[Drug-induced interstitial lung diseases: often forgotten]. / Medikamenteninduzierte interstitielle Lungenerkrankungen : Häufig vergessen.

Drug-induced interstitial lung diseases (DILD) are probably more common than diagnosed. Due to their potential reversibility, increased vigilance towards DILD is appropriate also from the radiologist's point of view, particularly as these diseases regularly exhibit radiological correlates in high-resolution computed tomography (HRCT) of the lungs.Based on personal experience typical relatively common manifestations of DILD are diffuse alveolar damage (DAD), eosinophilic pneumonia (EP), hypersensitivity pneumonitis (HP), organizing pneumonia (OP), non-specific interstitial pneumonia (NSIP) and usual interstitial pneumonia (UIP). These patterns are presented based on case studies, whereby emphasis is placed on the clinical context. This is to highlight the relevance of interdisciplinary communication and discussion in the diagnostic field of DILD as it is a diagnosis of exclusion or of probability in most cases.Helpful differential diagnostic indications for the presence of DILD, such as an accompanying eosinophilia or increased attenuation of pulmonary consolidations in amiodarone-induced pneumopathy are mentioned and the freely available online database http://www.pneumotox.com is presented.

[Management of solid pulmonary nodules]. / Management solider pulmonaler Rundherde.

The increasing availability of computed tomography has meant that the number of incidentally detected solitary pulmonary nodules (SPN) has greatly increased in recent years. A reasonable management of these SPN is necessary in order to firstly be able to detect malignant lesions early on and secondly to avoid upsetting the patient unnecessarily or carrying out further stressful diagnostic procedures. This review article shows how the dignity of SPNs can be estimated and based on this how the management can be accomplished taking established guidelines into consideration.

Diagnosis of pericardial effusion with a new generation hand-carried ultrasound device in cardiothoracic intensive care unit patients.

BACKGROUND: Technological advances introduced hand-carried ultrasound (HCU) imagers in daily clinical workflow providing several benefits such as fast bedside availability and prompt diagnosis. PURPOSE: To evaluate the diagnostic yield of a latest generation HCU imager compared to contrast-enhanced multidetector computed tomography (MDCT) for the detection of pericardial effusion (PE) in cardiothoracic intensive care unit (ICU) patients. MATERIAL AND METHODS: Thirty-six patients from a cardiothoracic ICU were enrolled to this study irrespective of their underlying disease. All patients were examined with a new generation HCU for the presence of PE. Definite diagnosis of PE was based on findings of MDCT as standard of reference. Statistical analysis was performed using PASW 18. RESULTS: PE was identified in 20 patients by MDCT (prevalence 56%). The HCU examination was carried out technically successfully in all patients. Sensitivity, specificity, positive and negative predictive value of HCU for the diagnosis of PE were 75%, 88%, 88%, and 74%, respectively. CONCLUSION: HCU provides rapid, practical, reliable, and cost-effective diagnosis of PE in patients on cardiothoracic ICU.

Degradable starch microspheres transarterial chemoembolisation (DSM-TACE) of HCC: Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based evaluation of therapeutic efficacy using a novel perfusion software.

PURPOSE: To evaluate therapeutic efficacy of degradable starch microsphere (DSM)-TACE in hepatocellular carcinoma (HCC) using Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based perfusion analysis. MATERIALS AND METHODS: A total of 60 DCE-US examinations were performed in 15 selected patients who underwent DSM-TACE with EmboCept®S for the treatment of advanced HCC. DCE-US was performed via i.v. application of ultrasound contrast media before and 24 hours post embolization. In addition DCE-US was performed with i.a. contrast application via the angiographic catheter right before and after the embolization. Microcirculation of embolized HCC lesions was quantified using a dedicated perfusion software by two experienced radiologists in consensus. RESULTS: Significant reduction of microvascularization (PE, WiAUC and WiR) was seen right after DSM-TACE and during 24 hour follow-up. Mean PE was 342.22 ± 97.80 prior to embolization, 59.28 ± 29.74 post embolization (p = 0.019) and 18.83 ± 7.03 during follow-up (p ≤ 0.01). Mean WiAUC was 1103.21 ± 432.05 prior to embolization 267.69 ± 151.80 post embolization (p = 0.023) and 105.10 ± 44.43 during 24 hour follow-up (p ≤ 0.01). The corresponding values for WiR were 224.91 ± 57.97 prior-, 38.14 ± 18.80 post embolization (p = 0.034) and 6.97 ± 2.68 during follow up (p ≤ 0.01). CONCLUSION: In this study, therapeutic efficacy of DSM-TACE in HCC using DCE-US based perfusion analysis could be demonstrated.

