[Consensus recommendations of the German Radiology Society (DRG), the German Cardiac Society (DGK) and the German Society for Pediatric Cardiology (DGPK) on the use of cardiac imaging with computed tomography and magnetic resonance imaging]. / Konsensusempfehlungen der DRG/DGK/DGPK zum Einsatz der Herzbildgebung mit Computertomografie und Magnetresonanztomografie.

Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) have been developed rapidly in the last decade. Technical improvements and broad availability of modern CT and MRI scanners have led to an increasing and regular use of both diagnostic methods in clinical routine. Therefore, this German consensus document has been developed in collaboration by the German Cardiac Society, German Radiology Society, and the German Society for Pediatric Cardiology. It is not oriented on modalities and methods, but rather on disease entities. This consensus document deals with coronary artery disease, cardiomyopathies, arrhythmias, valvular diseases, pericardial diseases and structural changes, as well as with congenital heart defects. For different clinical scenarios both imaging modalities CT and MRI are compared and evaluated in the specific context.

An efficient inverse radiotherapy planning method for VMAT using quadratic programming optimization.

PURPOSE: The purpose of this study is to investigate the feasibility of an inverse planning optimization approach for the Volumetric Modulated Arc Therapy (VMAT) based on quadratic programming and the projection method. The performance of this method is evaluated against a reference commercial planning system (eclipse(TM) for rapidarc(TM)) for clinically relevant cases. METHODS: The inverse problem is posed in terms of a linear combination of basis functions representing arclet dose contributions and their respective linear coefficients as degrees of freedom. MLC motion is decomposed into basic motion patterns in an intuitive manner leading to a system of equations with a relatively small number of equations and unknowns. These equations are solved using quadratic programming under certain limiting physical conditions for the solution, such as the avoidance of negative dose during optimization and Monitor Unit reduction. The modeling by the projection method assures a unique treatment plan with beneficial properties, such as the explicit relation between organ weightings and the final dose distribution. Clinical cases studied include prostate and spine treatments. The optimized plans are evaluated by comparing isodose lines, DVH profiles for target and normal organs, and Monitor Units to those obtained by the clinical treatment planning system eclipse(TM). RESULTS: The resulting dose distributions for a prostate (with rectum and bladder as organs at risk), and for a spine case (with kidneys, liver, lung and heart as organs at risk) are presented. Overall, the results indicate that similar plan qualities for quadratic programming (QP) and rapidarc(TM) could be achieved at significantly more efficient computational and planning effort using QP. Additionally, results for the quasimodo phantom [Bohsung et al., "IMRT treatment planning: A comparative inter-system and inter-centre planning exercise of the estro quasimodo group," Radiother. Oncol. 76(3), 354-361 (2005)] are presented as an example for an extreme concave case. CONCLUSION: Quadratic programming is an alternative approach for inverse planning which generates clinically satisfying plans in comparison to the clinical system and constitutes an efficient optimization process characterized by uniqueness and reproducibility of the solution.

[The role of cardiovascular magnetic resonance imaging in the diagnosis and prognosis of patients with heart failure]. / Die Rolle der Kardio-MRT bei Diagnose und Prognosebeurteilung der Herzinsuffizienz.

