The impact of disease-related immobilization on thigh muscle mass and strength in older hospitalized patients.

BACKGROUND: We assessed the quantitative changes in muscle mass and strength during 2 weeks of hospitalization in immobile and mobile acutely ill hospitalized older adults. METHODS: Forty-one patients (82.4 ± 6.6 years, 73.0% females) participated in this prospective longitudinal observational study. Mobility status was defined according to walking ability as described in the Barthel-Index. Functional status, including handgrip strength and isometric knee-extension strength, and mid-thigh magnetic resonance imaging (MRI) measurements of cross-sectional area (CSA) were conducted on admission and at discharge. RESULTS: Twenty-two participants (54%) were immobile and 19 (46%) mobile. In all, 54.0 and 12.0% were at risk of malnutrition and malnourished, respectively. The median time between baseline and follow-up for MRI scans were 13 days in mobile and immobile participants (P = 0.072). Mid-thigh muscle and subcutaneous fat CSA significantly decreased by 3.9cm2 (5.0%, P = 0.002) and 5.3cm2 (5.7%, P = 0.036) during hospitalization whereas intermuscular fat remained unchanged in immobile subjects. No significant changes were observed in mobile patients. In a regression analysis, mobility was the major independent risk factor for changes in mid-thigh muscle CSA as a percentage of initial muscle area (P = 0.022) whereas other variables such as age (P = 0.584), BMI (P = 0.879), nutritional status (P = 0.835) and inflammation (P = 0.291) were not associated with muscle mass changes. There was a significant decrease in isometric knee extension strength (P = 0.002) and no change in handgrip strength (P = 0.167) in immobile patients whereas both parameters increased significantly over time in mobile patients (P = 0.048 and P = 0.012, respectively). CONCLUSIONS: Two weeks of disease-related immobilization result in a significant loss of thigh muscle mass and muscle strength in older patients with impaired mobility. Concomitantly, there was a significant reduction of subcutaneous adipose tissue in immobile older hospitalized patients whereas no changes were observed in intermuscular fat among these patients. These data highlight the importance of mobility support in maintaining muscle mass and function in older hospitalized patients.

The Impact of Malnutrition on Acute Muscle Wasting in Frail Older Hospitalized Patients.

Very little is known about the effect of malnutrition on short-term changes of body composition, particularly muscle, among older hospitalized patients. We sought to investigate the association of malnutrition as assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria with changes of thigh muscle mass and muscle strength among older patients during hospitalization. Forty-one patients (age range 66-97 years, 73% female) participated in this prospective longitudinal observational study. Nutritional status was evaluated using the GLIM criteria on admission and at discharge. Functional status and mid-thigh magnetic resonance imaging (MRI) measurements of cross-sectional area (CSA) were conducted on admission and before discharge. In all, 17% were malnourished and 83% had no malnutrition. Mean mid-thigh muscle CSA declined by 7.0 cm2 (-9%) in malnourished patients during hospitalization (p = 0.008) and remained unchanged among non-malnourished patients (-1%, p = 0.390). Mean mid-thigh CSA of subcutaneous and intermuscular fat did not change significantly during hospitalization in both groups. Malnourished subjects lost 10% of handgrip strength (-1.8 kg) and 12% of knee extension strength (-1.5 kg) during hospitalization. However, the magnitude of both changes did not differ between groups. In a stepwise multiple regression analysis, malnutrition and changes in body weight during hospitalization were the major independent risk factors for the reduction of muscle CSA. Malnutrition according to the GLIM criteria was significantly and independently associated with acute muscle wasting in frail older patients during 2-week hospitalization.

Salvage lymph node dissection in hormone-naïve men: How effective is surgery?