Bedside diagnosis of pleural effusion with a latest generation hand-carried ultrasound device in intensive care patients.

BACKGROUND: Further development established hand-carried ultrasound (HCU) imagers in daily clinical workflow providing several advantages such as fast bedside availability and prompt diagnosis. PURPOSE: To evaluate the diagnostic yield of a latest generation HCU imager compared to chest radiography (CR) for the detection of pleural effusion (PE) in intensive care patients. MATERIAL AND METHODS: Forty-eight hemithoraces of 24 patients on surgical intensive care units were enrolled in this study. All hemithoraces were evaluated using both HCU and CR. Definite diagnosis of PE was achieved using a high-end ultrasound system as standard of reference. Statistical analysis was performed using 2 × 2 tables and a McNemar test. A P value of <0.05 was considered statistically significant. RESULTS: PE was present in 35 of 48 hemithoraces (73%). The HCU examination was carried out technically successfully in all hemithoraces. Sensitivity and specificity of HCU for the diagnosis of PE was 91% and 100%, respectively, whereas sensitivity and specificity of CR was 74% and 31%, respectively. The difference between HCU and CR was statistically significant with respect to specificity but not sensitivity (P = 0.008 and P = 0.11, respectively). CONCLUSION: Due to its ease of use and its high diagnostic yield HCU systems of the latest generation constitute a helpful technique for the primary assessment of PE.

[Clinical significance of conventional follow-through examinations of the gastrointestinal passage in a university hospital]. / Klinischer Stellenwert der Durchleuchtung der Magen-Darm-Passage (MDP) an einem Universitätsklinikum.

PURPOSE: The follow-through examination (FTE) is still a widely used radiological method. Modern sectional imaging techniques (CT, MRI, sonography) are established routine examinations offering a wider range of information. In this context the study tries to answer the question of the current significance of FTE of the gastrointestinal tract. MATERIALS AND METHODS: We retrospectively analyzed data of 300 patients, who had undergone FTE between 2001 and 2009 in a university hospital. The medical history, current anamnesis and the therapeutic consequences of the examination for each patient were evaluated based on radiological reports and electronic medical files. RESULTS: The most frequent indication to perform the examination was an uncertain gastrointestinal passage or/and the exclusion of stenosis (70%). In 10% of all FTEs there were complications which led to examination abortion in 2% of cases. In patients who underwent surgery of the abdomen, the examination was performed 8 days (median) after surgery. In 35% of these patients, FTE was done within the first 6 days after surgery. 87% of the patients received further diagnostics before getting pharmacotherapy or surgery. None of the analyzed patients had been operated on after an FTE of the abdomen without being investigated by another diagnostic method. The average radiation exposure was 7 mSv. CONCLUSION: Considering the wide availability of modern sectional imaging methods that are usually necessary for taking significant therapeutic steps, the indication for FTE examinations of the gastrointestinal tract should be very restrictive. The relatively high radiation exposure supports this suggestion.

Contrast-enhanced ultrasound for differential diagnosis of suspected GvHD in patients after allogeneic transplantation.

