Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a prospective randomized controlled trial.

AIMS: Among people with diabetes, 10-25% will experience a foot ulcer. Research has shown that supplementation with arginine, glutamine and ß-hydroxy-ß-methylbutyrate may improve wound repair. This study tested whether such supplementation would improve healing of foot ulcers in persons with diabetes. METHODS: Along with standard of care, 270 subjects received, in a double-blinded fashion, (twice per day) either arginine, glutamine and ß-hydroxy-ß-methylbutyrate or a control drink for 16 weeks. The proportion of subjects with total wound closure and time to complete healing was assessed. In a post-hoc analysis, the interaction of serum albumin or limb perfusion, as measured by ankle-brachial index, and supplementation on healing was investigated. RESULTS: Overall, there were no group differences in wound closure or time to wound healing at week 16. However, in subjects with an albumin level of ≤ 40 g/l and/or an ankle-brachial index of < 1.0, a significantly greater proportion of subjects in the arginine, glutamine and ß-hydroxy-ß-methylbutyrate group healed at week 16 compared with control subjects (P = 0.03 and 0.008, respectively). Those with low albumin or decreased limb perfusion in the supplementation group were 1.70 (95% CI 1.04-2.79) and 1.66 (95% CI 1.15-2.38) times more likely to heal. CONCLUSIONS: While no differences in healing were identified with supplementation in non-ischaemic patients or those with normal albumin, addition of arginine, glutamine and ß-hydroxy-ß-methylbutyrate as an adjunct to standard of care may improve healing of diabetic foot ulcers in patients with risk of poor limb perfusion and/or low albumin levels. Further investigation involving arginine, glutamine and ß-hydroxy-ß-methylbutyrate in these high-risk subgroups might prove clinically valuable.

In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection.

BACKGROUND: Portal vein embolization (PVE) has become a standard procedure to increase the future liver remnant (FLR) and enable curative resection of initially unresectable liver tumours. This study investigated the safety and feasibility of a new two-stage liver resection technique that uses in situ liver transection (ISLT) and portal vein ligation before completion hepatectomy. METHODS: A consecutive series of patients undergoing ISLT and extended right hepatectomy between 2009 and 2011 were compared with consecutive patients undergoing extended right hepatectomy after PVE. All patients had initially unresectable primary or secondary liver tumours, owing to an insufficient FLR (liver segments II/III). RESULTS: Fifteen patients who had PVE and seven who underwent ISLT before extended right hepatectomy were evaluated. ISLT induced rapid growth of the FLR within 3 days, particularly after insufficient PVE, from a mean(s.d.) of 293(58) ml to 477(85) ml, corresponding to a volume increase of 63(29) per cent. All patients who had ISLT underwent completion extended right hepatectomy within 8 days (range 4-8 days). CONCLUSION: ISLT is an effective and reliable technique to induce rapid growth of the FLR, even in patients with insufficient volume increase after PVE.

[Bilateral injuries of the internal mammary artery following blunt thoracic trauma]. / Bilaterale Verletzung der A. thoracica interna nach stumpfem Thoraxtrauma.

Injuries of the internal mammary artery after blunt thoracic trauma are rare but potentially fatal. A specific characteristic of these injuries is that they can become symptomatic even after a delay of several weeks. This article reports on the diagnosis and treatment of a 41-year-old motorcycle rider who suffered bilateral injuries of the internal mammary artery after a motorcycle accident without any additional bony lesions.

[Esophageal necrosis following endovascular treatment of a ruptured thoracal aortic aneurism: caused by mediastinal compartment syndrome]. / Osophagusnekrose nach endovaskulärer Versorgung eines rupturierten thorakalen Aortenaneurysmas : Folge eines mediastinalen Kompartments.

We report a case of acute esophageal necrosis after endovascular stenting for acute rupture of a thoracic aortic aneurysm into the mediastinum caused by mediastinal compartment syndrome and overstenting of intercostal arteries.

Diagnosis of colo-rectal cancer revealed by haemorrhagic complication of intraarterial thrombolysis.