OBJECTIVE: Salvage lymph node dissection (SLND) is still a questionable treatment approach for patients with nodal recurrence of prostate cancer after radical prostatectomy. We assessed the oncological benefit after SLND in hormone-naïve patients as well as the diagnostic accuracy of preoperative prostate-specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET/CT) scanning. MATERIAL AND METHODS: The study relied on retrospective collected data of 43 hormone-naïve men who received transperitoneal SLND between February 2011 and March 2017 at our institution. The oncological outcome for each patient was observed by serum prostate-specific antigen testing. Postoperative complications within 30 and 90 days were assessed according to the Clavien-Dindo classification. The accuracy of PSMA PET/CT was characterized by calculated sensitivity, specificity, positive, and negative predictive values. RESULTS: Overall 8 patients (18.6%) had a complete biochemical response 40 days after SLND. The median time from SLND to biochemical recurrence was 2 months. Adjuvant treatment encompassing radiotherapy, androgen deprivation therapy, or a combination of both, was administrated in 62.8%. According to the Clavien-Dindo classification, no high-grade complications were observed. Sensitivity and specificity for PSMA PET/CT were respectively 32% (95% confidence interval [CI]: 17.21-51.59) and 91.74% (95% CI: 85.45-95.45). Calculated positive predictive values (PPV) and negative predictive values (NPV) of PSMA PET/CT were 44.44% (95% CI: 25.98-64.58) and 86.72% (95% CI: 83.23-89.57). CONCLUSIONS: For most hormone-naïve men with a nodal recurrence of prostate cancer transperitoneal SLND is neither an appropriate treatment to cure nor an option to delay the need for salvage hormone manipulation. PSMA PET/CT scans in hormone-naïve patients are currently too imprecise to diagnose metastatic sites.

The Hinrichsen Embryology Collection: Digitization of Historical Histological Human Embryonic Slides and MRI of Whole Fetuses.

The number of human embryology collections is very limited worldwide. Some of these comprise the Carnegie Collection, Kyoto Collection, and the Blechschmidt Collection. One further embryonic collection is the Hinrichsen Collection of the Ruhr University Bochum, Germany, which also contains very well-preserved embryos/fetuses, along with approximately 16,000 histological sections. The digitization of this collection is indispensable to enable conservation of the collection for the future and to provide a large group of embryologists, researchers, and physicians access to these histological slides. A small selection of these scans is available at the website of the Digital Embryology Consortium [https://-human-embryology.org/wiki/Main_Page].

Detection of Acute Tubular Necrosis Using Blood Oxygenation Level-Dependent (BOLD) MRI.

BACKGROUND/AIMS: To date, there is no imaging technique to assess tubular function in vivo. Blood oxygen level-dependent magnetic resonance imaging (BOLD MRI) measures tissue oxygenation based on the transverse relaxation rate (R2*). The present study investigates whether BOLD MRI can assess tubular function using a tubule-specific pharmacological maneuver. METHODS: Cross sectional study with 28 participants including 9 subjects with ATN-induced acute kidney injury (AKI), 9 healthy controls, and 10 subjects with nephron sparing tumor resection (NSS) with clamping of the renal artery serving as a model of ischemia/reperfusion (I/R)-induced subclinical ATN (median clamping time 15 min, no significant decrease of eGFR, p=0.14). BOLD MRI was performed before and 5, 7, and 10 min after intravenous administration of 40 mg furosemide. RESULTS: Urinary neutrophil gelatinase-associated lipocalin was significantly higher in ATN-induced AKI and NSS subjects than in healthy controls (p=0.03 and p=0.01, respectively). Before administration of furosemide, absolute medullary R2*, cortical R2*, and medullary/cortical R2* ratio did not significantly differ between ATN-induced AKI vs. healthy controls and between NSS-I/R vs. contralateral healthy kidneys (p>0.05 each). Furosemide led to a significant decrease in the medullary and cortical R2* of healthy subjects and NSS contralateral kidneys (p<0.05 each), whereas there was no significant change of R2* in ATN-induced AKI and the NSS-I/R kidneys (p>0.05 each). CONCLUSION: BOLD-MRI is able to detect even mild tubular injury but necessitates a tubule-specific pharmacological maneuver, e.g. blocking the Na+-K+-2Cl- transporter by furosemide.

The additional value of the lateral chest radiograph for the detection of small pulmonary nodules-a ROC analysis.

