[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.

[Automated speech recognition for the generation of medical records in computed tomography]. / Digitale Spracherkennung bei der Erfassung computertomographischer Befundtexte.

PURPOSE: A study was performed to compare the performance of automatic speech recognition (ASR) with conventional transcription. MATERIALS AND METHODS: 100 CT reports were generated by using ASR and 100 CT reports were dictated and written by medical transcriptionists. The time for dictation and correction of errors by the radiologist was assessed and the type of mistakes was analysed. The text recognition rate was calculated in both groups and the average time between completion of the imaging study by the technologist and generation of the written report was assessed. A commercially available speech recognition technology (ASKA Software, IBM ViaVoice) running on a personal computer was used. RESULTS: The time for the dictation using digital voice recognition was 9.4 +/- 2.3 min compared to 4.5 +/- 3.6 min with an ordinary Dictaphone. The text recognition rate was 97% with digital voice recognition and 99% with medical transcriptionists. The average time from imaging completion to written report finalization was reduced from 47.3 hours with medical transcriptionists to 12.7 hours with ASR. The analysis of misspellings demonstrated (ASR vs. medical transcriptionists): 3 vs. 4 for syntax errors, 0 vs. 37 orthographic mistakes, 16 vs. 22 mistakes in substance and 47 vs. erroneously applied terms. CONCLUSIONS: The use of digital voice recognition as a replacement for medical transcription is recommendable when an immediate availability of written reports is necessary.

[The diagnosis and imaging of the a. hepatica after orthoptic liver transplantation--a comparison of frequency-modulated and amplitude-modulated color Doppler sonography]. / Diagnostik und Darstellung der A. hepatica nach orthotoper Lebertransplantation--Vergleich von frequenzmodulierter und amplitudenmodulierter Farb-Doppler-Sonographie.

PURPOSE: We examined whether amplitude-modulated color Doppler (power Doppler) sonography provides a better anatomic imaging of the vascular course of the hepatic artery after liver transplantation. PATIENTS AND METHODS: 82 patients were examined with Doppler sonography after liver transplantation. The distal section of the hepatic artery was imaged both with frequency-modulated color Doppler (color Doppler) and power Doppler and a Doppler spectrum derived from each mode for determination of the flow velocity. RESULTS: Native imaging of the hepatic artery was possible in 78/82 patients, in 2/82 patients only after administration of Levovist, and in 2/82 patients it could not be seen. In these two patients the diagnosis of hepatic artery occlusion was confirmed by angiography. The anatomic course was demonstrated more longitudinally by power Doppler than by color Doppler (p < 0.001; chi 2 test) which made the angle correction easier. A disadvantage of power Doppler was the lack of image contrast to the portal veins; thus evaluation of the vascular course in this section was better possible with color Doppler by means of a specifically generated aliasing in the flow of the hepatic artery (p < 0.001; chi 2 test). Determination of the flow velocity showed no significant differences between color and power Doppler supported duplex sonography. CONCLUSIONS: The combined use of color Doppler and power Doppler improves visualization of the hepatic artery after liver transplantation. The lack of visualization of the vessel after administration of Levovist is diagnostic for occlusion of the vessel.

Low nitric oxide concentrations in exhaled gas and nasal airways of mammals without paranasal sinuses.

To investigate whether relevant levels of nasal nitric oxide (NO) are produced in the absence of paranasal sinuses, we studied 17 healthy baboons, mammals without any paranasal sinuses. The animals were anesthetized with ketamine hydrochloride and breathed spontaneously. While the baboons breathed through a face mask (mouths closed) connected to a respirator, NO concentrations in exhaled gas were sampled from the expiratory limb and analyzed by chemiluminescence. While the animals were breathing ambient air, nasal gas was sampled via a thin plastic tube and analyzed for NO concentrations by chemiluminescence. Mean NO concentration in the exhaled gas was 1.00 +/- 0.59 parts/billion, and NO release was 4.28 +/- 2.72 nl/min. A NO concentration of 4.79 +/- 2.08 parts/billion was found in the nasal gas (NO release: 7.18 +/- 3.13 nl/min). An age-dependent increase in nasal NO levels was not observed. Exhaled and nasal NO concentrations in baboons were markedly lower than in mammals with paranasal sinuses, suggesting that paranasal sinuses might be an anatomic requirement for production of relevant nasal NO levels.

