A prospective study on MRI findings and prognostic factors in athletes with MTSS.

In medial tibial stress syndrome (MTSS) bone marrow and periosteal edema of the tibia on the magnetic resonance imaging (MRI) is frequently reported. The relationship between these MRI findings and recovery has not been previously studied. This prospective study describes MRI findings of 52 athletes with MTSS. Baseline characteristics were recorded and recovery was related to these parameters and MRI findings to examine for prognostic factors. Results showed that 43.5% of the symptomatic legs showed bone marrow or periosteal edema. Absence of periosteal and bone marrow edema on MRI was associated with longer recovery (P = 0.033 and P = 0.013). A clinical scoring system for sports activity (SARS score) was significantly higher in the presence of bone marrow edema (P = 0.027). When clinical scoring systems (SARS score and the Lower Extremity Functional Scale) were combined in a model, time to recovery could be predicted substantially (explaining 54% of variance, P = 0.006). In conclusion, in athletes with MTSS, bone marrow or periosteal edema is seen on MRI in 43,5% of the symptomatic legs. Furthermore, periosteal and bone marrow edema on MRI and clinical scoring systems are prognostic factors. Future studies should focus on MRI findings in symptomatic MTSS and compare these with a matched control group.

Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial.

BACKGROUND: We evaluated whether performing contrast-enhanced breast MRI in addition to mammography and/or ultrasound in patients with nonpalpable suspicious breast lesions improves breast cancer management. METHODS: The MONET - study (MR mammography of nonpalpable breast tumours) is a randomised controlled trial in patients with a nonpalpable BIRADS 3-5 lesion. Patients were randomly assigned to receive routine medical care, including mammography, ultrasound and lesion sampling by large core needle biopsy or additional MRI preceding biopsy. Patients with cancer were referred for surgery. Primary end-point was the rate of additional surgical procedures (re-excisions and conversion to mastectomy) in patients with a nonpalpable breast cancer. FINDINGS: Four hundred and eighteen patients were randomised, 207 patients were allocated to MRI, and 211 patients to the control group. In the MRI group 74 patients had 83 malignant lesions, compared to 75 patients with 80 malignant lesions in the control group. The primary breast conserving surgery (BCS) rate was similar in both groups; 68% in the MRI group versus 66% in the control group. The number of re-excisions performed because of positive resection margins after primary BCS was increased in the MRI group; 18/53 (34%) patients in the MRI group versus 6/50 (12%) in the control group (p=0.008). The number of conversions to mastectomy did not differ significantly between groups. Overall, the rate of an additional surgical intervention (BCS and mastectomy combined) after initial breast conserving surgery was 24/53 (45%) in the MRI group versus 14/50 (28%) in the control group (p=0.069). INTERPRETATION: Addition of MRI to routine clinical care in patients with nonpalpable breast cancer was paradoxically associated with an increased re-excision rate. Breast MRI should not be used routinely for preoperative work-up of patients with nonpalpable breast cancer.

Ultrasound-guided laser-induced thermal therapy for small palpable invasive breast carcinomas: a feasibility study.

BACKGROUND: The next step in breast-conserving surgery for small breast carcinomas could be local ablation. In this study, the feasibility of ultrasound-guided laser-induced thermal therapy (LITT) is evaluated. METHODS: Patients with large-core needle biopsy-proven invasive, palpable breast carcinoma (clinically or=2 cm in size (P = .026). CONCLUSIONS: Successful LITT of invasive breast cancer seems to be feasible when confined to small (<2 cm) nonlobular carcinomas without surrounding extensive in-situ component and angioinvasion. However, to implement LITT in a curative setting, improvements in imaging to more reliably preoperatively assess tumor size and monitoring of fiber tip placement and treatment affect are essential.

Contrast-enhanced 3.0-T breast MRI for characterization of breast lesions: increased specificity by using vascular maps.

