[Polymyalgia rheumatica in 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography : Improvement in diagnostic accuracy and differentiation from rheumatoid arthritis]. / Polymyalgia rheumatica in der 18-Fluordesoxyglukose-Positronenemissionstomographie/Computertomographie : Verbesserung diagnostischer Genauigkeit und Abgrenzung von rheumatoider Arthritis.

BACKGROUND: The diagnosis of patients with polymyalgia rheumatica (PMR) has relied upon the clinical examination of symptoms and laboratory parameters of inflammation until now. Currently, the use of different imaging modalities is being explored, including ultrasound, MRI and PET. OBJECTIVES: The aim was to evaluate the diagnostic value of 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography (18F-FDG-PET/CT) for PMR, in order to improve the sensitivity and specificity of diagnosing PMR and to improve the differential diagnosis of rheumatoid arthritis (RA). MATERIALS AND METHODS: Examinations using 18F-FDG-PET/CT of 284 rheumatological patients, including 97 patients with PMR, were retrospectively evaluated over a 44-month period. Furthermore, 13 regions changed by inflammation were analysed via a three-dimensional region of interest (ROI) measurement with determination of maximum standardized uptake values (SUVmax), followed by statistical analyses. RESULTS AND DISCUSSION: Patients with PMR presented significantly elevated uptake in all regions examined (p < 0.001), compared with a control group treated for rheumatological diseases. The method with the highest diagnostic relevance was represented by the combination of four SUVmax values of both anterolateral hip capsules and both ischial tuberosities, reaching a sensitivity of 91.3% and a specificity of 97.6% with a cut-off of 11.0 SUV at the initial diagnosis of PMR patients who had not yet received any immunosuppressive therapy. Patients with RA could be significantly distinguished from those with PMR at initial diagnosis in the same anatomical regions (p < 0.001).

Sentinel Lymph Node Biopsy in Patients with Breast Cancer: Comparison of Peritumoral and Periareolar Injection.

Introduction: Intradermal periareolar injection technique for sentinel lymph node biopsy (SLNB) may offer an advantage by including multifocal breast cancer as an additional indication. In May 2008 we changed our standard procedure from peritumoral (PT) to periareolar (PA) injection. We compared the results for corresponding periods before and after the change in procedure. Material and Method: A total of 117 patients (pts.) were investigated the year after we changed our technique; a total of 152 pts were investigated in the reference period 2007. We investigated the identification rates for sentinel lymph nodes (SLN) identified scintigraphically and surgically as well as the rates of metastatic involvement (LN). Results: After PT injection, scintigraphic detection of SLN failed in 5/152 pts., and in a further 10 pts. SLN was not found at surgery. In 7 of 15 pts. in whom SLN was not detected, histology demonstrated nodal involvement. Metastases were found in the SLN of 28 of 137 pts. with successful detection of SLN; no other lymph nodes were affected in 21 of these pts. (75.0 % of pts. with positive SLN detection). With PA injection at least one SLN could always be detected using scintigraphy; only 2/117 SLN could not be found intraoperatively. Metastasis was found in SLN in 34/115 pts.; in 19/34 pts., metastatic involvement was limited to the SLN with no other lymph nodes involved (55.9 % of pts. with positive detection of SLN). Discussion: The detection rate for SLN was significantly higher using PA injection (98.3 % vs. 90.1 %). As axillary dissection was not done in SLN-negative patients, rates of false-negative detection cannot be determined. PA injection not only results in better detection rates, it also offers the advantage that the technique can be performed correctly regardless of tumour localisation.

[Spontaneous intracranial hypotension. A rare syndrome with good treatment options]. / Das spontane LiquorunterdrucksyndromEin seltenes Krankheitsbild mit guter Therapieoption.

