[Alveolar echinococcosis (fox tapeworm)-a surprising diagnosis in a patient with epididymal tumor]. / Echinococcosis alveolaris (Fuchsbandwurmerkrankung) ­ eine überraschende Diagnose bei Nebenhodentumor.

Alveolar ecchinococcosis, caused by the fox tapeworm (echinococcosus multilocularis), is in principle a lethal illness. We report on a 31-year-old man presenting with an unclear epididymal tumor, in whom further examinations revealed multiple and extended partially cystic, partially solid intra-abdominal tumors. Diagnosis was achieved histologically by percutaneous biopsy of a spleen lesion and serologically. As a surgical resection of the lesions was not feasible, therapy with albendazol was initiated.

Spontaneous and Traumatic Splenic Rupture: Retrospective Clinical, B-Mode and CEUS Analysis in 62 Patients.

INTRODUCTION: Both B-mode ultrasound and contrast-enhanced ultrasound (CEUS) are well established procedures when diagnosing traumatic splenic ruptures (TSR). To date, there are no data about CEUS patterns in spontaneous splenic ruptures (SSR). It remains unknown whether TSR and SSR differ with respect to clinical characteristics, B-mode and CEUS characteristics. PATIENTS AND METHODS: Between 12/2003 and 2/2010, n=33 SSRs and n=29 TSRs were diagnosed in a tertiary referral center. All patients were examined with B-mode and CEUS, and clinical data and the outcome were retrospectively analyzed. RESULTS: Patients with SSR were significantly older than patients with TSR (62 years vs. 44 years; p=0.01). The 4-week mortality was significantly higher in SSR than in TSR (36% vs. 0%; p=0.001). No differences between the grading of TSR and SSR could be shown in B-mode or in CEUS. Notably, CEUS was significantly superior to B-mode with respect to the grading of splenic ruptures (p=0.01). Therefore, therapeutic management was influenced by CEUS. CONCLUSION: There are differences between SSR and TSR, especially concerning clinical data (age, course of disease and mortality). Regarding the sonographic pattern, SSR and TSR show identical grading. When splenic rupture is suspected, CEUS should always be performed to identify patients at risk who require interventional procedures.

Understanding the role of conceptual frameworks: Reading the ecosystem service cascade.

The aim of this paper is to identify the role of conceptual frameworks in operationalising and mainstreaming the idea of ecosystem services. It builds on some initial discussions from IPBES, which suggested that conceptual frameworks could be used to: 'simplify thinking', 'structure work', 'clarify issues', and 'provide a common reference point'. The analysis uses the cascade model as a focus and looks at the way it has been used in recent published material and across a set of case studies from the EU-funded OpenNESS Project as a device for conceptual framing. It found that there are examples in the literature that show the cascade model indeed being used as an 'organising framework', a tool for 're-framing' perspectives, an 'analytical template', and as an 'application framework'. Although the published materials on the cascade are rich, these accounts lack insights into the process by which the different versions of the model were created, and so we turned to the set of OpenNESS case studies to examine how they read the cascade. We found that the cascade was able to provide a common reference for a diverse set of studies, and that it was sufficiently flexible for it to be developed and elaborated in ways that were meaningful for the different place-based studies. The case studies showed that generalised models like the cascade can have an important 'awareness-raising' role. However, we found that using models of this kind it was more difficult for case studies to link their work to broader societal issues such as human well-being, sustainable ecosystem management, governance, and competitiveness, than to their own concerns. We therefore conclude that to be used effectively, conceptual models like the cascade may need to be supported by other materials that help users read it in different, outward looking ways. We also need to find mechanisms for capturing this experience so that it can be shared with others.

Sonographic patterns of renal lymphoma in B-mode imaging and in contrast-enhanced ultrasound (CEUS)--a retrospective evaluation.