OBJECTIVE: For the past 30 years, many authors have described different advantages of the use of the additional lateral chest radiograph. However, some radiologic departments gave up performing the lateral view recently. A potential reason for this might be a lack of evidence for any diagnostic benefit of the additional lateral view of the thorax in recent studies. The objective of this study was to evaluate the diagnostic benefit of the additional lateral view for the detection of small pulmonary nodules compared with CT examinations as a gold standard. METHOD: The patient population consisted of 45 patients with SPN and 45 patients without SPN. Four radiologists with varying experience in the assessment of thoracic imaging first examined the sole posteroanterior (PA) projection. After a few days, they were instructed to examine the PA and the additional lateral view. A receiver-operating characteristic analysis was accomplished to compare the documented results. RESULTS: The mean Az value of the sole PA view was 0.75 and 0.77 by the combination of PA and additional lateral view. So, there was no significant difference between the detectable Az values (Δ = 0.02; p = 0.384). With a cut-off value of >3, the additional view even reduced the sensitivity by averaging to 5.6%. The decrease of sensitivity by using the additional view was most detectable within the group of more experienced radiologists. CONCLUSION: The additional lateral view of the chest provides no diagnostic benefit in the detection of small pulmonary nodules in comparison with the sole PA projection. Nevertheless, the results of the present study must not be understood as a general evaluation of the benefits of the lateral radiograph per se, because we did not examine other relevant issues (i.e. cardiac failure, lung parenchyma diseases or abnormalities in hilar anatomy). Advances in knowledge: Our study demonstrates a lack of evidence for any diagnostic benefit of the additional lateral view of the thorax in detecting SPN.

Navigation of pedicle screws in the thoracic spine with a new electromagnetic navigation system: a human cadaver study.

INTRODUCTION: Posterior stabilization of the spine is a standard procedure in spinal surgery. In addition to the standard techniques, several new techniques have been developed. The objective of this cadaveric study was to examine the accuracy of a new electromagnetic navigation system for instrumentation of pedicle screws in the spine. MATERIAL AND METHOD: Forty-eight pedicle screws were inserted in the thoracic spine of human cadavers using EMF navigation and instruments developed especially for electromagnetic navigation. The screw position was assessed postoperatively by a CT scan. RESULTS: The screws were classified into 3 groups: grade 1 = ideal position; grade 2 = cortical penetration <2 mm; grade 3 = cortical penetration ≥2 mm. The initial evaluation of the system showed satisfied positioning for the thoracic spine; 37 of 48 screws (77.1%, 95% confidence interval [62.7%, 88%]) were classified as group 1 or 2. DISCUSSION: The screw placement was satisfactory. The initial results show that there is room for improvement with some changes needed. The ease of use and short setup times should be pointed out. Instrumentation is achieved without restricting the operator's mobility during navigation. CONCLUSION: The results indicate a good placement technique for pedicle screws. Big advantages are the easy handling of the system.

CT differentiation of enlarged mediastinal lymph node due to anthracosis from metastatic lymphadenopathy: a comparative study proven by endobronchial US-guided transbronchial needle aspiration.

PURPOSE: Anthracosis often results in mediastinal nodal enlargement. The aim of this comparative study was to evaluate if it is possible to differentiate endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) proven anthracotic lymph nodes from malignant lymph node enlargement by means of multislice computed tomography (MSCT). METHODS: We compared the MSCT findings of 89 enlarged lymph nodes due to anthracosis with 54 malignant lymph nodes (non-small cell lung cancer 75.9%, small cell lung cancer 18.5%, and non-Hodgkin lymphoma 5.6%). The lymph nodes were assessed for density (calcification, fat, and necrosis), shape (oval, round), contrast enhancement, and contour (sharp, ill-defined). RESULTS: Malignant lymph nodes showed significantly greater axis diameters (P < 0.001). Both anthracotic and malignant nodes were most often oval (86.5% of all malignant nodes vs. 81.5% of all anthracotic nodes, P = 0.420) and showed confluence in a remarkable percentage (28.1% vs. 42.6%, P = 0.075). Anthracotic nodes showed calcifications more often (18% vs. 0%, P < 0.001). Malignant lymph nodes showed a significantly greater short and long axis diameter (P < 0.001), and they had a higher frequency of ill-defined contours (27.8% vs. 2.2%, P < 0.001) and contrast enhancement (27.8% vs. 5.6%, P < 0.001). Nodal necrosis, which appeared in one third of the malignant nodes, was not observed in anthracosis (35.2% vs. 0%, P < 0.001). Confluence of enlarged lymph nodes was seen in malignant lymph nodes (42.6%), as well as in lymph node enlargement due to anthracosis (28.1%, P = 0.075). CONCLUSION: Our results show that there are significant differences in MSCT findings of malignant enlarged lymph nodes and benign lymph node enlargement due to anthracosis.

Standard versus inverted digital luminescence radiography in detecting pulmonary nodules: a ROC analysis.