PURPOSE: To assess the diagnostic accuracy of contrast-enhanced 3.0-T breast magnetic resonance imaging (MRI) for differentiating benign from malignant breast masses and subsequently to test if specificity could be further improved by scoring of the overall ipsilateral breast vascularity. MATERIALS AND METHODS: Fifty-four patients were prospectively enrolled in the study and underwent contrast-enhanced 3.0-T breast MRI. MR images were evaluated and classified according to the MRI BI-RADS lexicon criteria. Lesion size, number of lesions, and localization in the breast were systematically assessed. Maximum intensity projections (MIPS) were obtained by using high-resolution contrast-enhanced (0.1 mmol/kg gadobutrol) fat-saturated T1-weighted images. Breast vascularization was scored according to the methods from Sardanelli et al. by measuring the number, diameter, and length of the vessels on the MIPS. The score ranged from 0 (indicating absent or low breast vascularity) to 3 (indicating high breast vascularity). RESULTS: Final analysis of 56 lesions revealed 25 (45%) malignant lesions and 31 (55%) benign lesions. Correlation with the MRI BI-RADS classification revealed cancer in none (0%) of the BI-RADS II lesions, in 1 (12%) of the BI-RADS III lesions, in 5 (83%) of the BI-RADS IV lesions, and in 19 (100%) of the BI-RADS V lesions. Based on morphologic and kinetic data analysis, the sensitivity and specificity of 3.0-T breast MRI was 100% (25/25) and 74% (23/31), respectively. After adjustment for the breast vascularity score, specificity significantly (p = 0.048) increased to 87% (27/31) without affecting sensitivity. CONCLUSION: Diagnostic accuracy of contrast-enhanced 3.0-T breast MRI increased significantly when the vascularity score was added to the standard morphologic and kinetic data analysis, resulting in a specificity of 87% without affecting sensitivity, which remained 100%.

[Three patients with indinavir-related urolithiasis]. / Drie patiënten met urolithiasis als bijwerking van behandeling met indinavir.

Three HIV-seropositive patients were diagnosed with urolithiasis related to the use of indinavir. The first patient was a 45-year-old white male with severe haemophilia who presented with fever and flank pain referred to the glans penis. Ultrasound and intravenous pyelography (IVP) revealed a concrement in the left renal pelvis. Discontinuation of indinavir and acidification of the urine did not reduce the stone load. Percutaneous nephrolithotripsy was then performed. The second patient, a 41-year-old white male, presented at the emergency ward with flank pain and fever. Ultrasound examination showed dilatation of the left kidney. A percutaneous nephrostomy catheter was inserted. Antegrade contrast imaging showed a concrement in the proximal ureter. The patient underwent extracorporeal shock wave lithotripsy. A second antegrade image made a few days later showed no evidence of stone material. The third patient was a 56-year-old white male with a previous history of indinavir-associated urolithiasis. He presented at the emergency ward with flank pain and haematuria. A CT urography showed dilatation of the right kidney and distal portion of the right ureter with no evidence of concrement. The symptoms resolved after a percutaneous nephrostomy catheter was inserted and the antiviral medication was modified. The catheter was removed 2 weeks later. At last follow-up, none ofthe 3 patients had symptoms of urolithiasis. These cases illustrate that, although conservative therapy for indinavir-related urolithiasis can be sufficient, minimally invasive endourological surgery is sometimes necessary.

Accuracy of contrast-enhanced breast ultrasound for pre-operative tumor size assessment in patients diagnosed with invasive ductal carcinoma of the breast.

Our aim was to assess the feasibility and accuracy of contrast-enhanced ultrasound (CEUS) of the breast with SonoVue microbubbles for pre-operative size measurement of invasive breast carcinomas. Seven patients diagnosed with nine invasive breast carcinomas prospectively underwent gray-scale ultrasound and CEUS of the breast according to a standardized protocol. CEUS of the breast was performed by a Philips iU22 scanner equipped with a 4-8 MHz linear array transducer. We used a single dose of 2.4 ml SonoVue as contrast agent. Breast lesion morphology was scored according to the sonographic BI-RADS lexicon criteria and classified accordingly. The greatest tumor dimensions on gray-scale ultrasound and CEUS of the breast were finally compared with the greatest histopathologic tumor sizes. Gray-scale ultrasound underestimated the histopathologic tumor size in 6/9 cases (67%), whereas CEUS of the breast underestimated tumor size in only 3/9 (33%) cases. CEUS of the breast was significantly more accurate for tumor size assessment. Greatest tumor dimension as measured with gray-scale ultrasound of the breast was within 2 mm of the pathologic tumor size in only 2/9 cases (22%), whereas CEUS of the breast accurately assessed tumor size within 2 mm of pathologic tumor size in 6/9 (67%) of the cases (P<0.05). CEUS of the breast proved to be a feasible and safe procedure. It is more accurate than gray-scale ultrasound of the breast for pre-operative size assessment of invasive ductal breast carcinomas.

[A long-distance runner with a painful sesamoid bone in the forefoot]. / Een duurloper met een pijnlijk sesambeentje in de voorvoet.