INTRODUCTION: Retrospective analysis of sonographic patterns of renal lymphoma in B-mode imaging and contrast-enhanced ultrasound (CEUS). PATIENTS/METHODS: From January 2000 to June 2014, 27 patients with clinical or histologically confirmed renal lymphoma were examined with B-mode imaging, followed by CEUS in 8 cases. RESULTS: In B-mode imaging renal lymphoma were hypoechoic in all 27 cases (100%). 9 patients (33.3%) had a bilateral, 18 (66.7%) patients had an unilateral lymphoma infiltration of the kidneys. 8 (29.6%) cases of small nodular, 5 (18.5%) cases of large nodular and 6 (22.2%) cases of perirenal lymphoma infiltration of the kidney were observed in B-mode imaging. Bulky-formation of renal lymphoma was detected in 6 (22.2%) patients and 2 (7.4%) patients had a diffuse lymphoma infiltration of the kidneys. In CEUS an arterial isoechoic enhancement was observed in 5 (62.5%)- and, an arterial hypoechoic enhancement was observed in 3 (37.5%) cases of renal lymphoma. A hypoechoic enhancement in the parenchymal phase was observed in 8 (100%) cases of renal lymphoma infiltration. CONCLUSION: In B-mode-imaging, nodular lymphoma infiltration of the kidneys is the most common of all renal lymphoma patterns in B-mode imaging. In CEUS, renal lymphoma presented an arterial iso- or hypoechoic enhancement, followed by a hypoechoic enhancement in the parenchymal phase. In regard to the differentiation of renal lymphoma to benign lesions of the kidney, CEUS may be helpful. However, the differentiation of renal lymphoma from other malignant lesions of the kidney like renal cell carcinoma is not feasible by CEUS.

[Incidental findings in abdominal ultrasound. Characteristics and clinical interpretation]. / Zufallsbefunde in der Abdomensonographie: Charakteristika und klinische Interpretation.

Abdominal ultrasound is a common diagnostic procedure in internal medicine. The correct interpretation of incidental findings can be difficult at times and often results in expensive and sometimes invasive follow-up examinations. Therefore, detailed knowledge of incidental findings on abdominal ultrasound is of utmost clinical and economical importance. Incidental findings are often benign, however, an accurate evaluation and correct diagnosis is crucial for the subsequent clinical management. To this end B-mode ultrasonography is complemented by color flow Doppler sonography and contrast-enhanced ultrasonography to add dynamic information on blood flow and vessel formation. This article presents frequent incidental findings of the major abdominal organs and vessels, and describes the sonographic and clinical management to find the correct diagnosis.

[Focal liver lesions in patients with malignant haematological disease: value of B-mode ultrasound in comparison to contrast-enhanced ultrasound--a retrospective study with N = 61 patients]. / Stellenwert der kontrastunterstützten Sonografie im Vergleich zur B-Bild-Sonografie in der Charakterisierung fokaler Leberläsionen bei zugrunde liegender maligner hämatologischer Erkrankung: Eine retrospektive Studie mit n = 61 Patienten.

PURPOSE: The aim of the retrospective study is to illustrate the role of contrast-enhanced ultrasound (CEUS) in the dignity assessment of focal liver lesions compared to B-mode ultrasound (US) in patients with malignant haematological diseases (MHD). PATIENTS AND METHODS: Focal liver lesions were diagnosed in n = 61 patients (24 female, 37 male) with MHD via US within the period from November 2005 to February 2009. After the presentation of a not clearly cystic liver lesion (n = 48), CEUS was performed and documented in addition to US. The underlying diagnoses were stem cell diseases (n = 31) and malignant lymphomas (n = 30). The detection of a lesion was documented in n = 17 patients with at this time point primary diagnosed haematological disease, n = 13 patients were in relapse and n = 31 in complete remission (CR). The diagnoses of the liver pathology were confirmed through sonographic follow-up studies and clinical courses (n = 22), CT/MRI (n = 18) and histology (n = 21). RESULTS: In total 67 % of the cases were diagnosed as benign and 33 % as malignant liver lesions. Regarding the therapeutic state, the numbers of benign lesions differ from those of malignant lesions: primary diagnosis 53 vs. 47 %, relapse 69 vs. 31 %, CR 90 vs. 10 %. The frequency distributions of benign versus malignant lesions were 94 vs. 6 % in patients with stem cell diseases and 40 vs. 60 % in patients with malignant lymphomas. Regarding dignity assessment of focal liver lesions, CEUS showed a sensitivity of 90 vs. 45 % and specificity of 96 vs. 18 % (p < 0.0001) compared to US. CONCLUSION: CEUS possesses a significant diagnostic value in the characterization of focal liver lesions and should be used in the context of staging procedures in patients with MHD.

