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Brachytherapy consists of placing radioactive sources into or adjacent to tumors, to deliver conformal radiation treatment. The technique is used for treatment of primary malignancies and for salvage in recurrent disease. Permanent prostate brachytherapy seeds are small metal implants containing radioactive sources of I-125, Pd-103, or Cs-131 encased in a titanium shell. They can embolize through the venous system to the lungs or heart and subsequently be detected by cardiovascular computed tomography. Cardiovascular imagers should be aware of the appearance of migrated seeds, as their presence in the chest is generally benign, so that unnecessary worry and testing are avoided. We report a case of a patient who underwent brachytherapy for prostate cancer and developed a therapeutic seeds embolus to the right ventricle.

Anhaltendes Fieber und unspezifische Allgemeinsymptome fordern eine grundliche Anamnese und Infektionssuche. Wir berichten uber eine Amobiasis mit Leberabszessen bei einem 26-jahrigen Patienten. Der Patient hatte sich zuvor uber mehrere Wochen in Indien und Sudamerika aufgehalten. Nach einem beschwerdefreien Intervall von 4 Monaten stellten sich unspezifische Allgemeinsymptome und Fieber ein. Bei nachgewiesenen Leberabszessen erfolgte eine Kombinationstherapie. Hierunter wurde der Patient beschwerdefrei und konnte nach 12-tagigem Klinikaufenthalt entlassen werden.

Die akute Cholezystitis ist die haufigste Komplikation der Cholezystolithiasis und zahlt mit gut 64.000 stationar behandelten Patienten pro Jahr zu den relevanten chirurgischen Krankheitsbildern. Sie kann mild verlaufen, aber auch lebensbedrohliche Formen annehmen, wovon v. a. alte und vorerkrankte Patienten betroffen sind. Eine Komplikationsform ist die Gallenblasenperforation, die uberwiegend erst intraoperativ augenscheinlich wird. Als klassische Trias der akuten Cholezystitis konnen plotzlich einsetzender Oberbauchschmerz, Fieber und Leukozytose bezeichnet werden. Der klinische Verdacht lasst sich meist durch eine Sonographie bestatigen.

Purpose: The objective of the study was to determine whether the various breast biopsy procedures specified in the S3 guidelines are sensibly represented within the current German health system as considered from a cost evaluation perspective. Materials and Methods: This prospectively designed multicenter study analyzed 221 breast biopsies at 7 institutions from 04/2006 to 01/2007. Core needle biopsies, vacuum-assisted biopsies and surgical open biopsies under sonographic or mammographic guidance were evaluated. During an analysis of process costs, the individual process steps were recorded in diagrammatic form and assigned to the true consumption of resources. The actual resource consumption costs were entered. A process-related breakeven analysis was conducted to check whether the reimbursement of individual biopsy types covers the costs. Results: Only sonographically guided core needle biopsy and surgical open biopsy are adequately reimbursed in the current German health system. All other breast biopsies indicate a negative profit margin. The principal reasons for underfunding are found in the area of reimbursement of investment and non-personnel costs. Conclusion: The reimbursement of breast biopsies must be improved in order to guarantee nationwide care of the population using the breast biopsy methods recommended in the S3 guidelines and to avoid disincentives with respect to breast biopsy indications.

Die endovaskulare Therapie des infrarenalen Bauchaortenaneurysmas hat sich als Alternative zur offenen chirurgischen Versorgung etabliert. Im Gegensatz zu Letzterer ist die Aneurysmatherapie mittels Stent-Grafts auch bei schwerkranken, nicht operationsfahigen Patienten moglich, wobei der Nutzen kontrovers diskutiert wird. Im Gegensatz zur klassischen transabdominellen Operation ist die Stent-Graft-Technik anatomischen Einschrankungen unterworfen, die aber kunftig aufgrund bereits abzusehender technischer Weiterentwicklungen eine geringere Rolle spielen werden. Die Diagnostik, die Entscheidung fur eine endovaskulare Therapie, die prainterventionelle Planung und die Nachsorge erfordern den Einsatz bildgebender Verfahren, v. a. der Computer- und Magnetresonanztomographie sowie der Sonographie. Die fur die endovaskulare Aneurysmabehandlung relevanten Aspekte der Diagnostik werden dargestellt. Auf die Technik, die Materialien, die Ergebnisse und die Komplikationen der Stent-Graft-Behandlung wird ausfuhrlich eingegangen.

HISTORY AND ADMISSION FINDINGS Severe pain and increasing swelling in the region of the right lower leg occurred after unaccustomed physical activity in a 29-year-old man. Physical examination showed painful swelling and livid discoloration of the right lower leg. INVESTIGATIONS Laboratory tests were consistent with an acute inflammation. Colour Doppler duplex sonography of the leg and pelvic veins bilaterally revealed complete thrombosis of the deep leg and pelvic veins on the right. Spiral computed tomography of the abdomen confirmed deep pelvic vein thrombosis and also demonstrated complete agenesis of the inferior vena cava (IVC). TREATMENT AND COURSE The patient was fully heparinized and compression bandage applied to the right leg, which was kept elevated, Ibuprofen, 3 x 400 mg daily, was given for pain relief. Anticoagulation treatment with phenprocoumon (Marcumar) was initiated. The patient was discharged much improved after ten days. Duplex sonography after 3 months demonstrated partial recanalization of the right pelvic and deep leg veins. CONCLUSION Congenital malformations of the IVC are rare. Phlebothrombosis often results in affected patients. Treatment or prevention of thrombosis of the deep veins by anticoagulation is indicated. Additional risk factors for thrombosis--smoking, hormonal contraceptives, immobilization and unusual physical activity--should be strictly avoided.