Superimposing positive end-expiratory pressure during partial liquid ventilation in experimental lung injury.

This study was undertaken to determine the effects of superimposing incremental levels of positive end-expiratory pressure (PEEP) during partial liquid ventilation (PLV) on gas exchange, respiratory mechanics and morphological changes in experimental acute lung injury (ALI). In a prospective trial, six pigs weighing 30+/-5 kg (mean+/-SD) were tracheotomized, submitted to pressure-controlled mechanical ventilation (pc-CMV) and depleted of surfactant by lung lavage. Animals were then mechanically ventilated with three levels of PEEP: 0.5, 1.0 and 1.5 kPa. PLV was then initiated by intratracheal instillation of 30 mL x kg(-1) perfluorocarbon, followed by pc-CMV with PEEP 0.5, 1.0 and 1.5 kPa. Computed tomography (CT)-based analyses of lung volumes and density were obtained after lung lavage, in PLV and during the combined application of PLV and PEEP. Simultaneously, haemodynamics, gas exchange, dynamic compliance (Cdyn) and dynamic resistance (Rdyn) were determined. Statistical analysis was performed using multivariate analyses of variance for repeated measures (p<0.05). In ALI and before PLV, the application of PEEP significantly reduced cardiac output and intrapulmonary shunt. Arterial oxygen tension (Pa,O2) was increased from 6.9 kPa (52 (42, 54) mmHg) (median, (25th and 75th percentile)) to 8.6 kPa (65 (52, 133) mmHg) (PEEP 1.0 kPa) and 15.6 kPa (117 (90, 195) mmHg) (PEEP 15 kPa) (p<0.05). The lung volume obtained by CT increased, CT density was reduced (p<0.05), Cdyn tended to increase and Rdyn to decrease (nonsignificant). PLV increased arterial carbon dioxide tension and reduced pH (p<0.05). CT lung volume and lung density were increased (p<0.05). Superimposing PEEP on PLV increased Pa,O2 from 9.3 kPa (70 (52,124) mmHg) (PEEP 0.5 kPa) to 12.9 kPa (97 (55, 233) mmHg) (PEEP 1.0 kPa) and 403 kPa (303 (64, 426) mmHg) (PEEP 1.5 kPa) (p<0.05), but had no significant effect on CT lung volume and density. It was concluded that in experimental lung injury, positive end-expiratory pressure provided alveolar recruitment. The combined application of positive end-expiratory pressure and partial liquid ventilation significantly augmented oxygenation and might eventually allow either a reduction in the volumes of perfluorocarbons required, or a reduction in positive end-expiratory pressure necessary to maintain pulmonary gas exchange in acute lung injury.

[Imaging tumor extension of renal cell carcinomas with magnetic resonance tomography. Improved tumor-tissue contrast with Gd-DTPA-assisted spin-echo sequences and simultaneous fat suppression]. / Darstellung der Tumorausdehnung von Nierenzellkarzinomen mit der Magnetresonanztomographie. Verbesserung des Tumor-Gewebekontrastes mittels Gd-DTPA unterstützter Spin-Echo-Sequenzen und gleichzeitiger Fettsättigung.

PURPOSE: To evaluate the use of contrast-enhanced T1-weighted images with fat suppression (T1FS) to improve the contrast-to-noise ratio of renal cancer and renal parenchyma as well as perirenal fat. METHODS: 25 patients with histologically proven unilateral renal cancer after nephrectomy were examined before surgery. In addition to plane and contrast-enhanced T1-weighted as well as T2-weighted spin-echo images, all patients had T1 FS immediately after administration of Gd-DTPA in two planes. The contrast-to-noise ratio was calculated using circular regions-of-interest which outlined the tumor, the renal parenchyma, pyelon, and the perirenal fat. RESULTS: T1 FS significantly improved the contrast-to-noise ratio of renal cancer and renal parenchyma compared to all conventional spinecho sequences (p < 0.001; Wilcoxon-Test). Compared to contrast-enhanced T1-weighted images without fat-suppression T1 FS yielded a higher CNR of the tumor, the perirenal fat and the pyelon. Another advantage was the absence of the chemical-shift artifact which is mostly pronounced in T2-weighted images and a reduced number of observed artifacts due to breathing. CONCLUSION: T1 FS should replace conventional contrast-enhanced T1-weighted spin-echo images in the work-up of renal cancer using MRI.