[Measurement on printed paper strips or on the ultrasound device with computer assistance - which technique is more accurate in paediatric hip ultrasound?]. / Ausmessung auf Papier oder computergestützt am Ultraschallgerät - Welches Verfahren ist genauer in der Sonografie der Säuglingshüfte?

AIM: Two different measurement techniques of ultrasonograms of the infant hip were evaluated with respect to reproducibility of the Graf classification and variation of α- and ß-angles. MATERIAL AND METHODS: In a cross-sectional, blinded study, the hips of 207 consecutive newborn babies (101 male; 106 female) were sonographically screened at an average of 2.64 days after birth. Each hip was measured twice by three investigators with different levels of experience - a paediatric orthopaedic surgeon, a senior surgeon and a trained medical student. A mobile ultrasound system (SONOLINE G60S®, Siemens, Erlangen, Germany), equipped with a 7.5 MHz linear transducer, was used. Both hip joints were measured twice by all three investigators. The measurement was performed 6-8 weeks later in a blinded manner. The sonograms were initially printed out on high-quality paper strips and measured by pencil, ruler and goniometer. Finally, each investigator evaluated the same sonograms computer-assisted, using the trackball and dashboard of the ultrasound system. RESULTS: Concerning intraobserver reliability, we observed a significant reduction of variation both for α- and ß-angles in favour of the classic measurement on printed strips (p < 0.05). The interobserver calculation also detected a trend for higher angle variation when the angles were measured electronically. The reproducibility of Graf classification was not influenced by the kind of measurement technique. The outcome was not affected by investigator's level of experience (p > 0.05). CONCLUSIONS: This study demonstrated considerable advantages for the classic measurement of paediatric hip ultrasonograms with pencil and goniometer on printed paper strips compared to computer-aided measurement concerning variation of α- and ß-angles.

[Contrast-enhancend sonography (CEUS) in pneumonia: typical patterns and clinical value - a retrospective study on n = 50 patients]. / Kontrastunterstützte Sonografie (CEUS) bei Pneumonie: Darstellungsmuster und prognostische Bedeutung - eine retrospektive Studie bei n = 50 Patienten.

PURPOSE: To describe contrast-enhanced ultrasound (CEUS) patterns of pneumonia, to characterize CEUS patterns and to determine the clinical value of deviant CEUS patterns. PATIENTS AND METHODS: N = 50 patients with radiologically diagnosed alveolar pneumonia were investigated by CEUS and retrospectively evaluated. Pulmonary enhancement was differentiated from bronchial arterial enhancement by measurement of time to enhancement from the application of the contrast agent (CA). The echogenicity of the CA enhancement was evaluated (isoechoic/hypoechoic) using the spleen as an "in vivo reference". In addition, the homogeneity of the CA enhancement (homogeneous/ inhomogeneous) was recorded. The patients were divided into two groups according to the CEUS pattern (type 1/type 2) and compared to each other in terms of age, days of hospitalization, comorbidity, rate of complications and the presence of pleural effusion. RESULTS: The majority showed a type 1 CEUS pattern consisting of a pulmonary arterial supply (92 %), an isoechoic extent of enhancement (74 %) and a homogeneous enhancement (78 %) of the CA in the pulmonary lesions. The only significant difference found between the two groups was the average age. CONCLUSION: Pneumonia most likely shows a type 1 CEUS pattern consisting of a pulmonary arterial supply, an isoechoic extent of enhancement compared to the spleen and a homogeneous enhancement of the CA in the pulmonary lesions. Prognostic value of a type 2 CEUS pattern (bronchial arterial supply and/or hypoechoic extent of enhancement and/or inhomogeneous enhancement) in pneumonia regarding days of hospitalization, comorbidity, rate of complications and the presence of pleural effusion could not be shown.

Graph analytics-lessons learned and challenges ahead.