Two hundred and sixty-four shunt segments in 43 patients with 66 dialysis shunts were examined by colour-coded duplex sonography and the results compared with DSA. Sonography demonstrated shunt stenoses with an accuracy of 93.9% (sensitivity 90.6%, specificity 95.8%). Only central venous stenoses were shown better by DSA than by sonography. Sonography showed occlusions with a sensitivity of 83.3% and a specificity of 100%. All aneurysms demonstrated by DSA were correctly identified by sonography. In 18 patients PTA of the shunt was performed. The result of treatment could be quantified by measuring flow by means of sonography. The study confirmed the value of duplex sonography as a noninvasive diagnostic method for investigating insufficient dialysis shunts.

Diseases of the aorta are imaged using different modalities according to the cause and clinical situation. Current imaging strategies for the clinically most pertinent aortic diseases are analysed. These disease entities may be differentiated into congenital, acquired and inflammatory diseases. Traumatic and non-traumatic aortic aneurysms and dissections are emphasised in context with endovascular treatment options and subsequent follow-up.

Appropriate placement of an inferior vena cava (IVC) filter necessitates imaging of the renal veins because when an IVC filter is deployed its tip should be at or below the inferior aspect of the inferiormost renal vein. Traditionally, imaging during placement of IVC filters has been with conventional cavography and fluoroscopy. Recently, intravascular ultrasound has been used for the same purpose but with additional expense. Morbidly obese patients often exceed the weight limit of fluoroscopy tables. In addition, short obese patients are at risk of falling from narrow fluoroscopy tables. For such patients, computed tomography (CT) guidance is a viable alternative to conventional fluoroscopic guidance. IVC placement was performed in the CT suite for two obese patients who exceeded the weight limits of the available fluoroscopy tables. In one case, a Vena-Tech filter (Braun Medical, Melsungen, Germany) was placed using CT fluoroscopy. In the second case, a Recovery (Bard, Murray Hill, NJ) filter was placed using intermittent limited z -axis scanning. In the first case, the filter was placed below the level of the renal veins and above the confluence of the iliac veins, which is acceptable placement. In the second case, with refinement of technique, the filter tip was placed less than 1 cm below the inferiormost renal vein, which is considered optimal placement. CT of the IVC precisely images the renal veins and can characterize their number and their confluence with the IVC. CT guidance is a viable alternative to fluoroscopic guidance for the placement of IVC filters in morbidly obese patients.

Clinical radiology is a key to the management of bowel obstruction. Plain abdominal radiographs combined with history, clinical exam, and laboratory findings are essential for further individualized strategies. If the cause of obstruction is obvious after plain films and there is a need for emergent surgery, no further imaging is required. In all other cases, multislice CT with at least intravenous and rectal contrast is the method of choice due to its broad diagnostic spectrum. If CT is not available, contrast enema is recommended in suspected large bowel obstruction. Oral administration of water-soluble contrast agents has no significant value in the workup of bowel obstruction.

We investigated the impact of elevated donor serum sodium levels on outcome after heart transplantation in 336 consecutive heart transplantations. Mean donor serum sodium was 148.2 ± 10.2 mmol/liter (range 116 to 180 mmol/liter). Recipients were divided into 4 groups with serum sodium levels of 141, 147 and 155 mmol/liter, resulting in sodium levels of: 133 ± 6.1 mmol/liter for Quartile A; 144 ± 4.2 mmol/liter for Quartile B; 151 ± 4.3 mmol/liter for Quartile C; and 162 ± 6.6 mmol/liter for Quartile D, respectively (mean ± standard deviation). Mean occurrence of primary graft failure (PGF) was 3.6% with the following quartile breakdown: A, 3.6%; B, 4.8%; C, 3.6%; and D, 2.4% (p = non-significant [NS]). Mean 5-year survival was 81.32% with: A, 83.51%; B, 76.03%; C, 80.47%; and D, 85.25% (p = NS). Coronary allograft vasculopathy (CAV) occurred in 19% of patients with a quartile breakdown of: A, 16.5%; B, 21%; C, 20%; and D, 14.5% (p = NS). No impact of donor serum sodium levels was seen on early post-operative results or on long-term outcome, indicating that cardiac allografts from donors with elevated sodium levels may be transplanted successfully with favorable results.

Since two decades transarterial chemoembolization (TACE) of liver metastases has been investigated in numerous studies. However, no standardized therapeutic procedure exists so far. The present study retrospectively investigated survival, response and side effects after TACE of liver metastases in 21 patients with colorectal cancer and results are compared with previous literature. A total of 68 TACE procedures were performed. A suspension of degradable starch microspheres (DSM, Spherex) and Mitomycin C was applied selectively into hepatic arteries via a transfemoral approach. DSM effect a temporary arterial occlusion. Follow-up studies were performed by contrast enhanced spiral computed tomography (CT). The median survival was 13.8 months. Therapeutic response (according to WHO) was observed only in three patients. The progression free interval was 5.8 months. Patients developed a postembolization-syndrome (abdominal pain, fever, nausea) and increased transaminases in 27-43% of all interventions. A gastric ulcer occurred after four, cholecystitis after two TACE. As already shown in most previous studies, regardless of the used agents, also this investigation underlines the moderate therapeutic effect of TACE on colorectal liver metastases. So far, no significant survival benefit has been shown in the literature and the response rates are rather limited. In general, complications of TACE seem to be rare, but should not to be underestimated. Compared to TACE with long or permanent arterial occlusion, postembolization syndrome seems to be less pronounced using DSM. As TACE is rather a palliative therapeutic approach, DSM therefore might be more suited. Further studies on TACE of liver metastases should focus on to the patients' quality of life.

