The influence of bone quality on radiological outcome in 50 consecutive acetabular fractures treated with a pre-contoured anatomic suprapectineal plate.

PURPOSE: To investigate the range of indications of an anatomical-preshaped three-dimensional suprapectineal plate and to assess the impact of the bone mass density on radiologic outcomes in different types of acetabular fractures. PATIENTS AND METHODS: A consecutive case series of 50 acetabular fractures (patient age 69 ± 23 years) treated with suprapectineal anatomic plates were analyzed in a retrospective study. The analysis included: Mechanism of injury, fracture pattern, surgical approach, need for additional total hip arthroplasty, intra- or postoperative complications, as well as bone mass density and radiological outcome on postoperative computed tomography. RESULTS: Most frequently, anterior column fracture patterns with and without hemitransverse components as well as associated two column fractures were encountered. The anterior intrapelvic approach (AIP) was used in 98% (49/50) of the cases as primary approach with additional utilization of the first window of the ilioinguinal approach in 13/50 cases (26%). Determination of bone density revealed impaired bone quality in 70% (31/44). Postoperative steps and gaps were significantly greater in this subgroup (p < 0.05). Fracture reduction quality for postoperative steps revealed anatomic results in 92% if the bone quality was normal and in 46% if impaired (p < 0.05). In seven cases (14%), the plate was utilized in combination with acute primary arthroplasty. CONCLUSION: A preshaped suprapectineal plate provides good radiological outcomes in a variety of indications in a predominantly geriatric cohort. Impaired bone quality has a significantly higher risk of poor reduction results. In cases with extensive joint destruction, the combination with total hip arthroplasty was a valuable option.

Clinical presentation and long-term outcome of 144 patients with microscopic polyangiitis in a monocentric German cohort.

OBJECTIVE: To evaluate the clinical presentation and long-term outcome of a vasculitis centre cohort of patients with microscopic polyangiitis (MPA) with respect to organ manifestations, treatment, chronic damage and mortality. METHODS: We performed a retrospective chart review at our vasculitis referral centre. MPA patients admitted between 1991 and 2013 classified by a modified European Medicines Agency algorithm were diagnosed and treated according to a standardized interdisciplinary approach. RESULTS: Comprehensive data from standardized interdisciplinary workups was available for 144 patients (median follow-up 72 months). The overall standardized mortality ratio was 1.40 (95% CI 0.91, 2.07; P = 0.13). We observed a higher mortality [hazard ratio (HR) 4.04 (95% CI 1.21, 13.45), P = 0.02] in 17 patients with MPA-associated fibrosing interstitial lung disease (ILD) and 56 patients with peripheral nervous system involvement [HR 5.26 (95% CI 1.10, 25.14), P = 0.04] at disease onset. One hundred and fifteen patients (79.9%) responded to the initial treatment. Sixty-one (42.3%) achieved complete remission and 54 (37.5%) achieved partial remission. Twenty (13.9%) showed a refractory disease course. CONCLUSION: MPA patients at our tertiary rheumatology referral centre seemed to have a less severe phenotype resulting in a less severe disease course and better outcome than reported in other cohorts. Fibrosing ILD was significantly associated with mortality in this cohort.

Precision of pulmonary vein diameter measurements assessed by CE-MRA and steady-state-free precession imaging.

