC, 15 patients), GS predicted proximal extension of bowel involvement better than CT. In CD, CT is Superior to GS for localization of both active and fibrostenotic bowel disease, and in detection of the abscesses and fistulas. In UC, GS showed proximal extension more accurately than CT.

Clinical safety and efficacy of iobitridol in urography.

PURPOSE: Evaluation of imaging quality and safety of iobitridol 300 compared to iohexol 300 in urography. MATERIALS AND METHODS: 180 patients were included in an urography multicenter study (3 centers, 60 patients in each). RESULTS: There was no significant difference in either the imaging quality or the clinical safety between the 2 contrast media groups. CONCLUSION: Iobitridol is a safe and efficient contrast agent in urography.

Quantification of coronary artery bypass graft flow by magnetic resonance phase velocity mapping.

OBJECTIVES: Determination of the true coronary artery bypass graft function requires quantification of the flow rate within the graft. The purpose of the present study was to assess the feasibility of characterizing and quantifying graft flow by magnetic resonance phase velocity mapping. MATERIALS AND METHODS: Twenty-seven patients with 41 angiographically patent coronary artery bypass grafts underwent electrocardiographically gated magnetic resonance phase velocity mapping. Imaging was performed at 0.6 Tesla using a surface coil. Velocity maps of the bypass grafts were obtained throughout the cardiac cycle with a temporal resolution of 50 ms and a spatial resolution of 1.9 x 1.2 x 5 mm3, allowing calculation of phasic and mean graft flow. RESULTS: Adequate flow measurements were obtained in 84% (41 out of 49) of the grafts. Coronary artery bypass graft flow was characterized by a biphasic pattern with a first peak during systole and a second peak during diastole. Average maximum systolic and diastolic velocities over the cross-section of the grafts were 14 +/- 8 cm/s and 15 +/- 9 cm/s, respectively. Mean coronary artery bypass graft cross-sectional area was 0.28 +/- 0.13 cm2. Mean volume flow was 87 +/- 59 ml/min. CONCLUSION: Flow in coronary artery bypass grafts can be characterized and measured noninvasively by magnetic resonance phase velocity mapping.

Quantitative MRI of uterine leiomyomas during triptorelin treatment: reproducibility of volume assessment and predictability of treatment response.

Magnetic resonance (MR) imaging is increasingly applied for the quantitative evaluation of uterine leiomyomas. MR is thought to be more accurate in comparison to ultrasound (US) techniques. MR signal intensity (SI) may prove to be predictive of myoma response to GnRH agonist treatment. This study aimed to evaluate the precision of uterine volume assessment by a parallel planimetric MR method and the accuracy of the ellipsoid formula based calculations from MR and US images. It was also attempted to analyze the precision of MR leiomyoma volume measurements and examine the relation between pretreatment myoma SI patterns and the response to agonist therapy. Twenty-seven women with a myomatous uterus were scanned three times during GnRH agonist treatment for 6 months. T1- and T2-weighted, as well as T1 contrast-enhanced sequences of the uterus were obtained in the transverse and sagittal plane. Abdominal US of the uterus was performed with a conventional sector scanner. By the use of a software system for analysis of three-dimensional images obtained by MR, uterine volume was measured by a parallel planimetric method (MR-ROI) as well as the use of the ellipsoid formula (MR-ELL). Myoma volume was assessed by the MR-ROI method. SI of the myomas was estimated from selected tissue samples as well as from the integral myoma region of interest. By abdominal US, volume was assessed by the ellipsoid equation (US-ELL). Within- and between-observer and method reliability (Rw/Rb) was calculated from mean squares obtained by analysis of variance. For uterine volume assessment, reliability between observers and between methods when the MR-ROI and MR-ELL methods were analyzed was excellent. For the US-ELL measurements, the between-observer reliability was limited. Moreover, the reliability of the US-ELL was low when the MR-ROI method was used as the standard. Myoma volume assessment with the MR-ROI method showed high between-observer and between-method agreement. The myoma/fat SI ratio and the mean SI coefficient of variation failed to show a correlation with the degree of response to triptorelin treatment of individual myomas. In MR uterine volume assessment the MR-ELL method is very accurate compared with the more complicated MR-ROI method. The agreement between MR and US is limited. Therefore, the ellipsoid method on MR images is to be regarded as the method of choice for quantitative assessment of uterine volume response to hormonal treatment. Myoma SI patterns were shown to be of no value in the response prediction of myomas to treatment with GnRH agonists.

Magnetic resonance imaging of the pulmonary venous flow pattern in mitral regurgitation. Independence of the investigated vein.