Background Rhinorrhea from common colds or allergies in children is similar to that in adults, yet there are few data on the use of ipratropium bromide nasal spray in children younger than 5 years. Objective To evaluate the safety and efficacy of 0.06% ipratropium bromide nasal spray in 2- to 5-year-old children with rhinorrhea from a common cold or allergies. Methods A total of 230 children (43 with common colds and 187 with allergies) participated in an open-label, multicenter study. Patients with a common cold received ipratropium bromide nasal spray (84 μg per nostril) 3 times daily for 4 days; those with allergies received ipratropium bromide nasal spray (42 μg per nostril) 3 times daily for 14 days. Results In the common cold and allergy groups, 91% and 90% of the parents, respectively, found that ipratropium bromide was either "very useful" or "somewhat useful." Furthermore, 67% and 91% of parents in the common cold and allergy groups, respectively, found that administration of a nasal spray was either "extremely easy" or "very easy." Symptom scores were improved from baseline in both groups. The nasal spray was well tolerated and was not associated with serious or systemic anticholinergic adverse effects. Most adverse events were infrequent and mild to moderate, and study discontinuation due to an adverse event occurred in less than 3% of patients. Conclusions The 0.06% ipratropium bromide nasal spray, 42 or 84 μg per nostril 3 times daily, is easy to administer, safe, and effective for the control of rhinorrhea in children aged 2 to 5 years with a common cold or allergies.

Background The aim of this single-center study was to investigate whether trough level adjusted mycophenolate mofetil (MMF) is more efficacious in combination with tacrolimus (TAC) or cyclosporine (CsA) and to evaluate the impact of either drug on MMF dosage. Methods Sixty patients (TAC, n = 30; CsA, n = 30) undergoing heart transplantation were randomized into a prospective, open-label, controlled trial. Immunosuppression consisted of TAC or CsA in combination with MMF and corticosteroids. Target blood trough levels of TAC, CsA, and mycophenolic acid (MPA) were in the range of 10 to 15 ng/mL, 100 to 300 ng/mL, and 1.5 to 4.0 microg/mL, respectively. Acute rejection episodes (ARE); survival data; and adverse events with a special emphasis on infections, diabetes, hypertension, hypercholesterolemia, and the development of graft vessel disease (GVD) were recorded. Results Baseline characteristics were well balanced. All patients were successfully withdrawn from corticosteroids within 6 months of transplant. Freedom from acute rejection was significantly higher (P = 0.0001) and the incidence of ARE per 100 patient days significantly lower in the TAC-MMF group than in the CsA-MMF group (0.03 vs. 0.15; P = 0.00007). Overall patient survival during follow-up was similar (93% vs. 90%). To achieve the targeted MPA blood levels, a significantly lower dose of MMF was required for TAC versus CsA patients. After a follow-up time of 2 years, the mean GVD score was 1.85 +/- 3.18 in the TAC-MMF group and 3.95 +/- 4.8 in the CsA-MMF group (P = 0.08). Conclusions At the selected doses and target levels for TAC and CsA used in this study, trough level adjusted MMF was more efficacious in combination with TAC for prevention of ARE. Furthermore, CsA patients need significantly more MMF to achieve similar MPA levels.

The impact of sirolimus on hormone levels involved in the hypothalamus-pituitary-gonad axis in male heart transplant recipients was investigated. A pair-matched analysis with 132 male heart transplant recipients on either sirolimus based- or calcineurin inhibitor-based immunosuppression was performed. Matching criteria were age, years after transplantation and creatinine levels. Measured parameters were testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), sexual hormone-binding globulin (SHBG) and free androgen index (FAI). Mean testosterone was 3.86 +/- 1.41 ng/mL in the sirolimus group and 4.55 +/- 1.94 ng/mL in the controls (p = 0.025). Serum LH was 12.82 +/- 11.19 mlU/mL in the sirolimus patients and 6.2 +/- 5.25 mlU/mL in the controls (p = 0.015). Follicle stimulating hormone levels were 13.31 +/- 18.4 mlU/mL vs. 7.32 +/- 5.53 mlU/mL, respectively (p = 0.015). The analysis revealed a significant decrease in testosterone and a significant increase in FSH and LH in the sirolimus group. The duration of sirolimus treatment correlated positively with SHBG (p < 0.01), LH (p < 0.05) and FSH (p < 0.05) and negative with the FAI (p < 0.05). Sirolimus trough levels correlated with LH and FSH levels (p < 0.01). Heart transplant recipients treated with sirolimus revealed significantly lower testosterone levels and a significant increase in gonadotropic hormones. These effects were trough-level dependent. All candidates awaiting organ transplantation should be informed about these adverse effects.

Objective: Calcineurin inhibitor (CNI)-related renal failure is a common problem after cardiac transplantation (HTx). The aim of this prospective study was to evaluate the safety and efficacy of a completely CNI-free immunosuppressive regimen [mycophenolate mofetil (MMF) and sirolimus (Sir)] in HTx-recipients with late post-transplant renal impairment. Methods: Since 2001, 30 HTx-patients (25 men, 6 women; 0.2-14.2 years after transplantation) with CNI-based immunosuppression and a serum creatinine > 1.9 mg/dl were included in the study. Creatinine and cystatin levels were monitored to detect renal function. Conversion was started with 6 mg Sir or 500 mg MMF according to the pre-existing regimen and was continued with the dose adjusted to achieve target trough levels between 8 and 14 ng/ml (Sir) or 1.5 and 4 μg/ml (mycophenolate). Subsequently, the CNIs were tapered down and stopped. Clinical follow-up included endomyocardial biopsies, echocardiography and laboratory studies. Additionally, every HTx-patient treated at our centre between 1996 and 2001 due to chronic renal failure without immunosuppressive conversion and fulfilling the inclusion criteria were retrospectively analysed and acted as control group. Results: Patient demographics and 1-year survival [93 (conversion) vs 90% (control)] were compared. No acute rejection episode was detected in either group. Renal function improved significantly in the conversion group (creatinine: 3.18 ± 0.71 vs 2.22 ± 0.79 mg/dl, P = 0.001; cystatin pre- vs post-conversion: 2.95 ± 1.06 vs 2.02 ± 1.1 mg/l, P = 0.01). In three patients haemodialysis therapy was stopped completely after conversion. In the control group renal impairment was deteriorating, creatinine increased from 2.44 ± 0.8 to 3.28 ± 1 mg/dl (P = 0.01). In 10 out of 33 patients chronic haemodialysis had to be initiated within 1 year. Although side effects of CNI-free immunosuppression were common (76%), no patient had to be excluded due to adverse effects. Conclusions: Conversion from CNI-based immunosuppression to MMF and Sir in HTx-patients with chronic renal failure was safe, preserved graft function and improved renal function.

