A hairy cavity: endoscopic therapy of a presacral recurrence of a complex pilonidal sinus.

BACKGROUND: Recently, minimally invasive techniques to avoid radical excisions of the pilonidal sinus with long-lasting secondary wound healing were developed. We describe a rare case of an intrapelvic, pararectal recurrence of a pilonidal sinus, who was innovatively treated with flexible endoscopy. CASE PRESENTATION: A 43-year-old Caucasian man presented with an intrapelvic, pararectal recurrence of a primarily wide-stretched pilonidal sinus, originally located in the sacrococcygeal region and spreading laterally to the gluteal region and intrapelvic to the presacral area. No connection to the bowel was evident. Up until presentation in the endoscopic department, a total of five attempts of surgical resection were performed, always confirming the diagnosis of a pilonidal sinus. Endoscopic therapy consisted of a combination of debridement, laser ablation and endoscopic vacuum therapy. After completion of APC and VAC therapy, the patient irrigated the abscess cavity for a further 2 weeks with a rinsing syringe. The resulting deep scar at the gluteal fistula was resected after secondary wound healing was completed. Two years after the end of the therapy, no recurrence was evident. CONCLUSION: Flexible endoscopy is, with its multiple therapeutic applications, an effective tool even in very complex inflammatory fistula and abscesses. Correctly indicated, it is with its minimally invasive character an excellent alternative to open surgical approaches.

Investigating the association between variability in sulcal pattern and academic achievement.

Investigating how the brain may constrain academic achievement is not only relevant to understanding brain structure but also to providing insight into the origins of individual differences in these academic abilities. In this pre-registered study, we investigated whether the variability of sulcal patterns, a qualitative feature of the brain determined in-utero and not affected by brain maturation and learning, accounted for individual differences in reading and mathematics. Participants were 97 typically developing 10-year-olds. We examined (a) the association between the sulcal pattern of the IntraParietal Sulcus (IPS) and mathematical ability; (b) the association between the sulcal pattern of the Occipito Temporal Sulcus (OTS) and reading ability; and (c) the overlap and specificity of sulcal morphology of IPS and OTS and their associations with mathematics and reading. Despite its large sample, the present study was unable to replicate a previously observed relationship between the IPS sulcal pattern and mathematical ability and a previously observed association between the left posterior OTS sulcal pattern and reading. We found a weak association between right IPS sulcal morphology and symbolic number abilities and a weak association between left posterior OTS and reading. However, both these associations were the opposite of previous reports. We found no evidence for a possible overlap or specificity in the effect of sulcal morphology on mathematics and reading. Possible explanations for this weak association between sulcal morphology and academic achievement and suggestions for future research are discussed.

[Pancreatic anastomosis in operative treatment of chronic pancreatitis]. / Pankreasanastomosen bei operativer Versorgung der chronischen Pankreatitis.

Chronic pancreatitis (CP) is an irreversible, inflammatory process, which is characterized by progressive fibrosis of the pancreas and leads to abdominal pain, endocrine and exocrine insufficiency. Surgical therapy is indicated by the absence of pain relief and local complications. The target of the surgical approach is to relieve the pancreatic and bile ducts and resection of the fibrotic and calcified parenchyma. Drainage procedures, such as the Partington-Rochelle method, are used in patients with isolated congestion of the pancreatic duct without further organ complications, such as inflammatory processes of the pancreatic head; however, patients with CP often have an inflammatory swelling of the pancreatic head. In this case classical pancreatoduodenectomy (PD) or organ-sparing duodenum-preserving pancreatic head resection (DPPHR) with its various techniques (e.g. Beger, Frey, Bern and V­shape) can be applied. Due to similar long-term results PD should be carried out in cases of suspicion or detection of malignancies and DPPHR for treatment of CP.

Videomanometry reveals clinically relevant parameters of swallowing in children.

OBJECTIVE: The aim of this pilot study is to demonstrate the technical and clinical feasibility of videomanometry to assess swallowing in infants and young children presenting with dysphagia. METHODS: We performed videomanometry using a combined solid state catheter and a perfused manometric sleeve assembly in eight patients (2-28 months) presenting at a tertiary care institution with symptoms of dysphagia. Solid state sensors were positioned at the inferior margin of the valleculae and the laryngeal entrance and the upper esophageal sphincter sleeve assembly was positioned across the upper esophageal sphincter. Manometric and radiological data were digitally recorded simultaneously using a manofluoromixer. Liquid bolus swallows were recorded in each patient and different geometric parameters of deglutition were measured. RESULTS: Placement and fixation of the catheter was well tolerated and no adverse effects occurred. The children easily swallowed test boluses as selected during clinical examination. Results indicate that pharyngeal contractility can be evaluated as well as relaxation of the upper esophageal sphincter during swallowing of wet boluses. CONCLUSIONS: Videomanometry in young children is feasible with the limited discomfort of the placement of the catheter. It is a promising technique that will allow more accurate assessment of pediatric oropharyngeal dysphagia.