Lessons learned from developing four graph analytics applications reveal good research practices and grand challenges for future research. The application domains include electric-power-grid analytics, social-network and citation analytics, text and document analytics, and knowledge domain analytics.

[Unusual presentation of autoimmune pancreatitis type 1]. / Ungewöhnliche klinische Präsentation einer autoimmunen Pankreatitis Typ 1.

HISTORY AND ADMISSION FINDINGS: A-51-year-old man presented with increasingly severe upper abdominal pain, in reduced general state and mild weight loss. Ten years before the patient had undergone a Kausch-Whipple procedure (pancreaticoduodenectomy) for an inflammatory mass in the pancreas, at that time histologically identified as an inflammatory tumour with chronic pancreatitis. Since then he has had repeated episodes of stenosis of the biliary-digestive anastomosis, associated with acute cholangitis. Laboratory findings on admission revealed liver function tests that were moderately (AST, ALT) or markedly elevated (GGT and AP). INVESTIGATIONS: Abdominal ultrasound revealed cuffing of the portal vein and its side-branches with low echogenicity. Magnetic resonance imaging showed periportal edema with irregular bile ducts. Initially the histological examination strongly suggested a peripheral malignant T-cell lymphoma. However, subsequent examination revealed a chronic IgG4-associated, lymphoplasmatic sclerosing inflammation of the biliary tract. TREATMENT AND COURSE: Histological re-examination of the 10-year-old pancreatic resection specimens also showed severe lymphoplasmatic infiltrates suggesting a pancreatic manifestation of an IgG4-associated systemic disease (ISD), known nowadays as an type 1 autoimmune pancreatitis (AIP). Based on the initial diagnosis of an invasive periphere malignant T-cell lymphoma of the liver a pre-phase treatment with vincristine, prednisolone followed by one cycle of CHOEP were administered. This resulted in complete remission of the patient's symptoms. Once the true diagnosis had been revised this treatment was immediately stopped. Since the patient remained symptom-free, the initially elevated laboratory parameters returned to normal and a remission of low echogenicity cuffing of the portal vein was observed and no further steroid treatment was administered. Ursodesocycholic acid was then given as the only drug, to prevent any further episodes of cholangitis. CONCLUSIONS: Autoimmune pancreatitis continues to be frequently unrecognized in clinical practice. But because it responds well to corticosteroids, this clinical entity should be considered in the differential diagnosis of unclear inflammatory changes and strictures of the pancreatic and biliary tracts or even, if necessary, looked for retrospectively in resected pancreas specimens.

[Contrast enhanced sonographic patterns of hepatic candidiasis]. / Kontrastunterstützte sonografische Befunde bei hepatischer Candidiasis.

PURPOSE: B-mode ultrasound (US) of hepatic candidiasis (HC) shows an uncharacteristic pattern. The aim of this study is to display the pattern of HC by performing contrast-enhanced ultrasound (CEUS). PATIENTS AND METHODS: Between May 2006 and June 2008 HC was diagnosed in 12 patients (4 female, 8 male) by clinical and sonographic findings. The underlying diseases were acute leukemia (n = 10), aplastic anemia (n = 1), and testicular cancer (n = 1) in either the state of complete remission (n = 10) or relapse (n = 2). Due to neutropenic fever after chemotherapy all of the patients had received antifungal therapy. When HC was diagnosed all patients were afebrile and in a recovered hematological constitution. Additional diagnostic procedures were histological examination (n = 5), computed tomography (n = 8) and sonographic follow-up examinations (n = 12). All patients were examined with B-mode US and CEUS. RESULTS: In B-mode US the lesions were hypoechoic (n = 12), multiple (n = 10) and > 1 cm (n = 8) as well as > 2 cm (n = 4) in diameter. During CEUS no enhancement of contrast media in the centre of the lesions was seen in all cases during both phases. Additionally, in the arterial phase, the lesions showed no rim enhancement (n = 3) (type I), an isoechoic rim enhancement (n = 5) (type II), or a hyperechoic rim enhancement (n = 4) (type III). During sonographic follow-up a complete regression of the lesions (n = 9) or a stable disease (n = 2) was seen. One patient died due to a relapse. CONCLUSION: The CEUS pattern of HC is variable but characteristic. Therefore, CEUS should be performed in all patients with suspected HC.