Fatal leucoencephalopathy is a rare calcineurin inhibitor-related complication, especially in kidney and liver transplant recipients. The only means of clinical management reported so far is the discontinuation or reduction in the calcineurin inhibitor. We herein report a case of a 37-yr-old male who developed leucoencephalopathy 12 wk after heart transplantation and recovered after stabilization of metabolism and arterial blood pressure. The findings in this case support the hypothesis that tacrolimus-associated neurotoxicity is severely increased by an impairment of the blood-brain barrier. Withdrawal of tacrolimus was not necessary while other causes of endothelial injury were treated successfully.

Objective: Arterial revascularization with either internal thoracic artery (ITA) or radial artery (RA) appears to be particularly attractive in diabetic patients. Previous investigations have shown that endothelial dysfunction and artherosclerosis are seen more often in these patients. The aim of this study was to compare the vasoreactive properties of ITA and RA grafts in diabetic and non-diabetic patients. Methods: Arterial rings were harvested from 57 patients who underwent complete arterial revascularization. The patients were divided into a nondiabetic group (I: na 30) and patients with diabetes mellitus (II: na 27). Arterial rings of the ITA (I: na 30; II: na 27) and RA (I: na 28; II: na 19) were mounted on a strain gauge in oxygenated, normothermic Krebs’s‐Henseleit solution at optimal resting tension. With KCL (80 mM) serving as the control, assessment of force of contraction (norepinephrine), endothelium-dependent relaxation (acetylcholine) and smooth muscle-dependent relaxation (glyceroltrinitrate) were obtained. Results: After KCL, the RA showed a trend to lower maximum contraction forces in diabetics (I: 76 ^ 25 mN; II: 69 ^ 29 mN), which was pronounced in patients with diabetes of more than 10 years duration (55 ^ 23 mN; Pa 0:1). Maximum contraction force of the ITA was similar in both groups (I: 41 ^ 20 mN; II: 34 ^ 19 mN) and not influenced by the duration of diabetes. The two groups showed no significant differences of the relative vasoconstriction after norepinephrine in RA (I: 53 ^ 18%; II: 61 ^ 19%) and ITA rings (I: 70 ^ 23%; II: 69 ^ 25%). Also, endothelium-dependent relaxation with acetylcholine in RA (I: 53 ^ 14%; II: 57 ^ 16%) and ITA rings (I: 42 ^ 17%; II: 44 ^ 20%), and smooth muscle relaxation with glyceroltrinitrate of RA (I: 72 ^ 8%; II: 73 ^ 12%) and ITA rings (I: 64 ^ 12%; II: 58 ^ 20%) was comparable in both groups. No influence of duration of the diabetic disease was noted. Conclusions: Although RA rings of patients with a long duration of diabetes have decreased maximum contraction forces, their relative vasoconstriction after norepinephrine, endothelium-dependent relaxation and smooth muscle relaxation was similar to non-diabetic patients. We thus conclude that the RA is an adequate arterial conduit in the patient with diabetes mellitus. q 2001 Elsevier Science B.V. All rights reserved.

systems. An in vitro study. Purpose: Comparative evaluation of specimens obtained with different MR-compatible biopsy systems and a conventional ferromagnetic system. Methods: Biopsies of a pig liver were performed post-mortem with three different MR-compatible (Somatex; E-Z-EM; Daum) and one conventional biopsy system (Somatex), five with each device. The specimens were measured and the histopathological quality was graded on a scale from 0 (no tissue) to 9 (best). The tip of the needle was examined with an electron microscope before and after biopsy to demonstrate abrasion. Results: The histopathological score between the first and fifth specimen taken with one biopsy device showed no significant difference. The conventional system yielded significantly better results in nearly all categories (p

Ziel: Kleine, malignomverdachtige, nur mit der MRT nachweisbare Befunde der Mamma werden innerhalb dieser Studie MR-gesteuert mit einem Draht markiert, damit sie bei der anschliesenden Operation gewebesparend entfernt und histologisch geklart werden konnten. Wir berichten uber unsere ersten Erfahrungen. Methode: Praoperativ wurde bei allen Patientinnen mit einer kommerziell erhaltlichen Halterung der verdachtige Befund MR-gesteuert (bei 1,0 und 1,5 T, Philips Gyroscan NT) mit einem Hakendraht markiert und anschliesend operiert. Ergebnisse: Insgesamt wurden bei 19 Patientinnen 22 Befunde markiert. Bei einer Patientin war in der Kontrolluntersuchung der Herd nicht entfernt. Nach einer zweiten Markierung gelang die Entfernung des Herdes. Die Markierung dauerte im Mittel 66 ± 20 min (Minimum 38 min, Maximum 119 min). Bei zwei Frauen wurden zwei Herde markiert. Die Spitze des Hakendrahtes lag in der Abschlusskontrolle im Mittel 2,0 ± 2,6 mm vom verdachtigen Befund. 6 von 22 Lasionen erwiesen sich als maligne. Die Grose der Lasionen betrug im Mittel 7,6 ± 2,6 mm (Spannweite 3 mm - 14 mm). Schlussfolgerung: Malignomverdachtige Lasionen der Mamma, die nur in der MRT nachweisbar sind, konnen sicher MR-gesteuert markiert werden. Purpose: Small suspicious breast lesions that are only visible at MR imaging were preoperatively marked with a hook wire under MR-guidance to allow the removal of the lesion with tissue-sparing surgery. Method: In all patients the suspicious lesions were marked preoperatively under MR guidance with a hook wire using a commercially available stereotactic device. Interventions were performed with MR guidance on a 1.0 T and on a 1.5 T system. Results: In 19 patients 22 lesions were localized. One lesion was missed and removed in a second procedure. The mean duration for localization was 66 ± 20 min (range 38 - 119 min). In two patients two lesions were localized. The mean deviation of the wire tip to the lesion was 2,0 ± 2,6 mm. In this series, 6 of 22 lesions were malignant. The mean diameter of the lesion was 7.6 ± 2,6 mm (range 3 - 14 mm). Conclusion: Suspicious breast lesions detectable only in MR imaging can be accurately localized with a hook wire preoperatively under MR control to remove the lesion with a tissue-saving surgery.