OBJECTIVE: Pulmonary vein (PV) diameter assessment is important for planning and follow-up of PV ablation in atrial fibrillation. Therefore, the aim of our study was to evaluate inter- and intraobserver reliability of PV diameter measurements by contrast-enhanced magnetic resonance angiography (CE-MRA) and ECG-gated 2D multislice unenhanced steady-state-free precession sequences (multislice SSFP). METHODS: Sixty PV diameters in 17 consecutive patients were measured in transverse and coronal orientation with CE-MRA and multislice SSFP by two observers. Statistics to evaluate inter- and intraobserver reliability included Bland-Altman analysis and F-test. RESULTS: Intraobserver limits of agreement (LAG) ranged between ±0.50 cm (transverse) and ±0.86 cm (coronal) for CE-MRA versus ±0.40 cm (transverse) and ±0.67 cm (coronal) for multislice SSFP. Interobserver agreement showed LAG ranging between ±0.59 cm (transverse) and ±0.83 cm (coronal) for CE-MRA versus ±0.34 cm (transverse) and ±0.75 cm (coronal) for multislice SSFP. Intra- and interobserver variances did not reveal significant differences between CE-MRA and multislice SSFP in any orientation (all p-values >0.05). CONCLUSION: Multislice SSFP and CE-MRA enable comparable precision of PV diameter measurements. However, both methods reveal a wide range of intra- and interobserver agreement, which has to be thoroughly considered in clinical use. KEY POINTS: • Unenhanced magnetic resonance imaging can now provide measurement of pulmonary vein diameters • Steady-state-free precession offers a new method of performing unenhanced MR imaging • Both unenhanced and enhanced MRI measurements show wide intra- and interobserver variation • PV diameter measurements assessed by MRI have to be interpreted with care • Nevertheless, unenhanced MRI might replace some CT examinations for pulmonary vein demonstration.

Diagnostic Utility of Bronchoalveolar Lavage in Patients with Acute Leukemia under Broad-Spectrum Anti-Infective Treatment.

Despite therapeutic advances in the prevention and treatment of febrile neutropenia, acute leukemia (AL) patients still have considerable febrile neutropenia-related mortality. However, the diagnostic yield of flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) in acute leukemia patients is unclear. In this retrospective single-center study, we analyzed 88 BAL samples of patients with acute leukemia and pulmonary infiltrates in spite of treatment with broad-spectrum anti-infective agents. The aim was to investigate the impact of FB with BAL on detecting causative organisms, which would result in a change in treatment regimens. The median age was 59 years, and 86% had acute myeloid leukemia. In 47%, pathogens were detectable in BAL fluid (pathogen bacteria, viruses, and fungi in 2, 15, and 18%, respectively), with Aspergillus fumigatus detected most frequently. BAL-guided anti-infective therapy changes were performed in 15%. The detection of herpes simplex and influenza viruses were the main reasons for treatment changes. Despite broad-spectrum anti-infective treatment, in approximately half of all patients, pathogens could still be isolated in BAL samples. However, consecutive changes in anti-infective treatment were considerably less frequent, with most changes performed in patients with Herpes simplex virus and Influenza A detection. The need for FB with BAL in patients with AL receiving broad-spectrum empiric anti-infective treatment should therefore be weighed carefully.

Correlation of right ventricular dysfunction parameters and pulmonary vascular obstruction score in acute pulmonary embolism in a porcine model.

This paper aims to non-invasively determine right ventricular dysfunction parameters (RVDP) in acute pulmonary embolism (APE) and to correlate these parameters with a computed tomography (CT)-based pulmonary artery obstruction score (OS). In seven domestic pigs, magnetic resonance imaging (MRI) was performed before (n = 7) and after (n = 5) APE was induced. Analysis of relative changes in right ventricular stroke volume (RVSV%), output (RVO%), end-systolic (RVESV%), end-diastolic volume (RVEDV%), and heart rate (HR%) was performed. Additionally, for the determination of the OS, all animals underwent contrast-enhanced CT-pulmonary angiography. The CT-based OS correlated strongly with RVSV% (r = 0.9576; p = 0.0104) and RVO% (r = 0.9703; p = 0.0061). Contrarily, almost no correlation could be demonstrated for the OS and the increase of RVESV % (r = 0.3850; p = 0.5222), RVEDV% (r = 0.1830; p = 0.7683), and HR% (r = 0.5494; p = 0.3375). The results of this experimental study underline that the CT-based OS correlates with RVDP as determined by cardiac MRI and might be a helpful tool for the severity assessment in APE.

Extended cycle streptozotocin/5-FU chemotherapy for maintenance therapy in pancreatic neuroendocrine tumors.