Loss of dopamine-D2 receptor binding sites in Parkinsonian plus syndromes.

UNLABELLED: This study analyzed temporal changes of striatal dopamine-D2 receptor binding during the course of different extrapyramidal movement disorders using 123I-iodobenzamide (IBZM) SPECT. METHODS: Eighteen patients (9 with Parkinson's disease, 9 with parkinsonian plus syndrome) were followed for 11-53 mo. Dopamine-D2 receptor binding was assessed using 123I-IBZM SPECT at the beginning and at the end of the follow-up period. SPECT data were acquired 120 min postinjection of 3-5 mCi 123I-IBZM. A semiautomated algorithm was applied to the raw data for semiquantitative evaluation of regional cerebral receptor binding. RESULTS: Intraobserver (r = 0.992) and interobserver (r = 0.930) variance was low for the semiautomated interpretation of the SPECT examination of the dopaminergic D2 receptor binding, reflecting a highly reproducible SPECT algorithm. Mean specific dopamine-D2 receptor binding was lower in patients with parkinsonian plus syndrome compared to patients with Parkinson's disease on the initial (p < 0.001) as well as the follow-up study (p < 0.001). In patients with Parkinson's disease, we observed an unaffected receptor binding compared to a reduced binding of radiotracer in patients with parkinsonian plus syndrome during the course of the disease (p < 0.001). CONCLUSION: During the follow-up, patients with Parkinson's disease showed a constant dopamine-D2 receptor binding. In contrast, patients with parkinsonian plus syndrome revealed a decline of the binding of dopamine-D2 receptor. These findings are in agreement with histopathological data that demonstrated a preserved dopamine-D2 receptor status in patients with Parkinson's disease and a decline of the dopamine-D2 receptors in patients with parkinsonian plus syndrome. SPECT examinations using 123I-IBZM are useful for assessing dynamic changes of dopamine-D2 receptors in extrapyramidal movement disorders. Semiquantitative SPECT evaluations may provide valuable information for clinical management and prognosis of the patient with extrapyramidal movement disorders.

[When is it meaningful to support magnetic resonance tomography by administering a positive enteral contrast medium?--an account of practical experience]. / Wann ist die Unterstützung der Magnetresonanztomographie durch Gabe eines positiven enteralen Kontrastmittels sinnvoll?--Ein Erfahrungsbericht.

PURPOSE: To evaluate in which parts of the gastrointestinal tract and in what clinical situations the diagnostic quality of MR examination may be improved by a positive enteral contrast agent. METHODS: MR examinations of 37 patients performed before and after application of a Gadolinium-DTPA preparation suitable for oral and rectal application were evaluated. Exams were evaluated by two independent observers. Neoplastic disease of the gastrointestinal tract constituted the majority of indications followed by inflammatory changes and extraenteral space-occupying lesions. RESULTS: The majority of examinations (62%) were improved by the application of enteral contrast agent. No effect was observed in 35%; in two patients image quality was poorer after contrast application. The benefit of enteral contrast agents was highest in MR examinations of the sigma and rectum. The enteral contrast agent was most valuable in the detection of lymphoma if an evaluation according to indication was performed. CONCLUSION: In selected cases, the diagnostic quality of abdominal MRI can be improved by the application of an enteral contrast agent. Apart from the effect of greater signal intensity, the contrast agent does complement MR imaging by a functional aspect.

Quantitative estimation of I-123-Iomazenil receptor binding in temporal lobe epilepsies using two SPECT acquisitions--comparison with the regional cerebral blood flow and a compartment model.