Purpose: To compare magnetic resonance imaging (MRI) and X-ray tomography in assessing the type of fracture, degree of comminution and amount of articular surface depression in acute tibial condylar fractures and to describe the associated soft tissue injuries diagnosed with MRI. Method: 27 patients with acute tibial plateau fractures were investigated using linear X-ray tomography and MRI employing T 1 -weighted and proton density turbo spin echo, STIR, and T 2 -weighted gradient echo images. Fractures were classified according to the AO c'lassification system. The degrees of depression and comminution were measured and soft tissue injuries were recorded. Results: Fractures were classified as type B1 in 7, as B2 in 6, and as B3 in 6 cases by MRI. More complex C-type fractures were diagnosed in 8 cases. MR and X-ray grading were consistent with the exception of two B3 fractures, which were graded as B1 by X-ray tomography. X-ray tomography under-estimated the degree of comminution 63% of the patients had either meniscal tears or complete ruptures of their cruciate or collateral ligaments. Ten meniscal tears were diagnosed in 9 of 27 patients. Complete tears of the anterior cruciate ligament were seen in 4, and avulsions of the posterior cruciate ligament in 2 patients. Conclusion: MRI allows a detailed assessment of acute tibial plateau fractures and can replace conventional X-ray tomography. The high rate of fracture-associated soft tissue lesions makes MRI an especially valuable tool.

Recurrent parotitis is rare in childhood. Its occurrence is characterized by recurrent episodes of swelling and pain in the parotid gland, which are usually accompanied by fever and malaise. Inflammation usually resolves spontaneously during adolescence. The disorder is a condition of unknown etiology. Sialectasis and stricturing occurs in the distal ducts, whereas inflammation of the gland and duct epithelium is probably caused by a low salivary flow rate. Which one can be considered the primary event or secondary change remains unknown. The main-stay of diagnosis is sialography, which depicts typical intraparotidal duct system lesions as strictures or ectasias and excludes sialolithiasis. We here report two 10-year-old male monovular twins who suffered from recurrent swelling and pain in only their left parotid glands. Symptoms were noted approximately every 6 weeks in both patients strictly. Characteristic sialectasis of the distal ducts was demonstrated by magnetic resonance-sialography. Our findings support the hypothesis that recurrent parotitis is caused by a congenital abnormality of the salivary gland ducts. Diagnostic imaging was performed by magnetic resonance imaging during the acute phase of the disease. This technique helps to make the diagnosis without retrograde application of a contrast agent.

Beim Auftreten einer Cholangitis nach Hepaticojejunostomie ist die haufigste Ursache eine Stenose der biliodigestiven Anastomose. Die vorliegende Kasuistik beschreibt die Krankengeschichte eines Patienten, bei dem eine Hepaticojejunostomie infolge einer Gallengangsverletzung bei Mirizzi-Syndrom angelegt worden war, und der postoperativ unter rezidivierenden Cholangitiden litt. Die praoperative bildgebende Diagnostik zeigte eine Stenose der biliodigestiven Anastomose und eine massiv erweiterte Roux-Schlinge, so das zusatzlich der Verdacht auf eine Stenose dieser Schlinge im Mesocolonschlitz bestand. Intraoperativ fand sich jedoch eine anisoperistaltisch angeschlossene Roux-Schlinge. Diese Konstellation sollte als seltene Ursache rezidivierender Cholangitiden nach Hepaticojejunostomie differentialdiagnostisch berucksichtigt werden.

An anatomic study of the lateral extraosseous and intraosseous arterial supply of the calcaneus and the lateral soft tissue was carried out on 10 fresh lower adult cadaver legs using different anatomic and radiologic procedures (plastination, modified Spalteholz clearing technique, digital subtraction and rotational angiography and computed tomographic angiography). Consistent patterns of extraosseous and intraosseous lateral calcaneal vascular anatomy were demonstrated. The lateral calcaneal artery is a branch of the anterior tibial artery which crosses over the calcaneal tuberosity and forms a large lateral arch with the lateral tarsal artery which is a branch of the dorsalis pedis artery. The intraosseous circulation is supplied laterally by the lateral calcanear artery, medially via the short branches of the lateral plantar artery. Comparing magnet resonance images after fresh calcaneal fractures the lateral calcanear artery may be interrupted by the impacted lateral bulge, by the conventional lateral surgical approach, or by applying a lateral osteosynthesis plate. This may cause avascular bone necrosis. Furthermore the lateral calcanear artery can clinically serve as a vascular pedicle for a local rotational skin flap to cover soft tissue defects of the heel.