PURPOSE: The standard of care treatment for patients with advanced pancreatic neuroendocrine tumors (pNET) is a combination of streptozotocin and 5-FU. Although widely used, little is known about the best long-term strategy with these substances. METHODS: We here report our experience of 28 patients treated with streptozotocin/5-FU for advanced pNET with special consideration for long-term management using an extended cycle protocol. RESULTS: Standard 6-weekly Moertel protocol resulted in a median progression-free survival of 21 months (range 3-128) and a median overall survival of 69 months (range 3-157+) in the whole cohort. Thirteen of the 28 patients were switched to an extended 3-month cycle protocol for maintenance therapy. Of these 13 patients, 2 achieved complete remission, 1 partial remission, and 8 stable disease as best response while 2 showed progressive disease following switch to the extended protocol, resulting in an additional median progression-free survival of 23 months. Median overall survival after the start of chemotherapy in this patient group was 69 months (21-157+). Patients benefitted from extended periods free of chemotherapy-associated side effects after switching to the extended cycle protocol. CONCLUSIONS: Switching to an extended cycle protocol of 3 months for maintenance therapy following initial standard cycles may achieve long-term disease stabilization in selected patients with advanced pNET with good patient acceptance.

Accuracy of Magnetic Resonance Imaging for Grading of Subglottic Stenosis in Patients With Granulomatosis With Polyangiitis: Correlation With Pulmonary Function Tests and Laryngoscopy.

OBJECTIVE: To compare magnetic resonance imaging (MRI)-based and laryngoscopy-based subglottic stenosis (SGS) grading with pulmonary function testing (PFT) in patients with granulomatosis with polyangiitis (GPA). METHODS: In this retrospective study, we included 118 examinations of 44 patients with GPA and suspected SGS. All patients underwent MRI, laryngoscopy, and PFT. Stenosis was graded on a 4-point scale by endoscopy and MRI using the Meyer-Cotton (MC) score (score 1: ≤50%, 2: 51-70%, 3: 71-99%, and 4: 100%) and as percentage by MRI. Results were compared with peak expiratory flow (PEF) and maximum inspiratory flow (MIF) from PFT, serving as objective functional reference. RESULTS: In MRI, 112 of 118 examinations (95%) were rated positive for SGS (grade 1 [n = 82], grade 2 [n = 26], and grade 3 [n = 4]), whereas in laryngoscopy 105 of 118 examinations (89%) were rated positive for SGS (grade 1 [n = 73], grade 2 [n = 24], and grade 3 [n = 8]). MRI and laryngoscopy agreed in 75 of 118 examinations (64%). MRI determined higher scores in 20 examinations (17%) and lower scores in 23 examinations (19%) compared to laryngoscopy. MC scores as determined by both MRI and laryngoscopy showed comparable correlations with PEF (r = -0.363, P = 0.016, and r = -0.376, P = 0.012, respectively) and MIF (r = -0.340, P = 0.024, and r = -0.320, P = 0.034, respectively). The highest correlation was found between MRI-based stenosis grading in percentage with PEF (r = -0.441, P = 0.003) and MIF (r = -0.413, P = 0.005). CONCLUSION: MRI and laryngoscopy provide comparable results for grading of SGS in GPA and correlate well with PFT. MRI is an attractive noninvasive and radiation-free alternative for monitoring the severity of SGS in patients with GPA.

The immediate effect of long-distance running on T2 and T2* relaxation times of articular cartilage of the knee in young healthy adults at 3.0 T MR imaging.

