A fortunate bitten tongue-Hypothyroidism despite repeatedly normal plasma thyrotropin levels.

Key Clinical Message: Hypophyseal dysfunction may be overlooked by the currently generally accepted laboratory routine for the differential diagnosis in patients suffering from symptoms of depression or dementia. Abstract: Hypothyroidism is an important cause of depression and potentially reversible cognitive impairment. Whereas the determination of the plasma concentration of thyrotropin (TSH) is generally considered part of the laboratory screening tests for dementia, the measurement of total or free triiodothyronine (T3, FT3), thyroxine (T4, FT4) and cortisol in plasma does not belong to the routine diagnostic workup in patients with depression or suspected dementia. In an 87-year-old lady suffering from increasingly poor general health, decreased fluid and food intake, mood depression and lack of energy, three measurements of plasma TSH produced normal values. A cranial computed tomography (cCT) 2 days prior to hospital admission had been assessed as apparently normal. A second cCT performed following a loss of consciousness complicated by tongue bite showed a hypophyseal tumor. Then, low plasma levels of FT3, FT4 and cortisol were found. Following hormone replacement and transsphenoidal tumor resection, the patient recovered rapidly. The present case report illustrates the pitfalls of measuring merely the TSH level in the detection of thyroid and hypophyseal dysfunction.

Unilateral phrenic nerve lesion in Lyme neuroborreliosis.

BACKGROUND: Among a variety of more common differential diagnoses, the aetiology of acute respiratory failure includes Lyme neuroborreliosis. CASE PRESENTATION: We report an 87-years old huntsman with unilateral phrenic nerve palsy as a consequence of Lyme neuroborreliosis. CONCLUSION: Although Lyme neuroborreliosis is a rare cause of diaphragmatic weakness, it should be considered in the differential workup because of its potentially treatable nature.

Diagnosing cerebral aneurysms by computed tomographic angiography: meta-analysis.

OBJECTIVE: Cerebral aneurysms can cause substantial morbidity and mortality, specifically if they rupture, leading to nontraumatic subarachnoid hemorrhage (SAH). This meta-analysis summarizes evidence about the accuracy of noninvasive computed tomographic (CT) angiography for diagnosing intracranial aneurysms in symptomatic patients. METHODS: Four databases including PubMed were searched without language restrictions from January 1995 to February 2010. Two independent reviewers selected and extracted 45 studies that compared CT angiography with digital subtraction angiography (DSA) and/or intraoperative findings in patients suspected of having cerebral aneurysms. Data from eligible studies were used to reconstruct 2 x 2 contingency tables on a per-patient basis in at least 5 diseased and 5 nondiseased patients, with additional data on a per-aneurysm basis when available. RESULTS: The 45 included studies generally were of high methodological quality. Among the 3,643 patients included, about 86% had nontraumatic SAH, and 77% had cerebral aneurysms. Overall, CT angiography had a pooled sensitivity of 97.2% (95% confidence interval, 95.8-98.2%) for detecting and specificity of 97.9% (95.7-99.0%) for ruling out cerebral aneurysms on a per-patient basis. On a per-aneurysm basis, the pooled sensitivity was 95.0% (93.2-96.4%), and the specificity 96.2% (92.9-98.0%). The diagnostic accuracy of CT angiography with 16- or 64-row multidetector CT was significantly higher than that of single-detector CT, especially in detecting small aneurysms of ≤ 4 mm in diameter. INTERPRETATION: CT angiography has a high accuracy in diagnosing cerebral aneurysms, specifically when using modern multidetector CT. In the future, CT angiography may increasingly supplement or selectively replace DSA in patients suspected of having a cerebral aneurysm.

Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease.