Study objective To determine the efficacy of IV immunoglobulin (IVIg) in severe asthma to reduce steroid requirements. Design Pre- and posttreatment measurements were analyzed using Dunnett's multiple comparison procedure. Setting Hospital clinical research center. Patients Eleven adolescents and adults with severe, steroid-dependent asthma enrolled over a 14-month period. Interventions IVIg was administered at a dose of 2 g/kg every 4 weeks for a total of seven infusions. Measurements and results Steroid requirements, pulmonary function including lung volumes, symptom scores, bone densitometry, and airway reactivity monitored by methacholine challenge were followed over the course of 7 months. A significant decrease in steroid usage was achieved. Despite substantial steroid reduction, the patients demonstrated improvement in their pulmonary function and symptom scores. The responses to methacholine challenge were unaffected by IVIg treatment. Conclusions IVIg provides a potentially important adjunctive therapy in severe asthma, reducing oral steroid requirements and steroid side effects without deterioration of lung function.

The purpose of this review is to describe recent advances in non-invasive vascular imaging techniques and to discuss their current clinical applications for imaging of peripheral vessels. Principles for applying ultrasound, CT angiography (CTA), and magnetic resonance angiography (MRA) for non-invasive imaging of peripheral arteries and veins are presented. Clinical applications are reviewed for different vascular diseases, therapy planning, and follow-up studies. Conventional Doppler and color duplex sonography are the most cost-effective procedures to detect or rule out peripheral arterial occlusive disease (PAOD) and to provide specific recommendations for therapy. In the near future, contrast-enhanced MRA (CE MRA) with additional axial two-dimensional time-of-flight studies to search for non-anatomic runoff will replace diagnostic intra-arterial digital subtraction angiography (DSA) for planning of reconstructive surgery with acquisition slabs displaying projections similar to intra-arterial DSA. Color duplex sonography should also be the first non-invasive technique applied for the detection of peripheral aneurysms. Preoperative or preinterventional therapy planning of aneurysms may be performed by CTA or CE MRA. Compression ultrasound is the imaging procedure of choice in deep venous thrombosis (DVT). In the preoperative assessment of venous incompetence, color duplex sonography is the imaging technique which is sufficient in most cases.

In addition to generalized arteriosclerosis, connective tissue diseases, systemic necrotic arteritis, large-vessel vasculitis, and genetic metabolic diseases have been described as the cause of stenotic and aneurysmal vessel wall alterations. Although unusual, these must be considered in the diagnosis of a generalized vascular disease with arterial occlusion and aneurysm formation in order to determine the appropriate treatment procedure for the individual patient. Operative treatment should be avoided as long as possible for patients with Behçet's disease or Marfan's syndrome but is indicated for any kind of juvenile arteriosclerosis combined with arterial stenosis and dilatation. The patient described in this case report could be successfully treated surgically even though the cause of juvenile arteriosclerosis was inexplicable, and the local complications accompa nying the threatening rupture of the aneurysm could be controlled.

BACKGROUND: Glucocorticoids are important medications used to control the airway inflammation associated with asthma. Synthetic glucocorticoids vary in their binding affinity for the glucocorticoid receptor (GCR). METHODS: We compared hydrocortisone, beclomethasone dipropionate, triamcinolone acetonide, flunisolide, and budesonide with regard to their capacity to inhibit phytohemagglutinin-induced peripheral blood mononuclear cell proliferation from six patients with steroid-sensitive asthma and seven patients with steroid-resistant asthma. Peripheral blood mononuclear cell GCR binding affinities for dexamethasone and budesonide were also determined for both patient groups by using a radioligand binding assay and Scatchard analysis. RESULTS: Dose-dependent inhibition was demonstrated for all glucocorticoids in both patient groups, with the steroid-resistant group requiring approximately 2 log-fold more glucocorticoids for an equivalent degree of inhibition. The mean concentrations necessary to cause 50% inhibition of lymphocyte proliferation (IC 50 s) for the steroid-sensitive group ranged from 2 × 10 -10 mol/L for budesonide to 7 × 10 -8 mol/L for hydrocortisone, whereas the mean IC 50 s for the steroid-resistant group ranged from approximately 2 × 10 -8 mol/L for budesonide to greater than 10 -6 mol/L for hydrocortisone. In addition, a significant correlation was noted between the degree of inhibition of lymphocyte proliferation (IC 50 ) and the binding affinity of dexamethasone to the GCR. Patients with steroid-resistant asthma have been shown to have a reduced GCR binding affinity. The GCR binding affinity for budesonide was significantly higher in both groups (i.e., lower dissociation constant) than that obtained for dexamethasone. CONCLUSION: These data suggest that glucocorticoids such as budesonide, by virtue of their high GCR binding affinities and greater ability to suppress lymphocyte proliferation, may therefore be beneficial in the management of difficult-to-control asthma. (J Allergy Clin Immunol 1996;98:1073-9.)

PURPOSE: To evaluate the value of rapid T2-weighted turbo-spin sequences (TSE), turbo-spin-echo sequences with shortened echo spacing (UTSE), gradient-and-spin-echo sequences (GraSE) and T1-weighted echo-planar imaging (EPI) in comparison with conventional spin-echo sequences (SE) in the diagnosis of focal liver lesions. METHODS: 20 patients with malignant focal liver lesions underwent magnetic resonance imaging at 1.0 tesla. RESULTS: The use of fast T2-sequences (TSE, UTSE, GraSE) reduced the examination time to about 35-50%. Artifacts were reduced compared with the conventional T2-SE sequence. Quantitative analysis demonstrated that UTSE imaging had the highest tumor/liver contrast-to-noise ratio (CNR) followed by TSE, T2-SE and GraSE sequences. CNR with EPI was lower than with the T1-SE sequence (p < 0.05). CONCLUSION: Turbo-spin-echo sequences with shortened echo spacing yield a shorter imaging time and improved image quality without loss of signal intensity in tumor/liver-CNR, compared with conventional T2-pulse sequences in liver imaging at 1.OT.