GvHD is a serious complication in patients after allo-SCT, presenting with unspecific symptoms such as abdominal pain or cramps and diarrhea. Early diagnosis of GvHD, after differentiation from other causes leading to the same symptoms, such as viral or bacterial enteritis, is highly important because the time needed for diagnosing GvHD is directly correlated to a worsening of the outcome. We examined 23 patients presenting with the abdominal symptoms mentioned above, of whom 20 had received an allo-SCT in their history and were thus potential candidates for enteric GvHD. The other three patients were included because they also presented with abdominal symptoms similar to those of GvHD, which could be ruled out due to their history. We wanted to evaluate CEUS in these patients as an additional subgroup to gain more data on the value of CEUS in early detection of enteral GvHD and in the differentiation of GvHD against other causes of abdominal discomfort. All patients underwent CEUS with particular attention to penetration of the intravenously applied microbubbles in the bowel lumen. In the patients having allo-SCT in their history we strove to achieve histological confirmation of GvHD of the GI-tract. The resulting examinations were documented digitally. Out of 17 patients with confirmed GvHD of the GI tract, 14 showed penetration of the intravenously applied microbubbles into the bowel lumen, leading to a sensitivity and specificity of 82% and 100% for transmural bubble penetration for GvHD of the GI-Tract, since the patients without GvHD of the GI tract showed no transmural bubble penetration. In patients with viral or bacterial infections of the GI tract, no transmural penetration of the microbubbles into the bowel lumen was observed. For microbubble penetration as a criterion for GvHD of the GI-Tract, this leads to a negative predictive value (NPV) of 67%, and a positive predicative value (PPV) of 100%.

Quantification of left-to-right shunting in adult congenital heart disease: phase-contrast cine MRI compared with invasive oximetry.

Atrial septum defects (ASDs), ventricular septum defects (VSDs) and patent ductus arteriosus (PDA) are the most common adult congenital heart defects. The degree of left-to-right shunting as assessed by the ratio of flow in the pulmonary (Qp) and systemic circulation (Qs) is crucial in the management of these conditions. This study compared phase-contrast cine magnetic resonance imaging (PC-MRI), a non-invasive imaging technique, with invasive oximetry for the measurement of shunt volumes during cardiac catheterisation in adults with left-to-right shunting. Both invasive oximetry and shunt quantification by PC-MRI (1.5 T scanner; Sonata, Siemens Medical Solutions) were performed on 21 patients with left-to-right shunting (14 ASD, 5 VSD, 2 PDA) and data on Qp/Qs ratios and left-to-right shunt fraction compared. Mean Qp/Qs ratios assessed by PC-MRI and oximetry were 2.10+/-0.76 and 1.96+/-0.77, respectively (p = 0.37). Mean shunt fraction was 46.3+/-19.6% when calculated by PC-MRI and 42.3+/-20.1% when obtained by oximetry (p = 0.12). There was a strong correlation of Qp/Qs ratios and shunt fraction between both methods (r = 0.61, p < 0.01 and r = 0.84, p < 0.0001, respectively). The two methods had a good agreement according to Bland and Altman plots with a small but non-significant overestimation of Qp/Qs-ratios and shunt fraction by PC-MRI. On receiver operating characteristic analysis, the sensitivity and specificity of PC-MRI to detect an oximetry-derived Qp/Qs ratio of > or =1.5:1 were 93% and 100% at a PC-MRI threshold of a Qp/Qs ratio > or =1.75:1 (area under curve (AUC) = 0.99). Quantification of left-to-right shunting can be performed reliably and accurately by PC-MRI and the data obtained by this method correlate closely to those from invasive oximetry.

Unicuspid aortic valve disease: a magnetic resonance imaging study.

