[Radiologically guided interventional therapies for the treatment of neuroendocrine tumors]. / Radiologisch-interventionelle Möglichkeiten zur Behandlung von neuroendokrinen Tumoren.

BACKGROUND: The majority of patients with neuroendocrine tumors (NET) develop liver metastases during the course of the disease, significantly impacting prognosis and quality of life. CLINICAL ISSUE: Radiologically guided interventional therapies, such as thermal ablation, transarterial embolization (TAE)/chemoembolization (TACE), and selective internal radiotherapy (TARE), can play a crucial role in the treatment of metastatic NET. DATA: Due to the rarity of the disease, the majority of evidence is based on retrospective studies. For thermal ablation, the complete response rates ranging from 31.6 to 95.3% depending on the study. No significant differences in outcomes were found between TAE, TACE, and TARE. In several studies, all intra-arterial procedures led to a reduction of tumor-related symptoms and achieved disease control. CONCLUSION: Thermal ablation can be used as a curative therapy in oligometastatic patients with nonresectable liver metastases from NETs. In cases of disseminated liver metastases, intra-arterial therapy using TAE, TACE, or TARE can be employed.

[Lesions of the paravertebral mediastinum]. / Läsionen des paravertebralen Mediastinums.

BACKGROUND: Lesions of the paravertebral mediastinum are rare, and knowledge of possible differential diagnoses is essential for clinical practice. OBJECTIVE/METHODS: To review common lesions of the paravertebral mediastinum. RESULTS: The paravertebral mediastinum mainly includes fatty tissue and neurogenic structures. Imaging is commonly performed using computed tomography (CT) and magnetic resonance imaging (MRI). Neurogenic tumors are the most common lesions of the paravertebral mediastinum. Other pathologies include extramedullary hematopoiesis, lipomatous, lymphogenic, inflammatory, and cystic lesions. Moreover, also diaphragmatic hernias, vascular and esophageal pathologies may be found in the paravertebral mediastinum.

[Covered endovascular reconstruction of aortic bifurcation (CERAB)]. / Gecoverte endovaskuläre Rekonstruktion der Aortenbifurkation (CERAB).

BACKGROUND: Aortoiliac stenosis is common cause of peripheral arterial disease (PAD), which is particularly prevalent in older age (> 60 years) with a prevalence of 20%. In early stages (TASC [Trans-Atlantic Inter-Society Consensus] II A/B), these stenoses can be successfully treated by endovascular procedures. For more complex aortoiliac stenoses (TASC II C/D), open surgical treatment was the primary treatment in the past. CLINICAL ISSUE: Because of the advanced age and multiple comorbidities of PAD patients with complex aortoiliac stenoses, open surgical treatment is usually associated with high risk, and therefore endovascular procedures are an alternative despite their poorer outcome. Covered endovascular reconstruction of the aortic bifurcation (CERAB) aims to improve the primary patency rate compared with the usual endovascular implantation of kissing stents. DATA: With regard to the primary patency rate, open surgical treatment remains superior to both endovascular procedures; however, the CERAB technique shows a better 5­year outcome than the kissing stent technique. No differences are found in the secondary patency rate for any of the three procedures. The morbidity and mortality of the CERAB and kissing stent techniques are comparably low, and both procedures are superior to open surgical treatment. CONCLUSION: Because of the better long-term outcome of the CERAB versus the kissing stent technique, it should be used in patients with complex aortoiliac stenoses with increased risk of complications expected with open surgical treatment.

A direct access to heterobimetallic complexes by roll-over cyclometallation.

Complexes of the type [Cp*Ir(N,N')Cl]+ (N,N' = 2-(2-dialkylaminopyrimidin-4-yl)pyrimidine) can undergo roll-over cyclometallation leading to a novel N,N'-donor site. Following this strategy heterobimetallic complexes including iridium(iii) and a Group X metal centre in the oxidation state +II were achieved.

Clinical variability of neuroacanthocytosis syndromes-a series of six patients with long follow-up.