Summary A fundamental feature of asthma is abnormal airway function, now recognized to result from both acute and chronic inflammatory changes. Central to the development of these inflammatory changes may be the activation of T cells and the release of pro-inflammatory cytokines. In the skin, a similar cascade of events may underlie the pathogenesis of atopic dermatitis. Asthma and atopic dermatitis often share several features that may be important in their pathogenesis: T-cell infiltration of the tissues, elevated IgE levels, and a history of known triggers associated with positive immediate skin-test reactions. In both diseases administration of intravenou immune globulin (IVIG) on a regular basis appears to reduce the need for systemic corticosteroids, reduce symptoms and for asthmatics, reduce hospitalization costs. Although the mechanism of action of IVIG in these disorders remams to be defined, it may be exhibiting significant anti-inflammatory activity. IVIG may be a potent alternative in the treatment of severe, steroid-dependent allergic disorders, reducing steroid dependency.

31P magnetic resonance spectroscopy (MRS) was used to study an open therapeutic trial of coenzyme Q10 (CoQ) in mitochondrial encephalomyopathies. Eight patients were treated with 150 mg CoQ per day for 6 months. 31P MRS spectra of calf muscle were recorded at rest, during exercise and in the immediate postexercise recovery period. Although there was an improvement of the mean ratio of phosphocreatine (PCr) to inorganic phosphate during the post-exercise recovery period after 3 months of treatment, this finding was mainly due to a single therapy responder and did not reflect a beneficial effect on the whole group. Improved repletion of PCr persisted after 6 months of therapy. Our study identified a single responder to this therapy, whose response could not be predicted on the basis of clinical, biochemical or molecular data. These findings suggest that therapeutic trials of CoQ should be performed under close metabolic monitoring in order both to identify responders for subsequent long-term treatment and to evaluate possible mechanisms of this supportive therapy.

Glucocorticoids are used in the treatment of inflammatory diseases, including asthma. Their efficacy and incumbent profile of adverse effects are well established. On occasion, practitioners encounter asthmatic patients who are difficult to control despite standard glucocorticoid therapy. These individuals may present with persistent nocturnal symptoms, exercise intolerance, peak flow variability and spirometric evidence of poor control. Many of these patients demonstrate an apparent resistance to standard and even aggressive glucocorticoid interventions. Consequently, these patients continue to experience severe airway disease and, often, also experience concurrent adverse effects of therapy.

PURPOSE To determine the value of standard chest radiographs in the assessment of cardiac size. METHODS In 193 patients cardiac size was compared between standard chest radiographs in the posteroanterior and lateral projection and left ventricular angiograms. The following parameters were determined: transverse diameter, lateral horizontal transverse diameter, cardiothoracic ratio and end-diastolic volume index (EDVI) and ejection fraction (EF). RESULTS Subjective assessment of the left ventricular size resulted in a mean sensitivity/specificity/accuracy of 69.7%/87.4%/82.0% respectively, in comparison to EDVI. Estimation of global heart size yielded a mean sensitivity/specificity/accuracy of 48.8%/93.6%/77.8%, respectively, in comparison to EF. Cardiothoracic ratio for the detection of pathological EDVI or EF had a sensitivity of 77.3%/57.4% a specificity of 79.3%/80.8% and an accuracy of 78.9%/72.5%. CONCLUSIONS Standard chest radiographs with the determination of cardiothoracic ratio remain a clinically relevant procedure for screening and follow-up of heart disease.

A case of a tornado victim with a delayed presentation of injury to the aortic isthmus is discussed. Tornado forces resemble the forces of high energy explosions, and the injuries that can occur as a result of these forces can be bizarre. The patient presented with the unique computed tomography (CT) findings of isolated pseudoaneurysm of the thoracic aorta in the absence of other traumatic injury to the thorax. Equivocal results of the initial CT aortogram (CTA) were confirmed with ECG-synchronized CTA (ECG-CTA), demonstrating the superiority of ECG-CTA as compared to standard CTA.

A prospective study extending over 4 months was carried out in which 142 shunt volume flow measurements were performed on 43 patients; two up to four operators with varying degrees of experience took part. Flow volumes varied between 51 and 2409 ml/min with an average blood flow volume of 521 ml/min. Comparison of measurements of individual operators showed errors of between 0.5 and 19.8%. Average error was calculated as 11.3%. Shunt flow measurements by colour Doppler sonography provide an easily appreciated and reproducible method for quantifying changes in shunt flow.

The effect of section alignment and distance in volumetric determination of myocardial mass by means of cardiac magnetic resonance imaging (MRI) was studied in 19 isolated pig hearts. Double angulated views taken through the short axis of the heart with a slice thickness of 10 mm and slices at a distance of 0 mm, 1 mm, 3 mm and 5 mm produced accurate left ventricular measurements with cardiac MRI. Measurements in the long axis of the heart resulted in a marked underestimation of myocardial mass; depending on slice intervals, there was an error between 13% and 20%. In vivo measurements in 35 subjects confirmed the effect of section alignment. Measurements in the long axis of the heart produced results of 139.9 +/- 31.7 g, significantly less than measurements in the short axis of the heart of 157.8 +/- 32.3 g.

MRT with gadolinium-DTPA (0.1 mmol/kg body weight) was performed in 10 patients with renal insufficiency requiring dialysis and the clearance of gadolinium-DTPA was studied. After 3 dialysis on 3 successive days more than 97% of the initial concentration of gadolinium-DTPA had been eliminated. Average half-life was 1.87 hours. There were no side effects in any of the patients. Close laboratory observation of liver function showed no significant changes during the period of study. No contra-indication for the use of this contrast medium in patients with renal insufficiency requiring dialysis was found during this study.