BACKGROUND: Contrast-enhanced magnetic resonance angiography (MRA) is a noninvasive, radiation-free imaging method for studying peripheral arterial disease (PAD) of the lower extremities. PURPOSE: To summarize evidence of prospective studies about how well MRA identifies or excludes arterial steno-occlusions (50% to 100% lumen reduction) in adults with PAD symptoms. DATA SOURCES: PubMed and 3 other databases were searched from 1998 to 2009 without language restrictions. STUDY SELECTION: Two independent reviewers selected 32 studies that compared MRA with intra-arterial digital subtraction angiography in PAD. Eligible studies were prospective and provided data to reconstruct 2 x 2 or 3 x 3 contingency tables (<50% stenosis vs. > or =50% stenosis or occlusion of arterial segments) in at least 10 patients with PAD symptoms. DATA EXTRACTION: Two reviewers independently assessed the study quality and extracted the study data, with disagreements resolved by consensus. DATA SYNTHESIS: The 32 included studies generally had high methodological quality. About 26% of the 1022 included patients had critical limb ischemia with pain at rest or tissue loss. Overall, the pooled sensitivity of MRA was 94.7% (95% CI, 92.1% to 96.4%) and the specificity was 95.6% (CI, 94.0% to 96.8%) for diagnosing segmental steno-occlusions. The pooled positive and negative likelihood ratios were 21.56 (CI, 15.70 to 29.69) and 0.056 (CI, 0.037 to 0.083), respectively. Magnetic resonance angiography correctly classified 95.3%, overstaged 3.1%, and understaged 1.6% of arterial segments. LIMITATION: Similar to most studies of computed tomographic angiography in PAD, the primary studies reported the diagnostic accuracy of MRA on a per-segment basis, not a per-patient basis. CONCLUSION: This meta-analysis of 32 prospective studies further increases the evidence that contrast-enhanced MRA has high accuracy for identifying or excluding clinically relevant arterial steno-occlusions in adults with PAD symptoms. PRIMARY FUNDING SOURCE: None.

Therapeutic nihilism is inadequate in geriatric medicine.

Patients' wishes should guide therapeutic considerations in the face of options and necessities, particularly when an intervention carries the risk of death. Therefore, in the medical management of the young and the old, everything should be attempted as long as the patient has a strong will to live.

Intra-osseous ultrasound for pedicle screw positioning in the subaxial cervical spine: an experimental study.

BACKGROUND: In contrast to other regions of the human spine, dorsal fixation with rods and pedicle screws is comparatively rarely performed in the cervical spine. Although this technique provides a higher mechanical strength than the more frequently used lateral mass screws, many surgeons fear the relatively high rate of misplacements. This higher incidence is mainly due to the complex vertebral anatomy in this spinal segment. For correct screw placement, the availability of an immediate and efficient intra-operative imaging tool to ascertain the accuracy of the pedicle screw hole position would be beneficial. We have previously investigated the usefulness of an intraspinal, specifically, intra-osseous ultrasound technique in the lumbar spine. In this study its accuracy as a means of controlling intrapedicular screw hole positioning has been evaluated in the cervical spine. METHODS: An endovascular ultrasound transducer was used for the intra-luminal scanning of 54 pedicle screw holes in cadaveric human spine specimens. Twenty-three of these had been intentionally misplaced (cortex breached). The resulting image files were assessed by three investigators blinded to both the procedure and the corresponding CT findings. FINDINGS: The investigators differentiated correctly between adequately and poorly placed pedicle screw holes in 96% of cases. False negatives and false positives both occurred in no more than 1.8% of cases. CONCLUSIONS: Intrapedicular ultrasonography of pedicle screw holes in the cervical spine is a promising technique for the intra-operative assessment of bore hole placement and may increase operative safety and postoperative outcome in posterior cervical fusion surgery.

Antisynthetase Syndrome-Associated Interstitial Lung Disease: Monitoring of Immunosuppressive Treatment Effects by Chest Computed Tomography.

Background: Antisynthetase syndrome (ASyS) is a rare autoimmune disease characterized by inflammatory myopathy, arthritis, fever, and interstitial lung disease (ILD). Pulmonary involvement in ASyS significantly increases morbidity and mortality and, therefore, requires prompt and effective immunosuppressive treatment. Owing to the rarity of ASyS, limited data exists on progression and prognosis of ILD under immunosuppression. Objectives: The objective of the study was to evaluate the radiological progression and outcome measures of ILD with immunosuppressive therapy in patients with ASyS. Methods: Twelve patients with ASyS-associated ILD (ASyS-ILD) were included. Demographic and clinical data, including organ involvement, pulmonary function tests (PFT), laboratory parameters, imaging studies, and treatment regimens were retrospectively analyzed from routinely collected data. The extent of ground glass opacities, fibrotic changes and honeycombing was analyzed and scored using high-resolution chest computed tomography (HRCT) scans. HRCT findings were compared between baseline and follow-up examinations. In addition, patients were stratified depending on whether they had received rituximab (RTX) or not. Results: Pulmonary function tests revealed stable lung function and follow-up HRCT scans showed an improvement of radiological alterations in the majority of ASyS patients under immunosuppressive therapy. We did not detect significant differences between the RTX- and non-RTX-treated groups, but the RTX-treated patients more frequently had myositis and relapsing disease. Conclusions: Radiographic alterations in ASyS-associated ILD respond to immunosuppressive treatment. RTX is a feasible treatment option with similar clinical and radiographic outcomes in patients with relapsing disease and clinically apparent myositis.