A 38-year-old long-distance runner presented with pain in the left medial forefoot. In the presence of such symptoms, consideration should be given to a disease of or injury to a sesamoid bone. Radiology revealed a fracture line through the medial sesamoid bone under the first metatarsophalangeal joint. Conservative treatment was initially ineffective. Ultimately, local injections of lidocaine-methylprednisolone at the site of the pain, in the metatarsophalangeal joint and in the fracture line brought relief. In the diagnosis of patients with pain in the medial forefoot, apart from the patient's history and a physical examination, a skyline X-ray can be helpful to reveal a fractured or bipartite sesamoid. Almost all conditions affecting the sesamoids improve in the long run with conservative treatment. Besides reduction of weight-bearing pressure on the affected sesamoid, NSAIDs and ice massage, special attention should be paid to the foot (postural deformities), the shoe (inlays, sesamoid pad, shock absorption, stiff sole) and running on a soft surface. Insufficient therapeutic results may be due to osteonecrosis or non-union. These and persistent pain may, as a last resort, require surgical intervention such as screw fixation in case of a fracture or sesamoidectomy.

[Testicular torsion can also be present in adult men]. / Torsio testis ook mogelijk bij volwassen mannen.

Five adult men, aged 34, 33, 31, 56 and 52 years respectively, were admitted with acute scrotal pain. Testicular torsion was eventually diagnosed in all the patients. Two of the patients were initially treated with antibiotics due to a suspected epididymitis. One of them required orchidectomy due to necrosis. The remaining patients underwent orchidofixation and their testicles could be preserved. The most important different diagnosis for acute pain and swelling of the testicle is either acute epididymitis or testicular torsion. The latter is uncommon in adult men. Using a physical examination to distinguish epididymitis from testicular torsion can be difficult. Doppler ultrasound is a reliable diagnostic tool for confirming testicular ischaemia. If the intratesticular flow is diminished or absent, then testicular torsion should be considered and this should be followed by immediate surgical exploration.

A pressor effect of noncardioselective beta-blockers in mildly hypertensive patients during acute hospitalization.

Pressor effects of noncardioselective beta-blockers have been demonstrated in situations of increased sympathetic activity; however, data are limited and the clinical significance of this finding is in doubt. The present study was performed to supply data about the effect of noncardioselective beta-blockers on the stress of acute hospitalization. Of 2,989 patients acutely admitted to a 50-bed unit of general internal medicine in a 647-bed teaching hospital, 234 had used beta-blockers without intrinsic sympathicomimetic activity (ISA) for at least six weeks because of mild hypertension; 199 were evaluable, 56 using nonselective, 143 using selective beta-blockers. The authors found a marked pressor effect of noncardioselective beta-blockers as compared with selective (mean arterial pressure 125 versus 102 mm Hg, p less than 0.001). In the patients who could continue their outpatient medication this effect could be attributed to an overall increase of total peripheral resistance and disappeared within five days of admission. In the patients admitted because of unstable angina pectoris (nonselective n = 15, selective n = 48) myocardial oxygen demand as estimated by the double product (systolic blood pressure heart rate) was significantly higher in the nonselective group (12.926 versus 9.581 mmHg.beats/min, p less than 0.01). The present study supports the need for more controlled data to determine the ultimate place of noncardioselective beta-blockers in situations of increased sympathetic activity.

Effects of beta adrenergic receptor agonists and antagonists in diabetics with symptoms of postural hypotension: a double-blind, placebo-controlled study.

Eleven patients with hyperadrenergic diabetic postural hypotension and vagal neuropathy were treated in a double-blind, placebo-controlled study with different beta-agonists and antagonists. A single dose of the beta 2-agonist terbutaline (5 mg) and the beta 1 + 2-agonist orciprenaline (10 mg) did not reduce the fall in systolic pressure on standing up, despite a significant increase in both supine and standing heart rates. The beta 1-antagonist with intrinsic sympathicomimetic activity (ISA) acebutolol (200 mg) and the beta 1-antagonist metoprolol (50 mg) did not influence the fall in systolic pressure either, despite a significant decrease in supine and standing heart rates and disappearance of increase in heart rate on standing up. Only the beta 1 + 2-antagonist propranolol and the beta 1 + 2-antagonist with ISA pindolol (5 mg) could significantly reduce or practically abolish the fall in systolic and diastolic pressure on standing up. This was accompanied by a slight decrease of heart rates and disappearance of difference between supine and standing heart rates, as seen with the other beta-antagonists. Thus, only beta 2-blockade reduced or abolished the fall in systolic pressure on standing up in our patients. These data were confirmed by a three-week crossover trial in 10 of these patients.