OBJECTIVE: To quantitatively assess the immediate effect of long-distance running on T2 and T2* relaxation times of the articular cartilage of the knee at 3.0 T in young healthy adults. METHODS: 30 healthy male adults (18-31 years) who perform sports at an amateur level underwent an initial MRI at 3.0 T with T2 weighted [16 echo times (TEs): 9.7-154.6 ms] and T2* weighted (24 TEs: 4.6-53.6 ms) relaxation measurements. Thereafter, all participants performed a 45-min run. After the run, all individuals were immediately re-examined. Data sets were post-processed using dedicated software (ImageJ; National Institute of Health, Bethesda, MD). 22 regions of interest were manually drawn in segmented areas of the femoral, tibial and patellar cartilage. For statistical evaluation, Pearson product-moment correlation coefficients and confidence intervals were computed. RESULTS: Mean initial values were 35.7 ms for T2 and 25.1 ms for T2*. After the run, a significant decrease in the mean T2 and T2* relaxation times was observed for all segments in all participants. A mean decrease of relaxation time was observed for T2 with 4.6 ms (±3.6 ms) and for T2* with 3.6 ms (±5.1 ms) after running. CONCLUSION: A significant decrease could be observed in all cartilage segments for both biomarkers. Both quantitative techniques, T2 and T2*, seem to be valuable parameters in the evaluation of immediate changes in the cartilage ultrastructure after running. ADVANCES IN KNOWLEDGE: This is the first direct comparison of immediate changes in T2 and T2* relaxation times after running in healthy adults.

Improved image quality and low radiation dose with hybrid iterative reconstruction with 80 kV CT pulmonary angiography.

OBJECTIVES: To determine the impact of hybrid iterative reconstruction (HIR) on image quality in 80 kV CT pulmonary angiography (CTPA) in comparison to filtered-back-projection (FBP). METHODS: Fifty patients (body weight <80 kg) with suspected pulmonary embolism (PE) underwent CTPA at 80 kV (mean CTDIvol, 2.3 mGy; effective dose, 1.2 mSv). The raw data were reconstructed using FBP and three increasing HIR levels. Two radiologists assessed image quality and image noise. Conspicuity of PE was assessed in central, segmental, and subsegmental arteries. CT attenuation of pulmonary arteries, objective image noise (OIN) and contrast-to-noise ratios (CNR) were assessed. RESULTS: With each HIR level, a significant decrease in subjective and objective image noise was achieved with a reduction of OIN up to 46% in comparison with FBP. CNR significantly increased with the application of HIR compared to FBP. Image quality was rated significantly higher at HIR reconstructions in comparison with FBP. Diagnosis of PE was feasible with each data set; however, conspicuity of central and segmental PE significantly improved with the use of HIR. CONCLUSIONS: Eighty kilovoltage CTPA with HIR provides improved image quality and conspicuity of pulmonary embolism enabling low dose CTPA protocols close to 1 mSv in patients weighing less than 80 kg.

Assessment of anemia during CT pulmonary angiography.

OBJECTIVES: Anemia is associated with increased mortality in patients with acute symptomatic pulmonary embolism (PE). The purpose of this study was to evaluate the feasibility of Hounsfield unit (HU) measurements on the single unenhanced trigger slice of pulmonary CT angiography scans for diagnosis of anemia. MATERIAL AND METHODS: 150 consecutive patients (median age 64 ± 16 years) with suspected PE underwent pulmonary CT angiography. Two radiologists, blinded to laboratory results, performed HU measurements in the single unenhanced trigger scan independently by region-based analysis (ROI). HU values from ascending and descending aorta and the calculated mean of both were correlated with serum hemoglobin levels. Inter- and intraobserver variability was determined for HU measurements, and ROC analysis was performed for diagnosis of anemia. Calculated linear models were used to assess formulas for estimation of hemoglobin levels from HU measurements. RESULTS: HU measurements revealed high intra- and interrater reliability (ICC>0.981 and ICC>0.965, respectively). Calculated mean HU values showed a strong correlation with serum hemoglobin levels (r=0.734), which allowed generation of different formulas for calculation of hemoglobin levels from HU measurements. ROC analyses confirmed a high sensitivity (80.4 for men; 91.3 for women) and specificity (84.0 for men; 84.9 for women) for diagnosing anemia. CONCLUSION: Diagnosis of anemia and quantification of hemoglobin levels upon a single unenhanced trigger scan of pulmonary CT angiography is feasible. We suggest disclosing the anemic state in the radiological report, independent of the presence of PE, since anemia carries increased risks of morbidity and mortality.