Contrast-enhanced magnetic resonance angiography in carotid artery disease: does automated image registration improve image quality?

Contrast-enhanced magnetic resonance angiography (MRA) is a noninvasive imaging alternative to digital subtraction angiography (DSA) for patients with carotid artery disease. In DSA, image quality can be improved by shifting the mask image if the patient has moved during angiography. This study investigated whether such image registration may also help to improve the image quality of carotid MRA. Data from 370 carotid MRA examinations of patients likely to have carotid artery disease were prospectively collected. The standard nonregistered MRAs were compared to automatically linear, affine and warp registered MRA by using three image quality parameters: the vessel detection probability (VDP) in maximum intensity projection (MIP) images, contrast-to-noise ratio (CNR) in MIP images, and contrast-to-noise ratio in three-dimensional image volumes. A body shift of less than 1 mm occurred in 96.2% of cases. Analysis of variance revealed no significant influence of image registration and body shift on image quality (p > 0.05). In conclusion, standard contrast-enhanced carotid MRA usually requires no image registration to improve image quality and is generally robust against any naturally occurring body shift.

CNS tumor 22 years after spinal neuroblastoma IV: diagnostic dilemma between recurrence and secondary malignancy.

We present the very unusual case of a young woman suffering from a brain tumor 22 years after a stage IV spinal neuroblastoma as an infant, demonstrating the difficulties of differentiating late neuroblastoma relapse from secondary supratentorial primitive neuroectodermal tumor (sPNET). Lacking specific immunohistochemical features, the first cerebral tumor at the age of 21 was regarded as sPNET, and we pursued a therapeutic approach consisting of neurosurgical resection as well as irradiation and high-dose alkylator-based chemotherapy according to the HIT2000 protocol. Two years later the patient suffered from a diffusely infiltrating local recurrence, changing its imaging appearance as well as its immunohistochemical characteristics, now revealing disseminated positivity for neuron-specific enolase and neural cell adhesion molecule. Moreover, the lack of PNET-specific translocations (EWS/FLI1 gene fusion) in both brain tumors as well as the development of hepatic metastases was more compatible with the diagnosis of a very late relapse 22 years after initial stage IV spinal neuroblastoma.

Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment.

Rheumatoid arthritis (RA) is a type of inflammatory arthritis that affects ~1% of the general population. Although arthritis is the cardinal symptom, many extra-articular manifestations can occur. Lung involvement and particularly interstitial lung disease (ILD) is among the most common. Although ILD can occur as part of the natural history of RA (RA-ILD), pulmonary fibrosis has been also linked with methotrexate (MTX); a condition also known as MTX-pneumonitis (M-pneu). This review aims to discuss epidemiological, diagnostic, imaging and histopathological features, risk factors, and treatment options in RA-ILD and M-pneu. M-pneu, usually has an acute/subacute course characterized by cough, dyspnea and fever. Several risk factors, including genetic and environmental factors have been suggested, but none have been validated. The diagnosis is based on clinical and radiologic findings which are mostly consistent with non-specific interstitial pneumonia (NSIP), more so than bronchiolitis obliterans organizing pneumonia (BOOP). Histological findings include interstitial infiltrates by lymphocytes, histiocytes, and eosinophils with or without non-caseating granulomas. Treatment requires immediate cessation of MTX and commencement of glucocorticoids. RA-ILD shares the same symptomatology with M-pneu. However, it usually has a more chronic course. RA-ILD occurs in about 3-5% of RA patients, although this percentage is significantly increased when radiologic criteria are used. Usual interstitial pneumonia (UIP) and NSIP are the most common radiologic patterns. Several risk factors have been identified for RA-ILD including smoking, male gender, and positivity for anti-citrullinated peptide antibodies and rheumatoid factor. Diagnosis is based on clinical and radiologic findings while pulmonary function tests may demonstrate a restrictive pattern. Although no clear guidelines exist for RA-ILD treatment, glucocorticoids and conventional disease modifying antirheumatic drugs (DMARDs) like MTX or leflunomide, as well as treatment with biologic DMARDs can be effective. There is limited evidence that rituximab, abatacept, and tocilizumab are better options compared to TNF-inhibitors.

A prospective 1-year study on load reduction of school backpacks shows reversible changes of body posture in schoolchildren.