OBJECTIVE: To provide clinical clues to differential diagnosis in patients with chorea and other movement disorders with blood acanthocytes. METHODS: We present a long-term video accompanied follow-up of six Caucasian patients with neuroacanthocytosis from several centers, three diagnosed with chorea-acanthocytosis (ChAc): 34-y.o.(no.1), 36-y.o.(no.2), 43-y.o.(no.3), two diagnosed with McLeod Syndrome (MLS): 52-y.o.(no.4), 61-y.o.(no.5) and one 63-y.o.(no.6), a brother of no.5, with clinical suspicion of MLS. Additionally we report pathological findings of the mother of two brothers with MLS reported in our series with acanthocytes on peripheral blood smear RESULTS: The patients had an unremarkable family history and were asymptomatic until adulthood. Patients no. 1,2,4,5,6 developed generalized chorea and patient no. 3 had predominant bradykinesia. Patients no. 1,2,3 had phonic and motor tics, additionally patients no. 1 and 2 exhibited peculiar oromandibular dystonia with tongue thrusting. In patients no. 2 and 3 dystonic supination of feet was observed, patient no. 3 subsequently developed bilateral foot drop. Patients no. 2 and 4 had signs of muscle atrophy. Tendon reflexes were decreased or absent and electroneurography demonstrated sensorimotor neuropathy in patients no. 1,2,3,4,5, except no. 6. Generalized seizures were seen in patients no. 2,3,5,6 and myoclonic jerks in patient no. 1. Cognitive deterioration was reported in patients no. 1,2,3,5,6. Serum creatine kinase levels were elevated in all six patients. CONCLUSION: We highlight the variability of clinical presentation of neuroacanthocytosis syndromes and the long time from the onset to diagnosis with the need to screen the blood smears in uncertain cases, however, as in one of our cases acanthocytes may even be not found. Based on our observations and data from the literature we propose several red flags that should raise the suspicion of an NA syndrome in a patient with a movement disorder: severe orofacial dyskinesia with tongue and lip-biting (typical of ChAc), feeding dystonia, psychiatric and cognitive disturbances, seizures, peripheral neuropathy, elevation of creatine kinase, elevation of transaminases, hepatosplenomegaly, cardiomyopathy and arrhythmias, and an X-linked pattern of inheritance (McLeod Syndrome, MLS).

CT perfusion technique for assessment of early kidney allograft dysfunction: preliminary results.

OBJECTIVES: To assess the benefit of quantitative computed tomography (CT) perfusion for differentiating acute tubular necrosis (ATN) and acute rejection (AR) in kidney allografts. METHODS: Twenty-two patients with acute kidney allograft dysfunction caused by either AR (n = 6) or ATN (n = 16) were retrospectively included in the study. All patients initially underwent a multiphase CT angiography (CTA) protocol (12 phases, one phase every 3.5 s) covering the whole graft to exclude acute postoperative complications. Multiphase CT dataset and dedicated software were used to calculate renal blood flow. Renal biopsy or clinical course of disease served as the standard of reference. Mean effective radiation dose and mean amount of contrast media were calculated. RESULTS: Renal blood flow values were significantly lower (P = 0.001) in allografts undergoing AR (48.3 ± 21 ml/100 ml/min) compared with those with ATN (77.5 ± 21 ml/100 ml/min). No significant difference (P = 0.71) was observed regarding creatinine level with 5.65 ± 3.1 mg/dl in AR and 5.3 ± 1.9 mg/dl in ATN. The mean effective radiation dose of the CT perfusion protocol was 13.6 ± 5.2 mSv; the mean amount of contrast media applied was 34.5 ± 5.1 ml. All examinations were performed without complications. CONCLUSION: CT perfusion of kidney allografts may help to differentiate between ATN and rejection. KEY POINTS: • Quantitative CT perfusion of renal transplants is feasible. • CT perfusion could help to non-invasively differentiate AR from ATN. • CT perfusion might make some renal biopsies unnecessary.

Arterial wave intensity and ventricular-arterial coupling by vascular ultrasound: rationale and methods for the automated analysis of forwards and backwards running waves.

Wave intensity (WI) in the circulation is estimated noninvasively as the product of instantaneous changes in pressure and velocity. We recorded diameter as a surrogate for pressure, and velocity in the right common carotid artery using an Aloka SSD-5500 ultrasound scanner. We developed automated software, applying the water hammer equation to obtain local wave speed from the slope of a pressure/velocity loop during early systole to separate net WI into individual forwards and backwards-running waves. A quality index was developed to test for noisy data. The timing, duration, peak amplitude and net energy of separated WI components were measured in healthy subjects with a wide age range. Age and arterial stiffness were independent predictors of local wave speed, whereas backwards-travelling waves correlated more strongly with ventricular systolic function than with age-related changes in arterial stiffness. Separated WI offers detailed insight into ventricular-arterial interactions that may be useful for assessing the relative contributions of ventricular and vascular function to wave travel.

Is shared learning the way to bring UK neurology and psychiatry closer: what teachers, trainers and trainees think.