Failure of regression of atherosclerosis in dogs with moderate cholesterolemia.

Controversy exists as to whether regression occurs in atherosclerotic plaques in response to serum cholesterol reduction. In the present study, using sequential observation of canine atherosclerosis, we attempted regression in hypothyroid dogs. Animals with established lesions prior to a regression attempt were placed on a 0.05% cholesterol diet and observed up to 60 months. Weighted average cholesterols ranged from 235 to 587 mg/100 ml during the regression attempt. A control fed for the entire period of the experiment, 75 months, had an average weighted cholesterol of 435 mg/100 ml. We failed to obtain regression of atherosclerotic plaques in spite of reduction of serum cholesterol from high to moderate levels. The lesions in the experimental animals contained less lipid and more collagen and calcium than occurred in the control. Complicated plaques with aneurysm formation, stenosis of the distal aorta, and gangrene of the tail were also noted.

Laryngeal tumor volume measurements determined with CT: a study on intra- and interobserver variability.

PURPOSE: To investigate the intra- and interobserver variability of computed tomography-based volume measurements of laryngeal tumors. METHODS AND MATERIALS: The volume of 13 laryngeal tumors was repeatedly measured by five independent observers in four different sessions, using the summation-of-areas technique. Mean tumor volume and its standard deviation were calculated for each tumor. Statistical analysis was done with analysis of variance, Spearman rank correlation, and linear regression. RESULTS: Both the effect of the observers (p < 0.0001) and the effect of the session (p < 0.01) on tumor volume was statistically significant. Interobserver variability was the most important component of total variability (89.3%). A significant rank correlation was found between mean volume and standard deviation (p < 0.01); the relationship between mean tumor volume and standard deviation can be described using linear regression [standard deviation = 0.28 volume + 0.35 (R = 0.79)]. CONCLUSION: Total variability in the computed tomography-based measurement of laryngeal tumor volume can be reduced by having the measurements done by a single trained observer.

The relation of CT-determined tumor parameters and local and regional outcome of tonsillar cancer after definitive radiation treatment.

PURPOSE: To investigate the value of CT-derived tumor parameters as predictor of local and regional outcome of tonsillar squamous cell carcinoma treated by definitive radiation therapy. METHODS AND MATERIALS: The pretreatment CT studies of 112 patients with tonsillar squamous cell carcinoma were reviewed. After redigitizing the films, primary and nodal tumor volume was calculated with the summation-of-areas technique. The nodal CT aspect was graded using a 3-point scale (homogenous, inhomogeneous, and necrotic). Mean follow-up time was 33 months. Actuarial statistical analysis of local and regional outcome was done for each of the covariates; multivariate analysis was performed using Cox's proportional hazards model. RESULTS: In the actuarial analysis, CT-determined primary tumor volume was significantly correlated with local recurrence rate (p < 0.05) when all patients were considered, but primary tumor volume did not predict local control within the T2, T3, and T4 category. CT-determined nodal volume was significantly related to regional outcome (p < 0.01), but nodal density was not. Total tumor volume was not significantly related to locoregional outcome (p = 0.1). In the multivariate analysis, the T and N categories were the independent predictors of local and regional outcomes, respectively. CONCLUSION: Compared to other head-and-neck sites, primary and nodal tumor volume have only marginal predictive value regarding local and regional outcome after radiation therapy in tonsillar cancer.

The contribution of magnetic resonance imaging to the three-dimensional treatment planning of localized prostate cancer.