PURPOSE: Congenitally malformed aortic valves are a common finding in adults with aortic valve disease. Most of these patients have bicuspid aortic valve disease. Unicuspid aortic valve disease (UAV) is rare. The aim of our study was to describe valve morphology and the dimensions of the proximal aorta in a cohort of 12 patients with UAV in comparison to tricuspid aortic valve disease (TAV) using magnetic resonance imaging (MRI). MATERIALS AND METHODS/RESULTS: MRI studies were performed on a 1.5 T scanner in a total of 288 consecutive patients with aortic valve disease. 12 aortic valves were retrospectively classified as UAV. Annulus areas and dimensions of the thoracic aorta were retrospectively compared to a cohort of 103 patients with TAV. In UAV, valve morphology was unicuspid unicommissural with a posterior commissure in all patients. Mean annulus areas and mean diameters of the ascending aorta were significantly greater in UAV compared to TAV (12.6 +/- 4.7 cm (2) vs. 8.7 +/- 2.3 cm (2), p < 0.01 and 4.6 +/- 0.7 cm vs. 3.6 +/- 0.5 cm, p < 0.0001, respectively), while no differences were observed in the mean diameters of the aortic arch (2.3 +/- 0.6 cm vs. 2.3 +/- 0.4 cm, p = 0.69). The diameters of the descending aorta were slightly smaller in UAV compared to TAV (2.2 +/- 0.5 cm vs. 2.6 +/- 0.3 cm, p < 0.05). CONCLUSION: In UAV, visualization of valve morphology by MRI is possible with good image quality. Valve morphology was classified as unicuspid unicommissural in all UAV patients. Dilatation of the proximal aorta > 4.5 cm is a frequent finding in UAV. Additional assessment of aortic dimensions is therefore recommended in patients with UAV.

Assessment of the anatomic regurgitant orifice in aortic regurgitation: a clinical magnetic resonance imaging study.

BACKGROUND: The aim of our study was to determine whether planimetry of the anatomic regurgitant orifice (ARO) in patients with aortic regurgitation (AR) by magnetic resonance imaging (MRI) is feasible and whether ARO by MRI correlates with the severity of AR. METHODS AND RESULTS: Planimetry of ARO by MRI was performed on a clinical magnetic resonance system (1.5 T Sonata, Siemens Medical Solutions) in 45 patients and correlated with the regurgitant fraction (RgF) and regurgitant volume (RgV) determined by MRI phase velocity mapping (PVM; MRI-RgF, MRI-RgV, n = 45) and with invasively quantified AR by supravalvular aortography (n = 32) and RgF upon cardiac catheterisation (CATH-RgF, n = 15). Determination of ARO was possible in 98% (44/45) of the patients with adequate image quality. MRI-RgF and CATH-RgF were modestly correlated (n = 15, r = 0.71, p<0.01). ARO was closely correlated with MRI-RgF (n = 44, r = 0.88, p<0.001) and was modestly correlated with CATH-RgF (n = 14, r = 0.66, p = 0.01). Sensitivity and specificity of ARO to detect moderately severe and severe aortic regurgitation (defined as MRI-RgF > or =40%) were 96% and 95% at a threshold of 0.28 cm2 (AUC = 0.99). Of note, sensitivity and specificity of ARO to detect moderately severe and severe AR at catheterisation (defined as CATH-RgF > or =40% or supravalvular aortography > or =3+) were 90% and 91% at a similar threshold of 0.28 cm2 (AUC = 0.95). Lastly, sensitivity and specificity of ARO to detect severe aortic regurgitation (defined as MRI-RgF > or =50% and/or regurgitant volume > or =60 ml) were 83% and 97% at a threshold of 0.48 cm2 (AUC = 0.97). CONCLUSIONS: Visualisation and planimetry of the ARO in patients with AR are feasible by MRI. There is a strong correlation of ARO with RgV and RgF assessed by PVM and with invasively graded AR at catheterisation. Therefore, determination of ARO by MRI is a new non-invasive measure for assessing the severity of AR.

[Differential diagnosis in descending perineum syndrome]. / Differenzialdiagnostik der Beckenbodeninsuffizienz.

Clinical symptoms in descending perineum syndrome show considerable variations, ranging from obstructed defecation to combined fecal and urinary incontinence and including different types of prolapse. Differential diagnosis has to compete with this complexity. Common pelvic floor disorders associated with descending perineum are rectocele, rectal prolapse, enterocele, and sigmoidocele. Standardized diagnostic tools include detailed history and clinical examination with proctorectoscopy as well as anorectal manometry, endoanal ultrasound, defecography, and dynamic MR of the pelvic floor. The diagnosis and proposed therapy have to be developed within an interdisciplinary concept.