Cardiovascular magnetic resonance (CMR) imaging is a tomographic technique, which allows three-dimensional slice orientation without limitations from acoustic windows inherent to echocardiography. Further advantages of CMR are its high temporal and spatial resolution, its excellent soft tissue resolution and its high blood-to-tissue contrast. Cardiovascular magnetic resonance is currently the only imaging technique, which provides a comprehensive study of both structure and function of the heart as well as myocardial perfusion and viability. Moreover, post-processing of CMR images does not require any geometric assumptions as in echocardiography to determine ventricular dimensions. This is particularly important when evaluating ventricles of patients with chronic heart failure with severely altered morphology that may have regional variations in wall thickness and contractility at least in ischemic cardiomyopathy. The highly reproducible results of CMR imaging have turned this technique into a reference standard for the non-invasive assessment of ventricular dimensions, mass and function. In cases with indeterminate results of clinical, electrocardiographic and particularly echocardiographic findings CMR should be used early in the process of diagnosis of patients with heart failure. Not only can altered structure and degree of ventricular and valvular dysfunctions be accurately assessed but also regional perfusion deficits and/or myocardial scars are easily detected. For therapeutic and prognostic reasons a simple differentiation between ischemic and non-ischemic cardiomyopathy should be achieved as the first diagnostic step. In addition, the type and localization of the late gadolinium enhancement (LGE) phenomenon may aid in non-invasively differentiating the etiology of non-ischemic cardiomyopathy. CMR may also improve the assessment and extent of interventricular and intraventricular dyssynchrony in patients to be selected for cardiac resynchronization therapy (CRT). Lastly, the LGE phenomenon may provide independent prognostic information in patients with a CRT system implanted, as well as in patients with ischemic and non-ischemic cardiomyopathy. Thus, CMR imaging should be implemented early in the diagnostic process of patients with heart failure to significantly improve the speed and accuracy of diagnostic procedures, to control the effect of therapeutic measures, and to select patients with a limited prognosis by assessing the degree of ventricular dysfunction and the extent of myocardial scarring.

Assessment of left ventricular function with steady-state-free-precession magnetic resonance imaging. Reference values and a comparison to left ventriculography.

UNLABELLED: Ejection fraction (EF) and end-diastolic and end-systolic volume index (EDVI/ ESVI) derived from ventriculography are important prognostic parameters. Cine magnetic resonance imaging (MRI) using a steady-state, free-precession sequence (SSFP) offers excellent delineation of the endocardial borders and highly reproducible and accurate results for cardiac volumes. We evaluated MRI volumetry against routine x-ray ventriculography. In 200 patients EF, EDVI and ESVI were measured with MRI volumetry and x-ray ventriculography. The same MRI protocol was applied to 102 healthy persons in order to establish reference values. In healthy subjects mean EF was 68.8% +/- 5.4% (range 59-84%), mean EDVI 69 +/- 10 (43-90) and mean ESVI 22 +/- 5.8 (10-35 ml). In the patients, overall correlation (Spearman's R) of MRI with ventriculography was 0.86 for EF, 0.77 for EDVI and 0.88 for ESVI. For postextrasystolic beats (38% of the measurements), R was 0.73/0.65/0.73 for EF/EDVI/ESVI. MRI correlated best with biplane ventriculography during sinus rhythm (0.96/0.85/0.93); the worst correlation (0.78/0.81/0.83) resulted from patients with wall motion abnormalities in comparison to monoplane x-ray ventriculography. CONCLUSION: Contemporary MRI volumetry compares well to invasive data obtained under optimal conditions. In view of the known limitations of single plane ventriculography, MRI seems to allow exact volumetry independent from regional wall motion abnormalities.

[Problems with the stoma. How you can advise your patients]. / Probleme mit dem Stoma? Was Sie Ihrem Patienten raten können.

Stoma management is associated with various problems, depending on the type and location of the stoma and on the individual situation. Besides such general problems as smell, flatulence and local skin problems, typical surgical complications such as retraction and stenosis, prolaps and peristomal hernia are of major relevance. Many of these problems can be avoided by careful placement of the stoma and a meticulous surgical technique. Where indicated, the surgical correction of a problem is usually not very difficult, and is most helpful for the patient.

[Surgery in patients over 80 years of age--a retrospective analysis of 642 general surgery patients]. / Chirurgie bei über 80-jährigen--eine retrospektive Analyse an 642 allgemeinchirurgischen Patienten.

We evaluated the data on 642 patients over 80 years of age who underwent general surgery within the preceding 10 years. Lethality in elective surgery was higher compared to younger patients and showed a threefold increase in emergency procedures. Preexisting co-diseases strongly determined survival, which emphasises the fact that a thorough preoperative risk-assessment is essential for elective surgery. Age itself is not a contraindication for elective surgery.

Minitracheotomy: a new interventional technique for treatment of sputum retention.