OBJECTIVE: Observer performance tests were conducted to compare the effect of presenting digital luminescence radiography (DLR) monitor images in positive mode ("bones black") or negative mode ("bones white") in the detectability of subtle lung nodules. METHODS: Five radiologists independently reviewed digital radiographs of 55 patients with either (a) a single, small (6-12 mm), non- calcified peripheral nodule confirmed by chest CT (n=47) or (b) normal finding (n=8) confirmed by chest CT, respectively. Mean size of pulmonary nodules was 8.3mm (range 6-12 mm, median 7 mm). Radiographs were displayed either in standard mode (bones white) or inverse intensity (bones black). A total of 550 observations resulted. For the evaluation ROC analysis was performed using a specialized computer algorithm. RESULTS: The standard presentation mode showed a sensitivity of 61.7% and a specificity of 72.5%, the inverse presentation mode a sensitivity of 68.1% and a specificity of 75.0%. ROC- analysis showed that the difference between the standard mode (Az- value 0.694) and the inverse mode (Az- value 0.810) was significant in favour of the inverse presentation mode (p=0.001). This finding was especially observed in more experienced radiologist (Az- values 0.716 vs. 0.909, P<0.001). CONCLUSION: Our study demonstrates a significant advantage of the inverse mode in the detection of small pulmonary nodules compared with the commonly used negative mode when interpreted by more experienced radiologists. ADVANCE IN KNOWLEDGE: Inverse intensity images ("bones black") may have some advantages in the detection of small pulmonary nodules in experienced readers when presented on a stand-alone display.

Functional and morphological imaging of extraadrenal myelolipoma.

Myelolipoma is a rare, hormonally inactive, benign tumor consisting of fat and hematopoietic cells. It is often encountered in the adrenal gland. Less frequently, it may occur in extraadrenal sites. Although myelolipoma is well defined by criteria of morphologic imaging, functional characteristics may be crucial to exclude malignancy.We present a case of histologically proven extraadrenal myelolipoma which was successfully diagnosed by bone marrow scintigraphy, using a monoclonal antibody directed against myeloid elements.

Stone-containing periampullary duodenal duplication cyst with aberrant pancreatic duct.

This case report describes a unique variant of a duodenal duplication cyst in an 8-year-old boy who had recurrent episodes of upper abdominal pain. Imaging revealed a stone-containing cyst near the biliaropancreatic ducts and concomitant hydrops of the gallbladder. Open transduodenal marsupialization of the cyst and resection of the inflamed gallbladder were performed. Further episodes of pancreatitis did not occur for a follow-up of 2 years.

Diagnostic value of proton MR spectroscopy in peripheral arterial occlusive disease: a prospective evaluation.

OBJECTIVE: The objective of the present study was to determine the detectability of metabolic alterations in patients with peripheral arterial occlusive disease (PAOD) using proton MR spectroscopy (hydrogen-1 MR spectroscopy). SUBJECTS AND METHODS: Twenty-seven people were included in this study: 10 patients with PAOD and a pain-free walking distance of less than 200 m served as the patient group and 17 young healthy subjects served as a control group. Hydrogen-1 MR spectroscopy was performed on a 1.5-T scanner using an extremity coil and a point-resolved spectroscopy (PRESS) sequence (TR/TE, 1,500/30; 256 repetitions). For the patient group, a voxel was localized in the gastrocnemius muscle of the diseased leg. The data were processed using standard 1H MR spectroscopy tools. The identification of resonances detected on all MR spectra was made: intramyocellular lipids at 1.2 ppm, extramyocellular lipids at 1.6 ppm, lactate at 4.1 ppm, glucose with two main peaks at 3.4 and 3.8 ppm, choline at 3.2 ppm, and creatine at 3.0 and 3.9 ppm. To avoid operator bias, three spectral intensities were measured after correcting baseline and phase of MR spectra each time. The creatine signal was used as an internal reference; thus, all spectra were scaled relative to creatine. We compared the resultant intensity ratios between the two groups using the Mann-Whitney U test. RESULTS: The lactate-creatine quotient was higher in the patient group, with a ratio of 1.6, than in the control group, with a ratio of 0.6. The glutamate-creatine ratio was higher in the patient group than in the control group (1.3 vs 0.8, respectively). All other ratios were higher in the control group. The best ratio for differentiating between healthy subjects and patients with PAOD was the glucose-lactate ratio. The patient group had a glucose-lactate quotient of 5.4, whereas the control group had a glucose-lactate quotient of 21.5 (p = 0.001). CONCLUSION: Proton MR spectroscopy has the potential to allow identification of patients who have PAOD on the basis of altered muscle metabolism.

Multi-detector CT in the evaluation of patients with recurrence of rectal cancer.