Haemorrhage is a recognized complication of catheter-directed thrombolysis. We report one case of an afore unknown colo-rectal carcinoma, which was detected due to rectal bleeding following intraarterial thrombolysis. As reported with warfarin induced gastrointestinal bleeding complications, patients with unknown tumor developing rectal bleeding after thrombolysis procedure, should receive full diagnostic work-up of the gastrointestinal tract in order to exclude serious but potentially curable disease.

[Pulmonary embolism and deep vein thrombosis in the inferior vena cava affected by a rare anomaly]. / Embolisierende Thrombose bei Fehlbildung der V. cava inferior.

Persistent left-sided inferior vena cava (VCI) is a rare venous anomaly, its prevalence being estimated at 0.2-0.5%. Thrombotic occlusion of a VCI has been reported in only a few of these cases. We report the case of a 24-year old woman who suffered an acute thrombosis in a left-sided VCI and recurrent pulmonary embolism. After thrombectomy the course was uneventful. The diagnostic approach and the treatment strategy are discussed with reference to the literature.

In vivo morphometry of planum temporale asymmetry in first-episode schizophrenia.

Magnetic resonance imaging is a promising tool for in vivo analysis of the neuropathology underlying schizophrenia. One of the most consistent features emerging from the majority of published studies is the lateralization of pathological findings, and this has led to hypotheses of impaired hemispheric specialization in schizophrenia. In previous work, we have validated morphometry of supratemporal language-related cortex using high-resolution magnetic resonance imaging and analyzed the relation of the so defined planum temporale to functional parameters of hemispheric specialization. In the present study, we examined planum temporale structural asymmetry in first-episode schizophrenics. Asymmetry coefficients obtained in these patients did not differ significantly from those in equally right-handed controls and were not correlated to standard psychopathological measures. These data are contrasted with other studies reporting lateralized brain pathology in schizophrenia with special emphasis on methodological considerations in neuroimaging procedures.

Preoperative ECMO in congenital cyanotic heart disease using the AREC system.

BACKGROUND: In cyanotic congenital heart disease, oxygen delivery is impaired either by reduced pulmonary perfusion or by limited entry of oxygenated blood into the systemic circulation. Additional impairment of oxygen delivery (eg, in pulmonary hypertension) leads to hypoxic cerebral damage. Preoperative extracorporeal membrane oxygenation enables oxygenation in otherwise untreatable cases. METHODS: In 3 neonates suffering from cyanotic congenital heart disease (1 with tricuspid atresia and 2 with transposition of the great arteries) with arterial desaturation despite application of prostaglandins, balloon atrioseptostomy, and eventually inhaled nitric oxide during intermittent positive-pressure ventilation with an inspired oxygen fraction of 1, oxygenation could only be established by means of preoperative extracorporeal membrane oxygenation. We used a venovenous single-lumen cannula tidal-flow extracorporeal membrane oxygenation system described by Chevalier and associates that has previously been used for extracorporeal lung support. In this system, called AREC (assistence respiratoire extra-corporelle), alternating clamps and a nonocclusive roller pump were used. RESULTS: All 3 survived. CONCLUSIONS: We conclude that the AREC system enables sufficient preoperative oxygenation in patients with cyanotic congenital heart disease and hypoxia in spite of all conventional therapeutic means. This provides a stable preoperative condition for elective palliation or correction.

Scoring methods and application of the activity record (ACTRE) for patients with musculoskeletal disorders.

The National Institutes of Health (NIH) Activity Record (ACTRE) has been used to document daily activities in patients with musculoskeletal disorders. Quantification of the amount of time spent resting and physically active, the intensity of pain and fatigue associated with patterns of activities, and motivational considerations are possible with the ACTRE. Scoring has been streamlined to permit identification of the amount of pain, fatigue, and motivational factors as they relate to activity patterns (e.g., rest and physical activity). The ACTRE provides a performance-based, quantifiable measure of daily activity.

Validation of the NIH activity record: a quantitative measure of life activities.