OBJECTIVES: The aim of the present study was two-fold: first, to quantify characteristic parameters of the pulmonary venous flow pattern in patients with mitral regurgitation by using magnetic resonance phase velocity mapping; second, to determine whether this pattern is dependent on the vein being investigated and the direction of the regurgitant jet. BACKGROUND: Echocardiographic findings threw doubt on whether the pulmonary venous flow pattern is independent of the vein being investigated and whether the flow velocities in the pulmonary veins have a linear relationship with the volume flow. SUBJECTS AND METHODS: Flow patterns were assessed in all four pulmonary veins by magnetic resonance velocity mapping in healthy volunteers and in 17 patients with echocardiographically mild and 13 patients with severe regurgitation. RESULTS: No differences were found between the use of velocity or volume flow for characterizing individual curves. The pulmonary venous flow pattern in controls was characterized by six points, a biphasic systolic wave (maximum systolic volume flow: 29 +/- 18 ml.s-1), and end-systolic descent (24 +/- 18 ml.s-1), a biphasic diastolic wave (maximum diastolic volume flow: 69 +/- 22 ml.s-1) and an end-diastolic reversed flow. Reversed end-systolic flow was a characteristic sign of severe regurgitation (-10 +/- 18 ml.s-1). The systolic-to-diastolic flow ratio was lower in severe regurgitation (0.5 +/- 0.6) than in mild regurgitation (1.4 +/- 0.9), P < 0.0001). In severe regurgitation, the normalized time intervals from Q wave to the highest systolic peak and end-systolic descent were of less prolonged duration than in mild regurgitation and controls (P < 0.01). Flow patterns between veins were similar and the median of the correlation coefficients between the curves was the same in patients with or without an eccentric jet, 0.80 and 0.81, respectively. CONCLUSION: Magnetic resonance velocity mapping is helpful in determining and understanding pulmonary venous flow characteristics. It is demonstrated that the pulmonary venous flow pattern is independent of the vein being investigated irrespective of the regurgitant jet direction, and that it is useful in grading mitral regurgitation.

Computed tomography of the large bowel wall. Choice of slice thickness and intraluminal contrast medium.

RATIONALE AND OBJECTIVES: To determine the relative contribution of slice thickness and intraluminal contrast density to imaging of the large bowel wall. METHODS: The authors used phantom experiments to evaluate the partial volume averaging of 2-, 4-, and 8-mm slices on imaging a single density interface (320/-100 HU) and 5 dual-density interfaces (320/50/-100 HU, 160/50/-100 HU, 0/50/-100 HU, -100/50/100 HU, and -1000/50/100 HU). For the experiments with a dual-density interface, which simulated the bowel wall, the phantom was scanned at an angle 45 degrees to the scan plane. RESULTS: The most accurate display of interfaces was obtained with a slice thickness of 2 mm. When using 8-mm slices, walls can appear to be much thinner or thicker than normal or not even recognizable as a wall depending on the densities in the interface. Adjusting the density of the intraluminal contrast medium to within the range of the mean and window setting will improve the representation of the bowel wall. CONCLUSIONS: Slice thickness has a significant influence on the true representation of the bowel wall using computed tomography. This effect is greater than the effect of the intraluminal contrast medium density.

Monitoring the effect of chemotherapy in Ewing's sarcoma of bone with MR imaging.

Magnetic resonance (MR) imaging was performed in 26 patients with Ewing's sarcoma of bone preceding and following neoadjuvant chemotherapy, to assess tumour response non-invasively prior to surgery. T1- and T2-weighted spin echo images were obtained. Changes including intra- and extramedullary signal intensities, tumour demarcation, tumour volume and the appearance of residual extramedullary tumour were compared with histopathology of the resected specimens. Reduction of tumour volume was significantly higher in good responders. Other single parameters did not correlate with histologic tumour response. However, when several MR parameters summarized in a classification system were combined, a positive correlation with histopathologic response was found. A limited decrease of tumour volume (< 25%) and/or residual soft tissue mass following chemotherapy correlated with a poor response. An inhomogeneous, well-defined cuff of abnormal tissue encircling the bone and/or radiological disappearance of the soft tissue tumour component following chemotherapy correlated with good response. Twenty-three out of 26 patients were correctly classified by MR as good or poor responders. Minimal residual disease (< 10% of the entire tumour volume), observed histologically, could not be identified with MR imaging. Tumour volume reduction and residual extramedullary tumour, rather than changes of signal intensity, are major features for evaluating the response to chemotherapy in Ewing's sarcoma.

Magnetic resonance imaging of Carney's triad.

Carney's triad, a rare disorder affecting young females, is characterized by the presence of at least two of the three following neoplasms: gastric epithelioid leiomyosarcoma, extra-adrenal paraganglioma, and pulmonary chondroma. Diagnosis and follow-up evaluation of cases of Carney's triad may require an approach that uses a combination of modalities, including magnetic resonance imaging (MRI), metaiodobenzyl-guanidine (MIBG) I 131 scintigraphy, and computed tomography. MRI is as effective as MIBG scintigraphy in detecting functioning paragangliomas. In the evaluation of suspected cases of Carney's triad in which there is clinical and biochemical evidence of a paraganglioma, MRI is the modality of choice for screening and follow-up. We report a case of gastric leiomyosarcoma and extra-adrenal paraganglioma in a young woman whose initial presentation was at 7 years of age. To our knowledge, this is the earliest presentation of this disorder.

CT and MR distinction of adenomas and nonadenomas of the adrenal gland.

OBJECTIVE: Because the distinction between adenomas and nonadenomas of the adrenal gland is essential, we investigated which of the following parameters--size, CT attenuation values, MRI signal intensity ratios on T1- and T2-weighted sequences, calculated T2 relaxation times, or T2 relaxation time ratios--provides better discrimination. MATERIALS AND METHODS: We compared these parameters in 44 adrenal masses of 37 patients by means of the Student t test and receiver operating characteristics (ROC) analyses. RESULTS: Only size, CT attenuation values, and signal intensity ratios on T2-weighted MR images of adenomas showed a significant difference from those of nonadenomas. With use of ROC analysis, CT demonstrated a significantly larger area under the curve compared to size and T2 signal intensity ratios, indicating superior performance. CONCLUSION: We found attenuation values on non-contrast-enhanced CT to be the best method in discriminating adrenal adenomas from nonadenomas. Adrenal masses with CT attenuation values below 15 HU warrant no further investigations.