PURPOSE: To investigate whether the use of transaxial and coronal MR imaging improves the ability to localize the apex of the prostate and the anterior part of the rectum compared to the use of transaxial CT alone, and whether the incorporation of MR could improve the coverage of the prostate by the radiotherapy field and change the volume of rectum irradiated. METHODS AND MATERIALS: Ten consecutive patients with localized prostate carcinoma underwent a CT and an axial and coronal MR scan in treatment position. The CT and MR images were mathematically aligned, and three observers were asked to contour independently the prostate and the rectum on CT and on MR. The interobserver variability of the prostatic apex location and of the delineation of the anterior rectal wall were assessed for each image modality. A dosimetry study was performed to evaluate the dose to the rectum when MR was used in addition to CT to localize the pelvic organs. RESULTS: The interobserver variation of the prostatic apex location was largest on CT ranging from 0.54 to 1.07 cm, and smallest on coronal MR ranging from 0.17 to 0.25 cm. The interobserver variation of the delineation of the anterior rectum on MR was small and constant along the whole length of the prostate (0.09+/-0.02 cm), while for CT it was comparable to that for the MR delineation at the base of the prostate, but it increased gradually towards the apex, where the variation reached 0.39 cm. The volume of MR rectum receiving more than 80% of the prescribed dose was on average reduced by 23.8+/-11.2% from the CT to the MR treatment plan. CONCLUSION: It can be concluded that the additional use of axial and coronal MR scans, in designing the treatment plan for localized prostate carcinoma, improves substantially the localization accuracy of the prostatic apex and the anterior aspect of the rectum, resulting in a better coverage of the prostate and a potential to reduce the volume of the rectum irradiated to a high dose.

Xe-133 rebreathing system for ventilation studies on ventilator-assisted patients.

We describe a manually operated system, simple to assemble, that will enable xenon-133 lung ventilation studies to be performed on ventilator-assisted patients. It can be constructed from items readily available. Radiation exposure levels to the operator were measured and are reported.

Interobserver variations in gross tumor volume delineation of brain tumors on computed tomography and impact of magnetic resonance imaging.

PURPOSE: (1) To assess the interobserver variability of brain tumor delineation on computed tomography (CT). (2) To assess the impact of the addition of magnetic resonance imaging (MRI) information. METHODS: Nine physicians were asked to delineate the gross tumor volume (GTV) of five patients with supratentorial inoperable brain tumors on CT scans and 2 weeks (or more) later on MRIs. The delineations were performed on a computer screen. During delineation on MRI, the registered CT images (without delineation) were displayed on the screen (MRI+CT). RESULTS: A high interobserver variability in GTV delineation on CT is found: the ratio of the largest to the smallest defined volumes varies for the five patients by factors of resp. 2.8, 1.8, 1.8, 1.9 and 1.7. The interobserver variability is as large on MRI+CT as on CT alone (ratio largest/smallest volume: 2.4, 1.7, 1.9, 2.7 and 1.5). Volumes delineated on MRI+CT (mean: 69.6 cm(3)) are larger than on CT alone (mean: 59.5 cm(3)). Residual volumes (volume delineated on one image modality but not on the other) are >0 for CT alone and for MRI+CT. CONCLUSIONS: A large interobserver variability in GTV delineation of brain tumors is demonstrated. The addition of MRI to CT does not reduce interobserver variability. GTVs delineated on MRI+CT are larger than on CT alone, but some volumes are delineated on CT and not on MRI. Therefore, a combination of the two image modalities is recommended for brain tumor delineation for treatment planning.

Regression of atherosclerotic plaques in rhesus monkeys. Angiographic, morphologic, and angiochemical changes.

On a diet with high levels of cholesterol and sucrose, a beta-lipoproteinemia developed in rhesus monkeys that is similar to type II human hyperlipidemia. Lesion regression appeared in response to drastic lowering of serum cholesterol (SC) levels. This experiment analyzed angiochemical responses on the addition of a bile-acid sequestrant to continued atherogenic feeding, which resulted in ranges of moderate cholesterolemia that mimick those that occur in man. After two years of atherogenic diet, fatty fibrous plaques were demonstrated in ten monkeys; then cholestyramine resin, 1.5 g/100 g of the atherosclerotic diet, was added to the food of eight monkeys, whereas two served as controls during a 12-month regression period. Six adult control monkeys that did not receive the atherosclerotic diet were also killed. Seven experimental animals overall showed plaque regression when SC level fell from 400 +/- 130 to 237 +/- 74 mg/dL; one animal showed angiographic combinations of progression and regression. Angiochemical evaluation demonstrated discordant data with instances of decreased plaque cholesterol content and increased levels of collagen. On the average, plaque regression and final composition were related to absolute levels of SC reduction induced by cholestyramine. Regression required that the threshold levels of cholesterol be below 200 mg/dL. Plaques regressed mainly by lipid absorption; in this experiment and, in particular, arterial segments, collagen content sometimes increased.

Free cytosolic Ca2+ recordings from myenteric neurones in multilayer intestinal preparations.