BACKGROUND: The impact of backpack carrying on body postural changes in schoolchildren has been discussed intensively. However, findings are inconsistent mainly due to the lack of long-term results. OBJECTIVE: The purpose of this investigation was to study the influence of backpack weight on body posture and prevalence of back pain. METHODS: In our prospective, comparative study, we investigated the influence of backpack weight on 77 schoolchildren (average age 10.8 ± 0.7 years) over a 1-year period. Participants were evaluated at the beginning of the study by clinical examination and formal static posture analysis. Forty-nine students comprised the control group while 28 students in the intervention cohort had the weight of their backpacks reduced by 2 kg. All students were reevaluated after 6 and 12 months by formal postural examination. RESULTS: Children with reduced backpack weights had a significantly improved bending posture when wearing their backpacks when compared to the participants of the control group, whereas the analysis of the children while they did not wear their backpacks revealed no difference between the groups. Within the follow-up period all postural changes were reversible once the backpack weight was removed. CONCLUSIONS: Schoolchildren with heavy backpack loads show postural changes while carrying their backpack but this impact was reversible when backpacks were removed. Continuous reduction of backpack loads minimizes prevalence of back pain.

Bilateral thalamic infarction--a rare manifestation of dural venous sinus thrombosis.

Bilateral infarctions of the thalamus account for only a small fraction of ischemic strokes and carry a poor prognosis. These infarcts rarely have a venous etiology. A case secondary to straight sinus thrombosis is presented. Difficulties in considering the diagnosis and its radiological appearances are discussed. A simple imaging pathway including computed tomographic angiography and magnetic resonance imaging including a susceptibility-weighted sequence is presented in order to facilitate determination of the exact etiology in order to optimize therapy accordingly.

Viewing the effective k-space coverage of MR images: phantom experiments with fast Fourier transform.

The purpose of this experimental study was to evaluate whether the effective k-space coverage of MR images can in principle be viewed after multidimensional Fourier transform back to k-space. A water-soaked sponge phantom providing homogeneous k-space pattern was imaged with different standard MR sequences, utilizing elliptic acquisitions, partial-Fourier acquisitions and elliptic filtering as imaging examples. The resulting MR images were Fourier-transformed to the spatial frequency domain (the k-space) to visualize their effective k-space coverage. These frequency domain images are named "backtransformed k-space images." For a quantitative assessment, the sponge phantom was imaged with three-dimensional partial-Fourier sequences while varying the partial acquisition parameters in slice and phase direction. By linear regression analysis, the k-space coverage as expected from the sequence menu parameters was compared to the effective k-space coverage as observed in the backtransformed k-space images. The k-space coverage of elliptic and partial-Fourier acquisitions became visible in the backtransformed k-space images, as well as the effect of elliptic filtering. The expected and the observed k-space coverage showed a highly significant correlation (r=.99, P<.001). In conclusion, the effective k-space coverage of MR images becomes visible when Fourier-transforming MR images of a sponge phantom back to k-space. This method could be used for several purposes including sequence parameter optimization, basic imaging research, and to enhance a visual understanding of k-space, especially in three-dimensional MR imaging.

Thromboembolism in atrial fibrillation.

Thromboembolism is a severe complication in atrial fibrillation. This overview presents thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ischemia. The PubMed, Embase, and Cochrane databases were systematically searched for the terms "atrial fibrillation" and "thromboembolism" in reports published from January 1986 to September 2009. The information of 10 evidence-based practice guideline documents and 61 further sources was systematically extracted. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants.

Intraosseous ultrasonography to determine the accuracy of drill hole positioning prior to the placement of pedicle screws: an experimental study.

OBJECT: Dorsal fixation with rods and pedicle screws (PSs) is the most frequently used surgery to correct traumatic and degenerative instabilities of the human spine. Prior to screw placement, screw holes are drilled along the vertebral pedicles. Despite the use of a variety of techniques, misplacement of screw holes, and consequently of the PSs, is a common problem. The authors investigated the usefulness of an intraspinal, intraosseous ultrasonography technique to determine the accuracy of drill hole positioning. METHODS: An endovascular ultrasound transducer was used for the intraluminal scanning of bore holes in trabecular bovine bone, 12 pedicle drill holes in cadaveric human spine, and 4 pedicle drill holes in a patient undergoing thoracic spondylodesis. Seven of the experimental bore holes in the cadaveric spine were placed optimally (that is, inside the pedicle) and 5 were placed suboptimally (breaching the medial or lateral cortical surface of the pedicle). Computed tomography scans were obtained in the patient and cadaveric specimen after the procedure. RESULTS: The image quality achieved in examinations of native bovine bone tissue, the formalin-fixed human spine specimen, and human vertebrae in vivo was equal. The authors endosonographically identified correct intrapedicular and intravertebral positions as well as poor (cortex breached) placement of drill holes. CONCLUSIONS: Intraosseous ultrasonography is a promising technique for the investigation of PS holes prior to screw implantation, and may add to the safety of PS placement.