AIM: To compare published fractional rate constants of I-123-Iomazenil (IMZ) and C-11-Flumazenil (three-compartment/four-parameter model) with a I-123-Iomazenil receptor index calculated from two SPECT acquisitions and to compare the receptor index of the epileptogenic area with the contralateral side in patients with unilateral temporal lobe epilepsies. METHODS: 28 patients were studied. 13/28 patients had a drug-resistant unilateral temporal lobe epilepsy with a successful focus localisation performed by an extensive video/EEG monitoring. 15 other patients with clinically suspected focal epilepsy and a normal MRI and IMZ SPECT scanning were used as controls. SPECT scanning was performed in all patients 15 and 100 min after intravenous injection of 111 MBq IMZ and 10 min after application of 740 MBq Tc-99m-HMPAO. Quantification of the regional uptake was performed using ROI-technique and the specific and non-specific binding of IMZ was calculated. The receptor index was calculated by the difference of the specific binding from 15 to 100 min p.i. divided by the time interval. RESULTS: The receptor index showed a linear correlation with recently published fractional rate constants k3 (r = 0.69 and 0.67; p = 0.15) and a moderate correlation with the k4 constant (-0.53 and -0.43; p = 0.28) by the means of C-11-Flumazenil PET and I-123-Iomazenil SPECT studies, respectively. However, statistical significance was not reached due to the few data points available from the published reports. Furthermore, the IMZ receptor index was lower in the epileptogenic area of patients with unilateral temporal lobe epilepsies compared with their contralateral side (p = 0.02; Wilcoxon-test). The IMZ receptor index showed a weak correlation with the regional cerebral blood flow independent of the evaluated region (r < 0.4; p < 0.05). CONCLUSION: The IMZ receptor index indicated to be a simple routine approach to estimate the fractional rate constant k3 (r = 0.67). The lower value of the receptor index within the epileptogenic area might be due to a lower receptor density. However in further studies, IMZ might be a helpful tool to find out subtle changes of the receptor affinity due to its approximately 30-fold higher ligand-receptor affinity compared to C-11-Flumazenil.

High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation.

OBJECTIVE: We investigated whether a treatment according to a clinical algorithm could improve the low survival rates in acute respiratory distress syndrome (ARDS). DESIGN: Uncontrolled prospective trial. SETTING: One university hospital intensive care department. PATIENTS AND PARTICIPANTS: 122 patients with ARDS, consecutively admitted to the ICU. INTERVENTIONS: ARDS was treated according to a criteria-defined clinical algorithm. The algorithm distinguished two main treatment groups: The AT-sine-ECMO (advanced treatment without extracorporeal membrane oxygenation) groups (n = 73) received a treatment consisting of a set of advanced non-invasive treatment options, the ECMO treatment group (n = 49) received additional extracorporeal membrane oxygenation (ECMO) using heparin-coated systems. MEASUREMENTS AND RESULTS: The groups differed in both APACHE II (16 +/- 5 vs 18 +/- 5 points, p = 0.01) and Murray scores (3.2 +/- 0.3 vs 3.4 +/- 0.3 points, p = 0.0001), the duration of mechanical ventilation prior to admission (10 +/- 9 vs 13 +/- 9 days, p = 0.0151), and length of ICU stay in Berlin (31 +/- 17 vs 50 +/- 36 days, p = 0.0016). Initial PaO2/FIO2 was 86 +/- 27 mm Hg in AT-sine-ECMO patients that improved to 165 +/- 107 mm Hg on ICU day 1, while ECMO patients showed an initial PaO2/FIO2 of 67 +/- 28 mm Hg and improvement to 160 +/- 102 mm Hg was not reached until ICU day 13. QS/QT was significantly higher in the ECMO-treated group and exceeded 50% during the first 14 ICU days. The overall survival rate in our 122 ARDS patients was 75%. Survival rates were 89% in the AT-sine ECMO group and 55% in the ECMO treatment group (p = 0.0000). CONCLUSIONS: We conclude that patients with ARDS can be successfully treated with the clinical algorithm and high survival rates can be achieved.

Evidence of nitric oxide in the exhaled gas of Asian elephants (Elephas maximus).

Nitric oxide (NO) produced in the respiratory tract is released into the respiratory gases of humans, rabbits, guinea-pigs, and rats. We analysed the NO concentrations in the exhaled gas of four awake Asian elephants. Two methods were employed: (1) exhaled gas was sampled from the elephants' trunks with a 1 L syringe and analysed for NO concentrations by chemiluminescence; (2) respiratory gas was continuously aspirated via a thin plastic tube positioned within the trunk and on-line analysed for NO concentrations by chemiluminescence. Syringe sampling (n = 4), when corrected for dilution by ambient air using linear regression analysis, revealed a mean NO concentration of 31 parts per billion (ppb); highest exhalatory concentrations measured during continuous suctioning were 27 and 28 ppb (n = 2). The exhaled NO concentrations in elephants are similar to those found in humans measured with a comparable technique. This supports the hypothesis that a size-independent 'normal value' of endogenous NO is provided in the airways which may contribute to regulation of pulmonary ventilation and perfusion by autoinhalation in some mammals.