The ability to simultaneously monitor different myenteric neurones in a multilayer preparation may enhance our understanding of the enteric nervous system. Longitudinal muscle myenteric plexus preparations were mounted in recording chambers with a coverslip base and loaded with Indo-1-AM. cytosolic Ca2+ concentration ([Ca2+]i); changes were recorded at room temperature with a confocal microscope. In addition to mechanical (pressure-ring) and pharmacological (nifedipine) reduction of muscle contractions, purpose-designed software was developed to reposition regions of interest and avoid artefacts. Confocal scanning permitted optical selection of single cell layers. High K+ depolarization, used to distinguish between excitable and nonexcitable cells, caused a synchronous [Ca2+]i rise in 84.3% of the ganglion cells. Acetylcholine, substance P and serotonin (all at 10(-5) mol L(-1)) induced transient [Ca2+]i changes in subpopulations of myenteric neurones (45.1%, 42.9 and 21.9%, respectively). In addition to immediate responses to agonists, delayed [Ca2+]i changes were also recorded, suggesting the presence of both directly activated and synaptically driven neurones. Functionally identified neurones and other cells in close apposition to the ganglia (interstitial cells of Cajal) could also be studied. This study demonstrates the potential of optical Ca2+ recordings to monitor spread of activity in myenteric neurones and to study their interaction with non-neuronal targets.

Synaptic transmission induces transient Ca2+ concentration changes in cultured myenteric neurones.

The enteric nervous system controls most of the gastrointestinal functions. We applied confocal microscopy and the Ca2+ indicator Fluo-3 as an optical approach to study synaptic activation in cultures of myenteric neurones. The optical recording of [Ca2+]i (the intracellular Ca2+ concentration) was used to monitor activation, since [Ca2+]i is crucial in the coupling between neuronal excitation and the activation of several intracellular events. Extracellular fibre tract stimulation (2 s, 30 Hz) caused a transient [Ca2+]i rise in a subset of neurones (50%). These transients lasted for 5.2 s (n=36), with an average amplitude of 3.4 +/- 1.3 times the basal concentration. The removal of extracellular Ca2+ (n=15) or the application of 10-6 M tetrodotoxin (n=16) blocked this response. The N-type Ca2+-channel blocker omega-conotoxin (5 x 10 -7M) abolished the [Ca2+]i increase, while blockade of L-type and P/Q type Ca2+ channels had no effect. Single stimuli evoked a [Ca2+]i rise in the processes. omega-conotoxin-sensitive postsynaptic events required repetitive stimulation. Cholinergic blockade did not inhibit the [Ca2+]i rise in all neurones, suggesting that, besides acetylcholine, other neurotransmitters are involved. Optical imaging of [Ca2+]i can be used to study synaptic spread of activation in enteric neuronal circuits expressed in culture.

Diagnosis of ruptured intracranial dermoid cyst: value MR over CT.

The CT and MR findings of seven patients with pathologically proved ruptured dermoid cysts were reviewed to analyze the MR characteristics and to see if MR evaluation had significant advantages over CT. In six cases, both CT and MR identified fatty material in the CSF spaces. Hemorrhage complicated preoperative diagnosis in one case. Patterns of extraaxial fat distribution were as follows: intraventricular fat/CSF levels (three patients), generalized subarachnoid spread (six patients), and localized subarachnoid spread with sulcal widening (one patient). There was no correlation between fat distribution and clinical symptoms. MR showed the vascular involvement better than CT did in five of seven cases, and showed extension of the cysts into the skull base in two cases. Signal intensity of the solid mass was low on T1-weighted MR images and inhomogeneously high on T2-weighted images, which correlated pathologically with the presence of crystal cholesterol, hair, sebaceous glands, and epithelial cells in all cases. On MR, brain parenchyma showed little edema or other reaction to the masses, which were typically large. The value of MR over CT in the examination of ruptured dermoid cysts is the conspicuity of the extent of subarachnoid spread, involvement of the extraaxial structures, and evidence of vascular compromise, which can obviate angiography. MR had no advantage over CT in making the initial diagnosis of ruptured dermoid, but it would be the preferred preoperative study.

Magnetic resonance imaging of a third trimester abdominal pregnancy.

Abdominal pregnancies are rare, representing 1% of all ectopic pregnancies. Early and accurate diagnosis is essential in order to avoid the serious complications associated with the condition, including catastrophic hemorrhage secondary to placental separation. The clinical presentation of abdominal pregnancy is extremely variable and physical examination by itself may be insufficient for diagnosis. Ultrasound (US) is currently the imaging method of choice for establishing gestational location, but sonographic interpretation may be difficult due to gas within the gastrointestinal tract and distorted pelvic anatomy. The use of magnetic resonance imaging (MRI) in obstetric diagnosis, including abdominal pregnancy, has been described. We report a case of an abdominal pregnancy of 32 wk gestation diagnosed by MRI.