This article reports the results of the validation of a life activity record. We devised a self-administered daily log (the NIH Activity Record, ACTRE), for persons with rheumatoid arthritis (RA), which recorded specific daily activities over a 24-hour period and identified the level of physical effort for each task. In addition, each activity was assigned a level of pain, fatigue, difficulty, competence, meaningfulness and enjoyment. Twenty-one persons with RA completed the log. They underwent an articular examination (AI) (Ritchie Articular Index) as well as completed the following self-reports: Psychosocial Adjustment to Illness Scale (PAIS); The Feeling Tone Checklist (FTC), a measure of fatigue; The Modified Health Assessment Questionnaire (ALI); and the Pain and Disability Index (PDI). Significant correlations were found between fatigue measured by ACTRE and FTC (p = 0.028); pain measured by ACTRE, PDI (p = 0.002), and (p = 0.01) and the visual analog scale in the ALI (p = 0.0002). Pain experienced while performing self-care measured by ACTRE correlated with AI (p = 0.001) and ALI (p = 0.0013). Difficulty with self-care activities on the ACTRE correlated with difficulty (p = 0.007) and pain (p = 0.012) on the ALI. The ACTRE is a valid measure of symptoms and perceptions that can be quantified, and is unique in that it identifies specific daily activities likely to produce them.

Variation of perisylvian and calcarine anatomic landmarks within stereotaxic proportional coordinates.

This investigation describes the variability in location of functionally important persylvian landmarks and of the calcarine sulcus within the Talairach stereotaxic grid, a system frequently used for cortical localization in functional images. Twenty healthy volunteers (40 hemispheres) had MR imaging under stereotaxic conditions. Outlines of the following structures were directly identified on sagittal 5-mm MR sections and marked on individual proportional grid overlays: inferior central sulcus, inferior precentral sulcus, inferior postcentral sulcus, anterior ascending ramus and posterior rami of the sylvian fissure, superior temporal sulcus, and calcarine sulcus. Maximal variation zones for these landmarks were defined by superimposition of the standardized individual data on a standard stereotaxic grid. The sulcal variation zones measured 1.5-2.0 cm. The findings indicate that macroanatomic individuality in the cerebral surface cannot be accounted for adequately by proportional coordinates, and that this method does not allow precise definition of anatomically based regions of interest for functional imaging. Instead, MR mapping of the individual sulcus pattern should be used to generate brain templates.

Intracranial stenoocclusive disease: double-detector helical CT angiography versus digital subtraction angiography.

BACKGROUND AND PURPOSE: To our knowledge, no large-scale studies comparing the accuracy of CT angiography (CTA) to intraarterial digital subtraction angiography (DSA) of intracranial stenosis have been reported. We attempted to determine the diagnostic value of intracranial CT angiography (CTA) of normal vasculature and variants as well as of stenoocclusive disease. METHODS: One-hundred and twelve patients underwent CTA and intraarterial angiography, and 2205 vascular segments were examined to ascertain presence, visibility, and degree of arterial stenoses (n = 105) as well as anatomic variants. Source, maximum intensity projection (MIP), and MIP-generated multiplanar reformatted (MPR) images were evaluated. RESULTS: All 55 anatomic variants were identified correctly. Visibility of small-vessel segments was increased from 75% to 83% by using source images. MPR was helpful in differentiating distal vertebral hypoplasia from stenosis and in overcoming artifacts. All 43 occlusive segments were graded correctly (sensitivity = 100%, predictive value = 93.4%) as follows: severely stenotic ([n = 23], sensitivity = 78%, predictive value = 81.8%); moderately stenotic ([n = 36], sensitivity = 61%, predictive value = 84.6%); and mildly stenotic ([n = 3], sensitivity = 66%, predictive value = 28%). Normal segments (n = 2100) had a sensitivity of 99.5%, and CTA evinced a specificity of 99% for detecting stenoocclusive disease. Approximately one-third of wrong assessments were related to the petrous segment of the carotid artery. CONCLUSION: CTA with double-detector technology and advanced postprocessing algorithms, including MPR, is about as reliable as MRA in depicting the vasculature of the anterior and posterior circulation and in grading intracranial stenoocclusive lesions, with the exception of the petrous segment of the carotid artery. CTA might be superior to MRA in the evaluation of poststenotic low-flow segments.

Intracranial stenoocclusive disease: MR angiography with magnetization transfer and variable flip angle.