Sputum retention causing pulmonary atelectasis, secondary pneumonia, and respiratory failure is a frequent complication particularly in patients recovering from abdominal and thoracic surgery. Physiotherapy and conventional therapeutic means like blind tracheobronchial and bronchoscopic suction applied to prevent and treat postoperative respiratory complications have been shown to not be completely effective. Minitracheotomy is a new alternative method for the treatment of sputum retention. Endobronchial suction can be performed as often as required, using a thin uncuffed tube (ID 4.5 mm) which is inserted into the trachea through the cricothyroid membrane under local anaesthesia. Since respiration occurs normally through the nose, mouth, and larynx these patients retain speech and the ability to cough. Complications are rare. Endobronchial suction via minitracheotomy is minimally invasive, more comfortable, and at least as effective as conventional bronchoscopic suction. It therefore has become a routine method used in the treatment of postoperative sputum retention in high-risk patients in many intensive-care units.

[Aortic calcification in CT. Correlation with risk factors and cardiovascular diseases]. / Aortenverkalkungen im CT. Korrelation zu Risikofaktoren und kardiovaskulären Erkrankungen.

Computed tomography is a much more sensitive method of identifying aortic calcification than conventional radiographic methods. The present study was undertaken to explore the importance of various cardiovascular risk factors with regard to their calcifying effect on the aorta. A total of 2,130 individuals, aged 8-88 years, were included. In all cases continuous 8-mm-thick CT slices were obtained from the thoracic inlet caudally to the adrenal glands. There was a significant relationship between aortic calcification and age, smoking habits, hypertension, diabetes, relative body weight, hyperlipidemia and alcohol consumption. Aortic calcification was demonstrated to be strongly associated with vascular disease.

[Surgical therapy of chest wall tumors]. / Die chirurgische Therapie der Brustwandtumoren.

Tumors of the chest wall may occur as both primary and secondary tumors. Diagnosis is established by clinical examination, conventional and/or computed tomography. In most cases of chest wall tumors resection is the treatment of choice. It should be performed with a safe distance to the tumor, if necessary with bloc resection of another intrathoracic part or adjacent tissues. For skeletal reconstruction non-absorbable and absorbable mesh is available; even complete replacement of the sternum is possible. Large full thickness defects can be covered with sliding flaps or myocutaneous flaps from adjacent locations.

Results of surgical treatment of pulmonary metastases.

Surgical removal of one or several metastases with a potentially curative aim is possible in the case of isolated pulmonary metastases. Surgery is part of a combined oncological concept. Between 1972 and 1986, surgical resection was indicated in 368 patients and 419 thoracotomies were carried out. Of the patients, 38% had more uni- or bilateral metastases than expected even after the most careful preoperative diagnostic examinations. The 5-year survival probability of all patients operated on was 33%. Corresponding to a differentiation between potentially curative and non-curative resections, the operation was classified as potentially curative in 73%. In this group, the 5-year survival was 39%. Differentiation into tumour groups (carcinomas of caval type, carcinomas of portal type and sarcomas) revealed no statistically significant differences in prognosis. Due to the excellent chemotherapeutical regimens, testicular teratomas achieved the best results in the early postoperative years. Long-term survival is decisively influenced by the removal of all visible and palpable metastases. If complete removal of all tumour tissue is possible, the number of metastases does not influence survival significantly. Besides radicality, the duration of the disease-free interval showed prognostic differences which were statistically significant (P less than 0.001). Considering the metastatic route and the type of primary tumour, there were slight prognostic differences which were not statistically significant. Recently, the median sternotomy has become the preferred method of access. Predominating resection procedures are wedge and segmental resections which yield the best survival rates.

[Surgical therapy of bronchial cancer]. / Chirurgische Therapie des Bronchialkarzinoms.

Over the last decades the medical and social importance of bronchial carcinoma has increased because of its incidence and poor prognosis. Until recently only surgery has offered the chance of a cure for non-small-cell lung cancer with a 5-year-survival of 25%. Today with the development of tissue-sparing techniques curative treatment is accessible also to patients with limited lung function and centrally located tumors.