BACKGROUND: Rapid advances in brain sciences are challenging the validity of the traditional divide between neurology and psychiatry. The need for closer ties has been widely advocated. OBJECTIVE: To assess attitudes of neurologists and psychiatrists to closer links in general and to joint education in particular. METHODS: Postal questionnaire survey of trainees (SpRs) trainers (Members of Special Advisory Committees in Neurology and General and Old Age Psychiatry) and teachers (Undergraduate coordinators). Analysis based on 55 neurology and 50 psychiatry respondents. RESULTS: 5 general attitude questions on links showed most respondents "keen" on links and "unkeen" on current separation of disciplines. 15 topics possibly suitable for joint teaching were offered. 7 were rated between "keen" and very "keen" with maximum support for somatization, dementia, chronic pain and pharmacology. 7 were rated positively, only eating disorders was felt unsuitable. 6 options were offered for joint training opportunities. Trainees were keen on attending joint education, clinical and patient management sessions and outpatient clinics. Psychiatrists were even keener on links than neurologists with psychiatric SpRs significantly more in favour of certain items. CONCLUSIONS: The survey found widespread support from trainees, trainers and teachers for closer links. Trainees were keen to attend joint clinically focussed sessions. Psychiatrists tended to be keener that neurologists on links. This survey should encourage the establishment of closer educational links at all levels.

[Long term results after cochlear implantation in elderly patients]. / Langzeitergebnisse nach Cochlear-Implant-Versorgung älterer Patienten.

BACKGROUND: Cochlear implantation has become the method of choice for the treatment of deaf patients. A better technology of stimulation opened a wider field of patients suitable for cochlear implantation. Aim of the present study was to evaluate to which extent senior patients benefit by cochlear implantation. PATIENTS AND METHODS: 36 patients between 65 and 85 years were tested by the Freiburger speech test for monosyllabic words and by the HSM sentence test with and without noise. The results were compared to those of younger implanted patients (16 - 64 years, n = 101). RESULTS: The speech perception for monosyllabic words did not differ significantly between both groups. A maximum plateau in speech perception for monosyllabic words was reached after 2 years at 55 %. The HSM sentence test revealed significant differences in the increase of speech perception between senior and younger patients in the first post surgical year. After one year elderly patients reached the same perception score as younger patients with a maximum of approximately 80 % after 3 years. At a signal to noise ratio of 15 % younger patients achieved a maximal perception of 55 % after 1 year whereas senior patients needed 4 years to reach this level. CONCLUSIONS: Senior patients benefited by cochlear implantation to the same extent as younger patients did. Senior patients gained a similar speech perception level as younger implanted patients although the elderly needed more time to reach the same scores. Nevertheless, cochlear implantation should not be denied due to age alone.

"CADASIL coma": an underdiagnosed acute encephalopathy.

The main clinical features of CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy) are stroke, dementia, and migraine. A reversible acute encephalopathy was the principal presentation in six of 70 patients in a British prevalence study. The episodes lasted seven to 14 days, presenting with fever, acute confusion, coma, and fits; there was full recovery but in two cases identical episodes recurred some years later. All patients had a previous history of migraine with aura and were originally misdiagnosed as viral encephalitis. CADASIL should be considered in acute unexplained encephalopathies. MRI white matter changes, previous migraine with aura, and a family history of stroke and dementia may be useful pointers to the diagnosis.

[Cochlea implantation: results and costs, a review]. / Cochlea-Implantation: Ergebnisse und Kosten, eine Ubersicht.

The cochlear implantation, especially after bilateral operation provides a reliable and outstanding compensation in bilateral complete deafness or severe hearing impairment. Directional hearing can be restored with bilateral implantation so that warning signals are localized correctly and speech in noise is easier understood. Thus, rehabilitation is restored to a high degree. The involved expenses are severe, but are lower for the society when compared to the amount of money necessary to substitute a completely deaf patient lifelong.

[Evaluation of the demand for access to peridural obstetrical anesthesia in maternity units]. / Evaluation de la demande et de l'accès à la péridurale de travail dans une maternité de niveau III.