PURPOSE: To assess time-of-flight MR angiography that uses magnetization transfer contrast (MTC) pulses, tilted optimized nonsaturating excitation (TONE), and a 256 x 512 image matrix for the detection of small intracranial arteries and for the detection and quantification of intracranial arterial stenoocclusive disease. METHODS: To assess anatomic sensitivity, six interpreters, in a blinded fashion, reviewed the MTC/TONE MR angiograms and selective intraarterial angiograms obtained in 70 patients within a mean interval of 5.5 days (SD, 1.5). In addition, all intracranial angiograms were evaluated with regard to presence and degree of arterial stenosis and anatomic variants. RESULTS: Interobserver correlations for determining vessel length were comparably high for both methods. A strong correlation was found between measurements obtained on MR angiograms and those obtained on intraarterial angiograms. The mean vascular length averaged across all arteries was 34.8 mm (SD, 28.1) on MR angiograms and 53.2 mm (SD, 36.8) on intraarterial angiograms. Forty-one stenoses and occlusions and 30 anatomic variants were identified with intraarterial angiography. All arterial variants and 100% of occluded vessels were graded correctly. Moreover, 80% of stenoses greater than 70% and 88% of stenoses less than 70% were quantified correctly at MR angiography. Specificity for identifying stenotic disease was 99%. CONCLUSION: Despite inferior display of vessel length, MTC/TONE MR angiography with increased spatial resolution was able to show the vast majority of high grade lesions visible at selective intraarterial angiography and may suffice for clinical decision making in many patients.

Number of active joints, not diagnosis, is the primary determinant of function and performance in early synovitis.

OBJECTIVE: A substudy within a larger study of patients with inflammatory arthritis of less than one year, to analyze baseline measures or joint counts, laboratory values, patient questionnaires and ARA diagnostic criteria for rheumatoid arthritis, as predictors of one year performance and functional status. METHODS: 229 patients with synovitis of less than one year were enrolled and evaluated at baseline and one year. Measures included the number of swollen or tender joints [active joint counts]; biological indices of inflammation [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]; and patient questionnaire measures of pain [Wisconsin Brief Pain Inventory], fatigue [multi-dimensional assessment of fatigue], depression [Center for Epidemiologic Studies--Depression Scale], sleep [Sleep Quality Index], performance [Human Activity Profile], and function [Sickness Impact Profile ambulation subscale and Health Assessment Questionnaire]. Correlations between these measures were evaluated using the Spearman rank order correlation. Patients were classified according to whether they met ARA criteria for RA, had high (> 7) or low (< or = 7) numbers of affected joints; and high, intermediate, or low levels of performance; and were compared using the Kruskal-Wallis test. RESULTS: At baseline, an active joint count of > 7 versus < or = 7 was associated significantly with higher age, rheumatoid factor positivity, a diagnosis of rheumatoid arthritis versus spondyloarthropathy or undifferentiated arthritis, and receiving a disease modifying antirheumatic drug (DMARD), but not with sex, race, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), or receiving prednisone. Furthermore, high baseline active joint counts were associated significantly with patient questionnaire scores for maximum activity, fatigue and depression, but differences were not significant for sleep, ambulation and pain scores. A comparison of patients who met or did not meet criteria for RA indicated significant differences only according to the fatigue scores, but none of the other questionnaire measures. Correlations of baseline measures with one-year performance were highest for the baseline active joint count compared to laboratory and questionnaire variables. The maximum activity score at one year was predicted significantly by the baseline maximum activity score, active joint count, and age, but not by laboratory tests or whether the patient met criteria for RA. CONCLUSION: The active joint count predicts subsequent performance and function for patients with recent onset, inflammatory synovitis more effectively than whether patients met ARA criteria for RA.

Prediction of relapse after antithyroid drug therapy of Graves' disease: value of color Doppler sonography.