Image segmentation: methods and applications in diagnostic radiology and nuclear medicine.

We review and discuss different classes of image segmentation methods. The usefulness of these methods is illustrated by a number of clinical cases. Segmentation is the process of assigning labels to pixels in 2D images or voxels in 3D images. Typically the effect is that the image is split up into segments, also called regions or areas. In medical imaging it is essential for quantification of outlined structures and for 3D visualization of relevant image data. Based on the level of implemented model knowledge we have classified these methods into (1) manual delineation, (2) low-level segmentation, and (3) model-based segmentation. Pure manual delineation of structures in a series of images is time-consuming and user-dependent and should therefore be restricted to quick experiments. Low-level segmentation analyzes the image locally at each pixel in the image and is practically limited to high-contrast images. Model-based segmentation uses knowledge of object structure such as global shape or semantic context. It typically requires an initialization, for example in the form of a rough approximation of the contour to be found. In practice it turns out that the use of high-level knowledge, e.g. anatomical knowledge, in the segmentation algorithm is quite complicated. Generally, the number of clinical applications decreases with the level and extent of prior knowledge needed by the segmentation algorithm. Most problems of segmentation inaccuracies can be overcome by human interaction. Promising segmentation methods for complex images are therefore user-guided and thus semi-automatic. They require manual intervention and guidance and consist of fast and accurate refinement techniques to assist the human operator.

Integrating digital ICU viewing into the global working environment.

We illustrate that to benefit from the advantages of Picture Archiving and Communication Systems (PACS) for the Intensive Care Unit (ICU), the PACS must be strongly integrated within the overall working environment. This includes adaptation of the PACS toward specific working patterns and integrating it with the Hospital Information System (HIS). This is reflected in our prototype system in different ways. The user interface of the viewing station is centered around often used patterns in ICU viewing. Information about bed occupancy is retrieved from the HIS and exploited in the viewing station. A digital connection between the phosphorplate scanner and the HIS ensures that images are correctly related to other patient information and to previous images. Using minor adaptations to the existing HIS, PACS and HIS have been made to cooperate in integrated presentation of images and radiological reports, as a step towards a multi-media medical information system. We discuss the relation between PACS and the global information environment, emphasizing organizational issues rather than technological aspects.

The value of quantitative sacroiliac scintigraphy in detection of sacroiliitis.

To evaluate clinical usefulness of quantitative sacroiliac scintigraphy (QSS) in detecting sacroiliitis, we used a modified, pixel by pixel technique for calculating sacroiliac joint/sacrum uptake ratios (sacroiliac joint index - SII). We studied 90 controls, 18 selected patients with active sacroiliitis, 2 ankylosing spondylitis patients with completely ankylosed sacroiliac joints, 14 patients with nonspecific low back pain and 5 patients with rheumatoid arthritis. In the controls, we found that the SII decreases with increasing age (P less than 0.001) and is higher in males than in females (P less than 0.005). In the patients with active sacroiliitis, 9 out of 14 older than 30 had an abnormal SII; 3 of these patients showed no radiographic or CT abnormalities of the sacroiliac joints. None of the 4 patients with sacroiliitis under 30 years of age had values which fell out of the normal range for their age and sex. Only 1 of the 14 patients with non-inflammatory low back pain had an abnormally high SII. A borderline SII was found in 1 of the 5 patients with rheumatoid arthritis. QSS may be useful in detecting active sacroiliitis, sometimes even before the occurrence of radiologic abnormalities. However, because of its low sensitivity, its clinical usefulness is limited, especially in patients under 30 years of age.

Middle meningeal artery trauma.

We present the case of a patient who had the symptoms of a subarachnoid hemorrhage but was subsequently found to have an unusual combination of a separate traumatic pseudoaneurysm and a traumatic arteriovenous fistula of the middle meningeal artery. A review of the literature revealed a difference in the clinical course of patients with traumatic pseudoaneurysms compared to that of patients with arteriovenous fistulas. Patients who were found to have traumatic pseudoaneurysms of the middle meningeal artery frequently manifested signs of delayed hemorrhage. This mechanism may account for the prolonged lucid intervals exhibited in some patients subsequently found to have epidural hematomas.

CT demonstration of brain infarcts due to deep venous thrombosis in systemic lupus erythematosus.

Rapid development of low density bilateral lesions in the brain due to deep venous thrombosis in Systemic Lupus Erythematosis is described. To the best of our knowledge, this type of symmetry, distribution and appearance of brain infarcts in CT due to deep venous thrombosis has not been reported previously.