The spontaneous intracranial hypotension syndrome is a rare event but with increasing tendency. The clinical characteristics are comparable to those occurring after dural puncture and the most important clinical finding is the postural headache. The syndrome results from cerebrospinal fluid leakage but its etiology is still nearly unknown. The leaks are mainly located cervically or at the cervicothoracic junction. The syndrome may be associated with cranial subdural fluid build-up. Magnetic resonance imaging of the brain typically reveals diffuse pachymeningeal enhancement, frequently in association with displacement of the brain. Knowledge of this can be helpful to facilitate the diagnosis. Although conservative measures are often initially undertaken, placement of an epidural blood patch is the treatment of choice. Because of its similarity to postdural puncture headache, anaesthesiologists and pain therapists are increasingly involved in diagnosis and therapy. We report 2 patients with spontaneous intracranial hypotension. In addition to the cardinal feature of a postural headache, the patients suffered from subdural fluid build-up demonstrated by cranial magnetic resonance imaging.

[Regional fibrinolysis with rt-PA in hypothenar hammer syndrome]. / Regionale Fibrinolyse mit rt-PA beim Hypothenar-Hammer-Syndrom.

The hypothenar hammer syndrome (HHS) is characterized by lesions of the ulnar artery secondary to repetitive trauma to the hypothenar eminence. We report the case of an orthopedic surgeon with HHS due to his occupational practice. Angiography and MRI confirmed an aneurysm of the ulnar artery and embolic occlusions of his carpal and digital arteries. Patency was reestablished with regional thrombolysis using rt-PA. So far there have been no reports on thrombolysis with rt-PA in HHS.

[Value of dacryocystography in localization diagnosis of lacrimal duct stenosis]. / Stellenwert der Dakryozystographie in der Lokalisationsdiagnostik der Tränenwegstenosen.

PURPOSE: Evaluation of dacryocystography in the preoperative localisation of stenosis of the lacrimal passage. METHOD: The lacrimal system of 20 patients (25 eyes) suffering from lacrimal passage obstruction was examined either by conventional (n = 20) or by digital (n = 5) technique. Diagnostic imaging was evaluated concerning topographic Information of the pathologic lacrimal system, localisation of the level and differential diagnosis of the cause of the obstruction. RESULTS: Cause of the obstruction was chronic dacryocystitis (n = 16), dacryolithiasis (n = 1), atresia of the lacrimal duct (n = 2), posttraumatic lesions (n = 3), rhinosinusitis (n = 1) and carcinoma of the maxillary sinus (n = 1). In 23 of 25 cases (92%) we found an exact correlation between dacryocystography and the intraoperative findings. The variation of stenosis types as well as different examination techniques are presented and compared with literature findings. CONCLUSION: Dacryocystography is a valuable method in the diagnosis and preoperative planing in lacrimal system obstruction.

[MRI arthrography--improved diagnosis of shoulder joint instability]. / MRT-Arthrographie--Verbesserte Diagnostik bei Schultergelenkinstabilitäten.

In a prospective study, we examined 34 patients with shoulder instabilities and 5 patients with unclear chronic shoulder pain (4 females, 35 males; 18-56 years of age, median 28 years) by CT arthrography and MRT arthrography from August 1994 through December 1995. No complications were seen when gadolinium-DPTA was applied intra-articularly. Twenty-three patients were followed up by operation and/or arthroscopy; 20 patients underwent a modified, open Bankart operation. In this paper, we present a new classification for damage of the anterior capsule and labrum. MRT arthrography showed better results in judging the anterior labrum and in determining the degree of damage to the labrum (sensitivity, specificity and accuracy 100%) in comparison with CT arthrography (sensitivity 90%, specificity 100%, accuracy 91%). Furthermore, MRT arthrography gave clearer results than CT arthrography regarding SLAP and cartilage lesions. Thus, MRT arthrography has proved to be a very exact method for diagnosing shoulder instabilities and is superior to CT arthrography in diagnostic accuracy.

[Malignant schwannoma of the rectum]. / Malignes Schwannom des Rektums.

Malignant schwannomas are rare. These malignomas are primary nerve sheath tumors that usually arise from a peripheral nerve. They appear most frequently in the lower extremities, including the hips and buttocks (34.8%), the upper extremities (23.4%), and in the trunk (17%). To the best of our knowledge, this is the first reported case of a malignant schwannoma of the rectum. We describe the rare disease with reference to the literature.

[Circular dissection of the ascending aorta with intimo-intimal invagination. CT diagnosis of a rare form of aortic dissection]. / Zirkuläre Dissektion der Aorta ascendens mit intimointimaler Invagination. CT-Diagnose einer seltenen Form der Aortendissektion.