Opinions differ regarding the indications for antithyroid drugs, radioiodine and surgery in patients with Graves' disease because the likelihood of long-term remission after medical treatment cannot be predicted. The aim of this study was to assess the value of quantifying thyroid blood flow in an attempt to predict outcome following withdrawal of antithyroid drug therapy. Spectral Doppler recordings were obtained from the thyroid arteries in 24 patients with Graves' disease at the time of diagnosis. Thyroid blood flow levels measured at the time of diagnosis of Graves' disease were correlated with outcome following withdrawal of medical treatment (mean duration of treatment: 14 months). Clinical follow-up for at least 18 months (range: 18 - 39 months) after antithyroid drug withdrawal was possible in 13 patients (12 women). Mean peak systolic velocity and volume flow rate values as well as thyroid volume measured at the time of diagnosis were significantly higher (139 cm/s, SD 46; 195 ml/min, SD 170; 52 ml, SD 18) in patients who relapsed after drug treatment compared with patients in remission (71 cm/s, SD 27; 67 ml/min, SD 61; 25 ml, SD 13). The correlation between thyroid blood flow measurements and thyroid volume was high (r = 0.79 - 0.96). Recurrence of disease could be predicted with a sensitivity of 71 % and a specificity of 100 % based on thyroid blood flow measurements. This preliminary data suggest that quantification of thyroid blood flow by means of Doppler sonography might be a useful tool to predict the outcome of Graves' disease following withdrawal of medical treatment and could be helpful in finding the adequate kind of therapy.

Differential diagnosis of hyperthyroidism: Doppler sonographic quantification of thyroid blood flow distinguishes between Graves' disease and diffuse toxic goiter.

The aim of our study was to evaluate the usefulness of color duplex sonography to distinguish Graves' disease from diffuse toxic goiter. 24 patients with Graves' disease and 13 patients with diffuse toxic goiter underwent B-mode- and color duplex sonography of the thyroid gland. All patients had hyperthyroidism and elevated (99m)Tc-uptake. Spectral Doppler recordings were obtained at all thyroid arteries. Representative color flow maps of the thyroid gland were analyzed, calculating the percentage area of the thyroid gland, occupied by color pixels (color pixel density). The B-mode ultrasound pattern was subjectively assessed on a 4-point rating scale. In patients with Graves' disease the mean peak systolic velocity (PSV) (SD) was 110 (+/- 49) cm/s, the mean volume flow rate (VFR) was 123 ( +/- 67) ml/min and the mean color pixel density (CPD) was 33 (+/- 12) %. For patients with diffuse toxic goiter mean PSV (SD) was 43 ( +/- 9) cm/s (p < 0.001), mean VFR was 23 (+/- 10) ml/min (p < 0.001) and mean CPD was 9 (+/- 6) % (p = 0.007). CPD and spectral duplex recordings were positively correlated (CPD/PSV: rs = 0.77, CPD/VFR: rs = 0.75; p < 0.0001). No significant differences were observed concerning RI values. Sensitivity was 87% and specificity 92% for CPD and VFR and 87% and 100% for PSV. We conclude, that color duplex sonography can reliably distinguish diffuse toxic goiter from Graves' disease and therefore contributes significantly to the differential diagnosis of hyperthyroidism in diffuse thyroid disease.

Morphologic effects of a sulfur(IV) aerosol on the nasal cavity of beagle dogs.

Morphologic changes were observed in nasal cavities of beagle dogs after long-term exposure to a respirable sulfur(IV) aerosol at a concentration equivalent to a sulfur dioxide (SO2) concentration of 0.6 mg/m3. The changes were characterized by a thickened epithelial layer resulting from epithelial proliferation, by a loss of secretory material, and by moderate mononuclear cell infiltration.

Characteristics and clinical value of an intravenous echo-enhancement agent in evaluation of high-grade internal carotid stenosis.