OBJECTIVES: This prospective study was initiated by a multicentric work. Each participating hospital, was asked to give data about 20 patients. Because of the importance of these informations for our practice, we decided to continue the evaluation, using the same inquiry, until 200 patients were enrolled. PATIENTS AND METHODS: An independent student (resident pharmacist), using a preprinted inquiry from interviewed two hundred consecutive in the, 48 hours after delivery in order to evaluate the following aspects: reasons to wish an epidural analgesia (EA) or not, modalities of achievement of EA. Statistical study: Chi-square and logistic regression. RESULTS: Among 199 analyzable files, 137 women wished for an EA (68.5%) but in only 90 the procedure was performed. Reasons for non-achievement of EA were the following: labour too advanced (43/47), obstetrical contraindication (2/47), anaesthesiologist non available (2/47). Delay between arrival at hospital and EA performance was 5 h 30 during daytime and 4 h 40 during nighttime. Delay and rate of EA achievement were not different between day and night time. Logistic regression analysis found following criteria related to: Wish for an EA analgesia: anaesthesiology consultation (OR = 193, p < 0.001), nulliparity (OR = 4, p < 0.002) and satisfactory information about EA (OR 35, p = 0.051). Achievement of EA: nulliparity (OR 38, p < 0.002), length of labour (OR = 1.01/min, p < 0.001). CONCLUSION: This study underlined the fact that one third of parturients do not wish for an epidural analgesia, mainly out of fear for neurological complications. When the obstetrician indicated an EA, our organisation allowed its achievement in 98% of cases. The latency between arrival and EA should be shortened.

Speech understanding in quiet and noise in bilateral users of the MED-EL COMBI 40/40+ cochlear implant system.

OBJECTIVE: The purpose of the study was to investigate speech understanding in quiet and noise in subjects bilaterally implanted with multi-channel cochlear implants. DESIGN: Nine adults bilaterally implanted with MED-EL implants were included in the study. The subjects were tested in three conditions: with both implants, with the right implant only, and with the left implant only. Speech tests included monosyllables in quiet and sentences in noise (10 dB signal to noise ratio). Speech was presented from the front, and noise was presented from either 90 degrees or 270 degrees azimuth. RESULTS: All subjects reported benefit from bilateral stimulation. Speech scores for all subjects were higher with bilateral than with unilateral stimulation. The average score across subjects for sentence understanding was 31.1 percentage points higher with both cochlear implants compared with the cochlear implant ipsilateral to the noise, and 10.7 percentage points higher with both cochlear implants compared with the cochlear implant contralateral to the noise. The average score for recognition of monosyllabic words was 18.7 percentage points higher with both cochlear implants than with one cochlear implant. All of these differences in average scores were significant at the 5% level. CONCLUSIONS: Bilateral cochlear implantation provides a significant benefit in speech understanding in both quiet and noise.

[The Würzburg Ear Forms: a system to document surgery and follow-up evaluation]. / Der Würzburger Ohrbogen: Ein System zur Dokumentation von Operationen und Nachsorgeuntersuchungen in der HNO-Heilkunde.

BACKGROUND: About a decade ago a PC based system to document surgery and follow up evaluation was installed. At that time the wide spread DOS systems provided only inputs via the keyboard. However, we believed that to assure the system would be accepted by the user, a graphical user interface would be necessary. Such an interface provides greater user-comfort and ensures the validity of entered data. METHODS: A simple graphical platform was installed, which provided all the necessary functions without being too complex. Several forms were designed for data collection. The first form implemented was designed for ear surgery. It comprises 356 items. The relevant data in the form are selected by a mouse click from possible alternatives. Although a large number of items are provided, it takes only one to two minutes to fill in the form. RESULTS: At present, September 2001, the database contains 10 453 records related to ear operations, 9633 preoperative audiograms and the results from 16 140 follow up evaluations. A special language and an interpreter for analyzing the data were added to complete the system. CONCLUSIONS: The large number of cases stored in the database allows data analysis with a high level of statistical confidence for any conclusions based upon the data. It also allows investigations of the simultaneous influence of a large number of variables on the results.

[The Würzburg questionnaire for assessing the quality of hearing in CI-children (WH-CIK)]. / Würzburger Fragebogen zur Hörqualität bei CI-Kindern (WH-CIK).

BACKGROUND: The goal of this study was to compare the auditory behaviour of bilaterally implanted children while using both CIs to their auditory behaviour during the time when they were using one CI. METHODS: For this purpose a questionnaire looking at different aspects of hearing such as hearing in background noise, in complex listening situations and directional hearing was developed. The questionnaire was completed by the parents of 28 bilaterally implanted children. They were instructed to state their judgement on the behaviour of their children. The parents scaled their judgements using a method of extended category scaling similar to that applied in the loudness scaling with the Würzburg hearing field (WHF). Each of the five verbal categories was subdivided into 10 numerical subdivisions, so that the parents were able to express judgements lying between the different categories. RESULTS: Eight out of eleven items showed that hearing with bilateral CIs was significantly better than with one CI (p < 0,003). The two items, which did not show a significant difference between the two conditions were those related to the interest in auditory rehabilitation and to aversion to noise. CONCLUSIONS: The questionnaire has proven to be a useful instrument to assess the quality of hearing in children. The possibility of bilateral implantation should be considered during the decision process prior to implantation.