Intimointimal intussusception is a rare type of aortic dissection. The intimal tear occurs circumferentially with intussusception of the intimal flap downstream into the aortic arch causing obstruction of the great supraaortic vessels. A CT diagnosis has only once been reported. CT and angiographic findings of this rare complication of aortic dissection are described.

[Emboliform sarcoma of the right pulmonary artery]. / Emboliformes Sarkom der rechten Arteria pulmonalis.

Sarcoma of the pulmonary artery is a rare tumor. The histopathologic features of these tumors differ widely, with leiomyosarcomas representing less than 20% of all pulmonary sarcomas. Diagnosis is very difficult because most of the cases have no specific clinical signs: the major differential diagnosis is that of pulmonary thromboembolism. We report the case of a 45-year-old woman, who was first treated for pulmonary thromboembolism until the diagnosis of an intravascular growing tumor was made by means of computed tomography, pulmonary angiography and nuclear magnetic resonance tomography. The patient underwent right pneumonectomy and microscopically a leiomyosarcoma of the right pulmonary artery was found.

[Sagittal burst fracture of the talus]. / Sagittale Berstungsfraktur des Talus.

Fractures of the talus have a relatively low incidence, accounting for 0.3% of all bone fractures and 3.4% of fractures of bones in the foot. These injuries affect the neck of the talus more frequently than its head or body. Because of the combined traumatic mechanism, sagittal fracture of the talar body is extremely rare; the literature contains only a few case reports, all with severe dislocation of the fragments. Plain film radiographs and CT pictures recorded in a rare case of nondisplaced fracture of the talar body are presented.

[Leiomyomatosis of the esophagus]. / Leiomyomatose des Osophagus.

A rare case of dysphagia caused by leiomyomatosis of the esophagus is presented. Esophageal leiomyomatosis is triggered by diffuse proliferation of smooth muscle cells in the wall of the entire esophagus. Only 1.0% of all tumors of the esophagus are benign lesions; 0.4% of all esophageal neoplasms are leiomyomas. Only a few cases of leiomyomatosis-a special form of diffuse leiomyomas-have been described so far in the literature. Modern diagnostic imaging techniques such as CT and MR are described in esophageal leiomyomatosis.

[Diagnosis of a left-sided cervical aortic arch with nuclear magnetic resonance tomography]. / Diagnose eines linksseitigen zervikalen Aortenbogens mittels Kernspintomographie.

Aortic arch anomalies are rare. They arise as a failure of the normal development of the left fourth dorsal arch. Cervical aortic arches are believed to result from persistence of the third dorsal arch, which re-routes the aortic arch in the cervical region. We describe a case of a left-sided cervical aortic arch in which the diagnosis was confirmed, and the anatomy defined, using magnetic resonance tomography.

[An epidural hematoma following single shot epidural anesthesia]. / Epidurales Hämatom nach Single shot-Epiduralanästhesie.

The formation of an epidural or subdural haematoma is a well-known but very rare complication when anaesthetic procedures are conducted near the spinal cord. The major reasons are impaired blood coagulation and the trauma of puncture, which represents the initiating factor and determines the extent of the vascular lesion, while defective coagulation may cause the bleeding to continue. We report on a 30-year-old slender female patient of ASA group II undergoing epidural anaesthesia at L3/4 with a 19-gauge Crawford needle for an ankle joint injury. Unexpected puncture difficulties made several approaches necessary. Prevention of thrombosis with low-molecular heparin was not started preoperatively but 8 h following the intervention. On the first postoperative day the patient was mobilized and, in spite of the repeated punctures, there were no complaints until the fourth postoperative day. Subsequently, sudden significant complaints occurred, first suggesting infection near the spinal cord. Immediate magnetic resonance imaging revealed an epidural haematoma, which did not require intervention. Puncture of the spinal fluid was not performed. Laboratory analysis of coagulation showed a prothrombin time of 56%; PTT was normal with 36 s. Following three days of symptomatic therapy, the complaints had improved markedly, so that mobilization could be started again. For another 10 days the patient had a minor diffuse sensation of pressure when moving the lumbar spine in this region. Subsequently, there were no complaints at all, as proved by an investigation one year later. Unfortunately, the patient refused to undergo another MRT at that time. In the present case the haematoma was caused by tissue trauma due to several puncture attempts.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of vertebral mineral determination by dual-energy quantitative computed tomography.