Although ultrasound is a highly useful tool for clinical diagnosis, it has certain limitations in accurately quantifying internal carotid stenosis or diagnosing internal carotid occlusion. However, these limitations can be overcome by increasing the echogenicity of flowing arterial blood by use of echo-enhancement agents. Two phase III studies assessed the usefulness of the IV transpulmonary echo enhancer Levovist (SH U 508A) in improving characterization and quantification of severe internal carotid stenosis on ultrasound scans. In addition, Levovist-induced enhancement characteristics of the Doppler frequency spectrum have been analyzed. To be included in the study reviewed here, patients had to have a high-grade (> or = 70%) stenosis or occlusion of an internal carotid artery (ICA), as judged by conventional angiography or by standard cervical Doppler ultrasound. Patients were excluded from consideration if they were pregnant or nursing, had a history of galactosemia, or had received an ionic contrast medium within 24 hours before or after the intended administration of Levovist. Written informed consent was obtained from all patients before entry into the study. Of 32 patients (14 women, 18 men, median age 64 yr) who were included in this study, high-grade stenosis was verified in 30 ICA vessels and occlusion was verified in two vessels. After admission into the study, the carotid bifurcation was insonated in all patients using a 7.5-MHz linear array transducer for color Doppler-assisted duplex imaging and a 4-MHz pulsed-wave Doppler for velocity spectrum measurements before and after injection of the echo enhancement agent Levovist. Levovist-induced increases in carotid blood echogenicity began 11 +/- 2 seconds (mean +/- SD) after the start of injection, peaked at 21 +/- 2 dB, and had a half-life of 75 seconds. A fast Fourier transform of the original Doppler velocity spectrum demonstrated Levovist-induced enhancement throughout the entire velocity spectrum, with an increase in ICA blood flow velocity paralleling an increase in reflected ultrasound energy. Quantitative vascular measurements (cross-sectional luminal area reduction and plaque length) obtained before and during echo enhancement were highly correlated (r > 0.90). However, visualization of the entire length of the intrastenotic residual flow lumen, was significantly improved by Levovist enhancement (52% versus 83%; p = 0.01). Levovist considerably increased interpretable data by improving image quality in patients with high-grade carotid stenosis. Furthermore, the significant improvement in visualization of the residual flow lumen suggests that echo-enhancement agents may be most useful in improving the ultrasonography-based diagnosis of internal carotid occlusion.

Estimation of antithyroid drug dose in Graves' disease: value of quantification of thyroid blood flow with color duplex sonography.

The purpose of this study was to evaluate if there is an association between the antithyroid drug dose that is needed to establish euthyroidism and thyroid blood flow measurements. A total of 23 Graves' disease patients with euthyroidism taking antithyroid drug therapy were enlisted to undergo spectral duplex sonography of the thyroid arteries and color-flow mapping of the thyroid gland. Color pixel density (CPD) was calculated with computer assistance from the color-flow maps. There was a strong correlation between the CPD and methimazole dose (rp = 0.79). Methimazole maintenance dosage could be predicted from CPD values with a coefficient of determination of 0.62. In conclusion, CPD measurements could be a useful tool for the clinical endocrinologist to estimate the antithyroid drug dose that is needed to maintain euthyroidism.

Exclusion of brain lesions: is MR contrast medium required after a negative fluid-attenuated inversion recovery sequence?

We hypothesized that in patients with negative fluid-attenuated inversion recovery (FLAIR) images T(2) weighted fast spin-echo (FSE) images and T(1) weighted spin-echo (SE) images before and after intravenous administration of gadolinium-based contrast medium display no pathology either. Thus, we assessed the negative predictive value of FLAIR images to rule out MR-detectable brain lesions. 1026 consecutive cranial MR examinations were reviewed. Routine MRI of the brain included T(1) weighted coronal imaging before and after administration of gadopentetate dimeglumine, axial T(2) weighted FSE and fast-FLAIR imaging. The FLAIR images were rated by two radiologists into categories of 0 (without pathologic changes) and 1 (with pathologic changes). Two other radiologists analysed the complete examination. In 284 MR examinations of the brain no abnormalities were found (28%). FLAIR-ratings were false-negative in four cases and false-positive in 30 cases. Sensitivity and specificity of the FLAIR sequence for MR-detectable brain lesions were 99.5% and 89.4%. The unselective application of gadolinium avoided one false-negative MR-reading and improved the sensitivity of the MR-examination from 99.5% to 99.6%. Positive and negative predictive values were 96.1% and 98.4%, respectively. The interobserver reliability was kappa=0.93 for the FLAIR-readers and 0.89 for the readers who rated the complete examination. In conclusion, negative FLAIR images provide a high negative predictive value for MR-detectable brain lesions. Thus, in patients with negative FLAIR images the unselective application of gadolinium seems to be unnecessary.