What should be done with echoic splenic tumors incidentally found by ultrasound?

PURPOSE: The incidentally found primary intrasplenic tumor is mostly benign, but leads to a well known clinical problem: B-mode sonography, as well as computed tomography and MRI are often non-specific, and it is unclear whether a histological verification is warranted or a sonographic follow-up is justified. PATIENTS AND METHODS: etween October 2003 and October 2007 40 consecutive patients showed an echoic primary tumor of the spleen incidentally found by B-mode ultrasound (US) and were included in this prospective study. All tumors were classified regarding size and echogenity. In all patients contrast-enhanced ultrasound (CEUS) was perfomed and tumor enhancement was characterized in comparison to normal splenic enhancement. Patients were followed up every 3 months during the first year, and then once a year. RESULTS: Sizes of the lesions were < 3 cm in diameter in 28 (70 %), between 3 - 5 cm in 10 (25 %) and > 5 cm in 2 (5 %) patients. Lesions were classified as predominantly hypoechoic (n = 27) and hyperechoic (n = 13) on B-mode US. During the arterial phase the lesions showed a hyperechoic (n = 12), isoechoic (n = 8), hypoechoic (n = 14), and anechoic (n = 6) enhancement on CEUS. Median follow was 24.8 months (range 3 - 48 months). Lesions were constant in size (n = 34) or shrinking (n = 5). In one patient a new 5 mm lesion was seen during follow-up. This patient refused the splenectomy and follow-up was continued without further tumor growth. CONCLUSION: Echoic splenic tumors incidentally found by ultrasound can be managed by sonographic follow-up examinations.

[Differentiation of abdominal lymphadenoptahy with power Doppler sonography]. / Dignitätsbeurteilung von abdominellen Lymphadenopathien in der Powerdoppler-Sonografie.

PURPOSE: Recent studies have reported high accuracy of power Doppler sonography (PDS) and color Doppler sonography (CDS) in the differentiation of benign and malignant peripheral superficial lymphadenopathy. This study was conducted to determine whether PDS can differentiate benign from malignant abdominal lymph nodes on the basis of defined vascular patterns. MATERIALS AND METHODS: We retrospectively evaluated 88 color pictures of abdominal lymph nodes (39 benign lymph nodes, 24 malignant lymphomas, 25 lymph node metastasis) done in the power Doppler mode. The goal was to determine whether benign and malignant abdominal lymph nodes can be differentiated in power Doppler sonography on the basis of 9 defined vascular patterns. RESULTS: Three vascular patterns showed a significantly (p < 0.05) higher appearance in malignant than in benign lymph nodes: aberrant vessel (specificity 87 %), avascular focus (specificity 92 %) and subcapsular vessel (specificity 100 %). The vascular pattern hiliar vessel showed a significantly higher appearance in benign lymph nodes (specificity 87.8 %). CONCLUSION: Three vascular patterns are detectable in power Doppler mode (avascular focus, aberrant vessel, subcapsular vessel) in abdominal lymph nodes, which are typical for malignant abdominal lymphadenopathy. The presence of one of these vascular patterns means with a high specificity (87 - 100 %) that an abdominal lymphadenopathy is malignant. One vascular pattern (hiliar vessel) shows a significantly higher appearance in benign lymph nodes.

Contrast-enhanced ultrasound pattern of splenic metastases - a retrospective study in 32 patients.