In a prospective study DSA sialography, conventional sialography (100mm technique) and sonography of the salivary glands were performed in 124 patients. The results of imaging could be correlated with those of operation and/or histology in 70 patients. Performing sialography in only one projection DSA sialography is superior to the conventional technique. The results of DSA are equivalent to those of conventional sialography in more than one projection. DSA sialography is the method of choice demonstrating salivary calculi, whereas sonography is superior to DSA sialography in the detection of tumors. In the diagnosis of chronic inflammation of the salivary glands DSA is slightly superior to the other imaging modalities.

Chest examinations were carried out in 60 individuals using film-screen and digital storage phosphor techniques and identical radiation doses. 29 of these individuals were patients with interstitial pulmonary disease; 31 were normals. Postprocessing of the digital images was carried out with filtering using an unsharp mask and identical parameters for all patients. An ROC analysis using 10 observers showed no significant difference in the evaluation of the interstitial lung disease. Correlation analysis showed a significant positive correlation (p less than 0.001) for the findings in both techniques. Under the present circumstances, film-screen and digital storage phosphor technique are of equal value in the diagnosis of interstitial pulmonary disease.

31P-magnetic resonance (MR) spectra of the heart can be obtained from well-defined myocardial regions by combined MR imaging and variable selected volumes for spectroscopy. 31P-spectra of 33 volunteers and of 43 patients with dilated and hypertrophic cardiomyopathy and with coronary artery disease were quantified using a curve-fitting routine. To optimize our technique, we recorded unsaturated and partially saturated spectra in several volunteers. Relative peak areas and signal-to-noise ratios showed significant changes with varying pulse repetition times. Saturation factors were applied to correct spectra from volunteers and patients for the effects of partial saturation. Under resting conditions, peak areas of volunteers and patients from the various groups were statistically indistinct.

The findings of color Doppler flow imaging of the extracranial cerebral arteries in 75 patients were compared with i.a. DSA. Carotid stenoses greater than 50% and carotid occlusions were shown by sonography with a sensitivity of 91% and a specificity of 97%. The severity of the stenosis was in agreement in 88% of cases using the two methods. Sonography of the vertebral arteries achieved a sensitivity of only 65% and a specificity of 88%. Sonographic examination of the ophthalmic artery in order to demonstrate carotid stenosis achieved a sensitivity of only 29% and provided no additional information. Retrobulbar kinking of the ophthalmic artery was found in 30/178 vessels and may be a cause of misinterpretation.

In a retrospective study over two years, the costs of 2909 CCDS examinations were compared with 1893 digital subtraction angiograms. The cost of each CCDS examination was calculated as 147 DM and each DSA examination with intra-arterial contrast medium, or for shunt angiography was 709 DM. By using CCDS, it was possible to reduce the cost of angiographic examinations by 177,000 DM per year.

The accuracy of quantifying the degree of vascular stenosis with color Doppler flow imaging (7.5-MHz, linear array system) was determined in an experimental study carried out on six concentric and five eccentric model stenoses (cross-sectional area reduction, 13.4%-93.8%). The measurements were made with use of pulsatile flow at four different flow rates (70.8-339.0 mL/min). The degree of stenosis was calculated from the ratio of prestenotic to intrastenotic flow velocity. The most exact measurement of the degree of stenosis could be achieved with Doppler spectral analysis by determining the maximum peak systolic velocity (r = .994, y = 0.98x - 3.2). With the velocity values derived only from the color-coded image, it was also possible to find the most exact degree of stenosis (r = .995, y = 0.99x - 2.9). For quantification of stenosis, pre- and intrastenotic Doppler spectral analysis is no longer necessary if the stenosis can be imaged sufficiently with color Doppler.

On 10 dialysis patients we performed 12 balloon dilatations, 2 catheter lyses, 6 stent implants (Palmaz stent) and one atherectomy of central venous stenoses or occlusions (v. subclavia, v. brachiocephalica) at the shunt arm of the patient. The primary success rate was, in balloon PTA and lysis, 12/14 interventions, and in stent placement and atherectomy 7/7. The angiographical and clinical primary result after stent implantation was significantly better than after conventional dilatation. After 66% of the balloon dilatations recidivation occurred within the first year; this can be treated by means of repeated PTA. Whether long-term exclusion of recurrence can be achieved by stent implantation, must be established by means of follow-up studies that are at present in progress.

In a retrospective study angiographic image material of percutaneous direct portographies carried out in 43 patients was evaluated according to anatomic and radiologic criteria. These examinations were performed for therapeutic purposes (embolisation of vessels supplying varices). All the hepatofugally perfused veins were analyzed according to their localisation and course. Apart from the known portocaval collateral pathways a number of other collaterals not yet described could be documented by means of angiography.

Forty hands of 39 patients with rheumatic joint disease were examined by MRT. The method differentiates between inflammatory exudative and proliferative processes in soft tissues and bone. T2-weighted images provided criteria for judging the activity of the disease. MRT provided better demonstration of the soft tissues than just conventional radiography. The methods were of equal value for showing bone lesions. MRT is suitable as a means of diagnosing rheumatoid changes in the hand.

The value of color-coded duplex sonography in the pelvic and lower limb arteries was studied prospectively in 52 patients and the findings were compared with intra-arterial DSA. There was high diagnostic accuracy (sensitivity 91.7%, specificity 98.9%) for the demonstration of vascular abnormalities. In 84.3% of cases a correct diagnosis could be obtained based entirely, or largely, on the color-coded signal. Both before and after PTA color-coded duplex sonography is a non-invasive method that is superior to conventional duplex sonography.