[Magnetic resonance tomography in patients with Parkinson's disease and Parkinson-plus syndromes]. / Magnetresonanztomographie bei Patienten mit Morbus Parkinson und Parkinson-Plus-Syndromen.

PURPOSE: To define characteristic MR-findings in patients with clinically typical extrapyramidal movement disorders. METHODS: 15 patients with Parkinson's disease (PD), 9 with multisystem atrophy (MSA), and 6 with progressive supranuclear palsy (PSP) underwent MRI using a 1.5 T. Magnetom unit. Two investigators analysed the images with special regard to global and/or focal atrophy and to changes in signal intensity of the CNS in the consensus mode. Normal images of 10 subjects served as controls to patient's images. RESULTS: In all patients with PSP and MSA characteristic pathological findings on MRI were observed including regional changes within the extrapyramidal nuclei. In contrast all patients with PD had an unremarkable MRI study of the CNS. CONCLUSION: MRI enables us to define characteristic morphological changes of the brain in patients with extrapyramidal movement disorders. Early recognition of these findings avoids misdiagnoses in patients who are difficult to diagnose.

Drug smuggling by ingested cocaine-filled packages: conventional x-ray and ultrasound.

PURPOSE: To evaluate the imaging characteristics and the diagnostic value of both abdominal ultrasound and conventional abdominal x-ray in identifying ingested drug packages in "body packers." MATERIALS AND METHODS: Twelve individuals were studied prospectively by abdominal ultrasound and by abdominal x-ray to rule out incorporated drug containers. RESULTS: Both abdominal ultrasound and abdominal x-ray correctly identified the 7 of 12 individuals who had ingested multiple drug packages. In 5 of the 12 individuals, ultrasound as well as abdominal x-ray were correctly unremarkable with regard to abdominal foreign bodies. CONCLUSIONS: Abdominal ultrasound and abdominal x-ray both represent valuable diagnostic tools in the assessment of ingested drug packages. Abdominal x-ray is superior to ultrasound in differentiating ingested drug-filled condoms from "pseudocondoms."

[Roentgen diagnosis of body packers--radiological and forensic considerations]. / Röntgendiagnostik bei Körperschmugglern--Radiologische und juristische Betrachtungen.

The diagnostic value of abdominal ultrasonography and plain abdominal radiographs for the detection or exclusion of body smugglers was investigated prospectively. Both methods showed equally high sensitivity and specificity in the detection of swallowed drug packages. Possibilities for misinterpretation of physiological abdominal contents are illustrated. In addition to the radiological aspects, the legal implications of the subject are discussed.

[Estimating patient dosage in radiologic examinations. Effective doses of the most frequent roentgen examinations]. / Zur Abschätzung der Patientendosis bei radiologischen Untersuchungen. Effektive Dosen der häufigsten Röntgenuntersuchungen.

The effective dose (E) measures the stochastic risk of radiation exposure from the viewpoint of the induction of cancer and genetic diseases. In order to compare this risk in roentgen examinations, the effective dose was calculated for the most frequent roentgen examinations. The calculations were performed with a mathematical human phantom for a standard patient. Acquisition parameters were chosen according to national recommendations. The highest values were found for the small bowel enema and lumbar myelography, the lowest values for X-rays of the cervical spine, the paranasal sinuses and the upper thigh.

[Estimating patient dose in radiologic examinations using conversion factors]. / Abschätzung der Patientendosis bei radiologischen Untersuchungen durch Anwendung von Konversionsfaktoren.

The principles for estimation of the patient's radiation dose from conventional radiographic and computed tomography examinations are presented on the basis of published exposure simulation data. The relationship between absorbed dose in air, or axis dose, organ doses, and effective dose is explained. It is shown how organ doses can be calculated from the absorbed dose free in air or axis dose using published computed conversion factors. Calculation of the effective dose from organ doses using tissue weighting factors is described. Finally, examples of dose calculation are given for a conventional radiographic and a CT examination.