PURPOSE: To characterize the pattern of contrast-enhanced ultrasonography (CEUS) in splenic metastases compared to standard B-mode ultrasonography. MATERIALS AND METHODS: Between January 2004 and March 2009, about 50,000 abdominal ultrasound examinations were performed, and n = 279 (< 0.6 %) of focal splenic lesions were detected of which n = 32 (11.5 %) were highly suggestive for splenic metastases of various solid tumors. The number of lesions, size, echogenicity, rim appearance, presence of halo sign and necrosis were recorded via B-mode sonography. Contrast enhancement was determined in the arterial phase (5 - 30 sec) and parenchymal phase (3 - 5 min). B-mode sonography and CEUS were compared in terms of the visibility of splenic metastases. All data was evaluated retrospectively. RESULTS: On B-mode sonography lesions were solitary n = 18 (56 %), multiple n = 14 (44 %), < 2 cm n = 11 (34 %), > or = 2 cm n = 21 (66 %), hypoechoic n = 14 (44 %), isoechoic n = 12 (38 %) and hyperechoic n = 6 (19 %), with regular rim appearance n = 27 (84 %), and with irregular rim appearance n = 5 (16 %). During the arterial phase CEUS lesions were hypoechoic n = 21 (66 %), isoechoic n = 2 (6 %), hyperechoic n = 1 (3 %) and complex n = 8 (25 %). During the parenchymal phase lesions were hypoechoic n = 24 (75 %) and complex n = 8 (25 %). CEUS provided improved visualization of splenic metastases in n = 12 (38 %) cases. CONCLUSION: CEUS of splenic metastases is characterized by reduced contrast enhancement in both the arterial and the parenchymal phase in most cases. Moreover, CEUS improved the visualization of splenic metastases in about 40 % of cases in comparison to standard B-mode sonography.

[The value of a standardized ultrasound in patients with fever]. / Diagnostische Wertigkeit einer standardisierten internistischen Sonografie bei Patienten mit Fieber.

PURPOSE: Transcutaneous ultrasound is not a common imaging procedure in patients with fever. The aim of this study is to demonstrate the diagnostic value of a complete standardized ultrasound examination of patients with fever. MATERIALS AND METHODS: From March 2003 to October 2003, we examined 200 patients with fever using ultrasound. We performed a standardized ultrasound examination including the collar, thoracal, cardial, abdominal regions, and small parts/soft tissue regions depending on clinical symptoms. We retrospective analyzed the patient history regarding fever (origin known vs. unknown) and the diagnostic value of ultrasound (no ultrasound diagnosis vs. ultrasound diagnosis). RESULTS: At the time of inclusion in the study, the origin of fever was known in 124 of 200 patients (62 %) and unknown in 76 of 200 patients (38 %). Ultrasound did not result in a diagnosis in 86 of 200 patients (43 %). A pathological finding was detected in 114 of 200 cases (57 %) as the origin of the fever. New causes for fever were found in 24 of 200 patients (12 %) by means of ultrasound. The most common diagnoses (67 %) in this subgroup were abscesses and splenic infarcts. CONCLUSION: In the clinical course of patients with fever, ultrasound is a diagnostic tool for the documentation and exclusion of medical findings. With this study we were able to show that ultrasound results in the correct diagnosis in one third of patients with fever of an unknown origin and may provide important additional information in patients with fever.

Contrast-enhanced ultrasound of epiploic appendagitis.

PURPOSE: To present our experience with contrast-enhanced ultrasound (CEUS) in patients with epiploic appendagitis (EA). PATIENTS AND METHODS: From May 2005 to December 2007, 15 patients with the clinical and B-mode sonographic diagnosis of EA (13 men and 2 women, aged 11 - 78 years) were included in the study. All patients were examined by CEUS. The extent of contrast enhancement of the fatty tissue masses was measured using the normal surrounding fat tissue enhancement as an in vivo reference (no, hyperechoic, mixed enhancement). B-mode sonographic follow-up examinations were performed in all cases. As additional diagnostic procedures, computed tomography (n = 8), colonoscopy (n = 5), and surgery (n = 1) were used. RESULTS: With CEUS all 15 masses showed a central area of no enhancement. Masses with a central unenhanced area and with broad perilesional enhancement (> 1 mm) were classified as mixed enhancement (n = 11). In the 4 cases classified as no enhancement the central unenhanced area was demarcated by only a marginal hyperechoic rim (< or = 1 mm). CONCLUSION: EA is diagnosed by clinical, laboratory and B-mode sonographic patterns. EA shows a fairly characteristic CEUS feature. CEUS may therefore be helpful to confirm the diagnosis of EA in equivocal cases.