The advantages of multiplanar reconstruction in rectal cancer recurrence diagnostics using medium resolution multi-detector CT are evaluated. We included 40 patients after a rectal cancer operation in this study. During follow-up ten patients developed a recurrence. All patients received a minimum of two CT-examinations in their follow-up program. A total of 131 CT-scans were evaluated. Each examination was reviewed by two experienced radiologists in respect to recurrence. Each examination was presented in axial reconstruction with a slice thickness of 8mm with an increment of 7 mm and a slice thickness of 3 mm with an increment of 2 mm. The thin slices were used for the multi-planar reconstruction. Multi-planar reconstructions showed better results for the detection of recurrence than axial reconstruction. A reduced slice thickness did not lead to better results in axial reconstruction. Multi-planar reconstruction showed a sensitivity of 0.88, a specificity of 1.0 and an accuracy of 0.97. Our axial reconstruction results were: 0.86, 0.96, and 0.93, respectively. Sensitivity and accuracy showed a significant increase after the first and second examinations. Multi-planar reconstructions allow for better detection of rectal cancer recurrence when compared to axial reconstructions. Thinner axial slice thickness shows no diagnostic advantage.

Multislice computed tomography angiography of the abdominal arteries: comparison between computed tomography angiography and digital subtraction angiography findings in 52 cases.

Since the introduction of multislice CT scanners, CT angiography (CTA) has become a powerful tool for imaging the vascular system. We compare conventional angiography to CTA in the diagnosis of morphological changes in the abdominal aorta and its branches. A retrospective analysis of 52 patients who underwent both multislice CT angiography (MSCTA) and digital subtraction angiography before surgical treatment is presented. All CT examinations were performed after administration of 100 mL contrast medium with a collimation of 4 x 1 mm and a pitch of 7. A standardized evaluation of the axial, multiplanar and 3D reconstructions was performed by two experienced radiologists. Stenoses were classified as high-grade and low-grade, and aneurysms, occlusions and arteriosclerosis were evaluated. The CTA findings were compared with conventional angiography. All aneurysms, occlusions, stenoses and calcifications were diagnosed correctly by CTA in axial and multiplanar projections (sensitivity 1.0; specificity 1.0). The degree of stenosis was overestimated in three cases when using axial projections. Three-dimensional volume-rendered CTA showed a sensitivity of 0.91 for aneurysms, 0.82 for stenoses, 0.75 for occlusions and 0.77 for calcifications. The specificity was 1.0 in all cases. Multislice CT angiography seems to be similar to conventional digital subtraction angiography for abdominal vessels if multiplanar projections are used.

Magnetic resonance imaging of bone marrow metastasis with fluid-fluid levels from small cell neuroendocrine carcinoma of the urinary bladder.

Fluid-fluid levels have been reported as an extremely infrequent and non-specific condition in many benign and malignant bone lesions. We present the first reported MRI findings of bone marrow metastasis with fluid-fluid levels from small cell neuroendocrine carcinoma of the urinary bladder to the lumbar spine. Radiologists should be aware of the MRI appearance of these extraordinary lesions in order to provide a complete differential diagnosis and to guide clinicians in adequate treatment.

CT fluoroscopy-assisted puncture of thoracic and abdominal masses: a randomized trial.

PURPOSE: We investigated the benefit of real-time guidance of interventional punctures by means of computed tomography fluoroscopy (CTF) compared with the conventional sequential acquisition guidance. MATERIAL AND METHODS: In a prospective randomized trial, 75 patients underwent either CTF-guided (group A, n = 50) or sequential CT-guided (group B, n = 25) punctures of thoracic (n = 29) or abdominal (n = 46) masses. CTF was performed on the CT machine (Somatom Plus 4 Power, Siemens Corp., Forchheim, Germany) equipped with the C.A.R.E. Vision application (tube voltage 120 kV, tube current 50 mA, rotational time 0.75 s, slice thickness 10 mm, 8 frames/s). RESULTS: The average procedure time showed a statistically significant difference between the two study groups (group A: 564 s, group B 795 s, P = 0.0032). The mean total mAs was 7089 mAs for the CTF and 4856 mAs for the sequential image-guided intervention, respectively. The sensitivity was 71% specificity 100% positive predictive value 100% and negative predictive value 60% for the CTF-guided puncture, and 68, 100, 100 and 50% for sequential CT, respectively. CONCLUSION: CTF guidance realizes a time-saving but increases the radiation exposure dosage.