Quantitative computed tomography is an established method for the non-invasive assessment of bone mineral content. Scanning with two different X-ray energies allows material-selective image reconstruction and separation on the basis of differing atomic numbers. As proven by chemophysical analysis of 45 bone samples, dual-energy quantitative computed tomography with basis material decomposition allows highly accurate measurement of bone mineral density with an error of 1.4%, independent of fat and soft tissue content.

[Structural changes in the lung in the late stage of fatal paraquat poisoning]. / Strukturveränderungen der Lunge in der Spätphase einer letalen Paraquatintoxikation.

Poisoning with Paraquat, an efficient weedkiller, causes a progressive interstitial fibrosis of the lung starting after about one week's latency. The X-ray findings of a 30-year-old female patient who died 12 days after oral ingestion of Paraquat could be documented. We found a correlation between X-ray examination and microscopic post mortem findings of necrotizing alveolitis of the lung changing from exsudative to sclerosing alterations. This diffuse interstitial fibrosis was accompanied by an increase of contractile filament laden cells, characterized by an expression of alpha-smooth muscle actin, which could be identified by immunohistochemical methods. The substantial increase in alpha-actin containing cells has recently been observed in cases of Bleomycin-injured lungs.

Surgical treatment of bilateral chylothorax due to benign lymphangioma of the thoracic duct.

We present a female patient in whom after an 8-year history of recurrent bilateral pleural effusions, a benign lymphangioma of the thoracic duct was diagnosed and successfully treated by ligation of the duct, resection of the tumour and simultaneous decortication of the right pleural space and lung. This observation supports surgical intervention in this condition even in patients of advanced age.

[Pulmonary artery hypertension in chronic obstructive lung disease. The place of morphometric studies in thoracic radiography]. / Pulmonal-arterielle Hypertonie bei chronisch obstruktiver Lungenerkrankung. Stellenwert morphometrischer Untersuchungen in der Thoraxröntgendiagnostik.

Standard biplane chest X-rays were tested for the validity of morphometric criteria in the diagnosis of pulmonary artery hypertension. Twenty-seven patients suffering from chronic obstructive lung disease were examined and compared with a control group without cardiopulmonary disease. The diameter of the right and left pulmonary artery, pulmonary conus and the hilar-to-thoracic ratio were significantly increased in patients with chronic obstructive lung disease (p less than 0,0001). Measurement of the right pulmonary artery was 19.7 +/- 3.9 mm compared to 13.6 +/- 1.2 mm of the control group; mean hilar thoracic index was 0.35 compared to 0.31. Thus if the width of the descending branch of the right pulmonary artery was above 16 mm, pulmonary arterial hypertension was suggested, with a specificity of almost 100%, although the sensitivity of the diagnosis was only 59%. The mean pulmonary arterial pressure obtained by right heart catheterization correlated poorly with the morphometric criteria obtained.

[Hypophosphatemic osteomalacia in adults]. / Hypophosphatämische Osteomalazie im Erwachsenenalter.

Hypophosphataemic osteomalacia occurred in a 38-year-old woman. The leading clinical symptom was severe bone pain. X-ray studies demonstrated fractures of the iliac crest and pubic and ischiadic bone, as well as Looser's zones and demineralization of the skeleton. Computerized densitometry of the bone revealed a 31% reduction of hydroxyapatite. Histological evaluation showed nearly absence of osteoclasts and extensive demineralisation of the bone. Hypophosphataemia (0.48 mmol/l), increased urinary phosphate clearance (36 ml/min), reduced renal-tubular reabsorption for phosphate (73%) and increased alkaline phosphatase (355 U/l) were present. Parathyroid hormone and 1,25-dihydroxyvitamin D were normal. No inborn errors, disturbances of the calcium metabolism or paraneoplastic signs could be detected. Defective renal tubular reabsorption of phosphate is likely to be the underlying cause of the disease. Phosphate supplementation and intermittent vitamin D administration remains the therapy of choice.