In vivo experiences with magnetic resonance imaging scans in Vibrant Soundbridge type 503 implantees.

OBJECTIVE: To observe the effects of magnetic resonance imaging scans in Vibrant Soundbridge 503 implantees at 1.5T in vivo. METHODS: In a prospective case study of five Vibrant Soundbridge 503 implantees, 1.5T magnetic resonance imaging scans were performed with and without a headband. The degree of pain was evaluated using a visual analogue scale. Scan-related pure tone audiogram and audio processor fitting changes were assessed. RESULTS: In all patients, magnetic resonance imaging scans were performed without any degree of pain or change in pure tone audiogram or audio processor fitting, even without a headband. CONCLUSION: In this series, 1.5T magnetic resonance imaging scans were performed with the Vibrant Soundbridge 503 without complications. Limitations persist in terms of magnetic artefacts.

MRI-Based Estimation of Scalar Cochlear-Implant Electrode Position.

The position of the cochlear-implant electrode is important to audiological outcomes after cochlear implantation. The common technique to evaluate the intracochlear electrode's position involves the use of ionized radiation in MSCT, DVT, or flat-panel tomography (FPT). Recent advances in knowledge regarding the handling of MRI artifacts in cochlear implantees indicate that estimating the intracochlear electrode's position with an MRI could be possible. This study's aim was to evaluate the ipsilaterally position of electrodes using MRI at 1.5 T. In a retrospective study of 10 implantees with postoperative need for MRI scanning, we evaluated the intrascalar electrode's position using a T2-weighted sequence at 1.5 T. We compared the resulting estimate of the intracochlear position with the estimates from the postoperative FPT scan and the intraoperative NRT ratio. For each ear, the MRI-estimated scalar position corresponded with the estimated positions from the FPT and NRT ratio. For eight ears, a scala tympani's position was observed in the MRI. In one case, an electrode scalar translocation was found. In one case, the scala vestibuli's position was observed. Thus, MRI-based estimation of the scalar position of a cochlear-implant electrode is possible. Limitations to this method include implant-specific magnet and fixation configurations, which can cause complications.

Postoperative imaging of the internal auditory canal : Visualization of active auditory implants.

BACKGROUND: Assessment of the internal auditory canal (IAC) and cochlea is of central importance in neurotology. The artefacts and visibility of active auditory implants on magnetic resonance imaging (MRI) vary because of their specific magnetic components. Knowledge of the size of MRI artefacts and the options for handling them is important for the auditory rehabilitation of specific diseases (e. g., vestibular schwannoma). METHODS: The current article is a literature review. RESULTS: MRI assessment of the IAC and cochlea after surgical placement of an active auditory implant is feasible only with a percutaneous bone-anchored hearing aid (BAHA, Ponto). When specific factors (implant position and MRI sequence) are taken into consideration, these structures can be visualized even after cochlear implantation. Complications such as magnet dislocation and pain may occur. CONCLUSION: The possibility of assessing the IAC and cochlea by MRI is an important aspect that needs to be taken into consideration when planning the auditory rehabilitation of patients after acoustic neuroma surgery.

[Postoperative imaging of the internal auditory canal : Visualization of active auditory implants. German version]. / Postoperative Bildgebung des inneren Gehörgangs : Darstellung aktiver auditorischer Implantate.

BACKGROUND: Assessment of the internal auditory canal (IAC) and the cochlea is of central importance in neurotology. The artefacts and visibility of the different types of active auditory implants in MRI vary, due to their specific ferromagnetic components. Knowledge of the size of MRI artefacts and the options for handling these is important for the auditory rehabilitation of specific diseases (e. g., vestibular schwannoma). METHODS: The current paper is a literature review RESULTS: MRI assessment of the IAC and cochlea after surgical placement of an active auditory implant is feasible only with a percutaneous bone-anchored hearing aid (BAHA, Ponto). When specific factors (implant position and MRI sequence) are taken into consideration, these structures can be visualized even after cochlear implantation. Complications such as magnet dislocation and pain may occur. CONCLUSION: The possibility of assessing the IAC and cochlea by MRI is an important aspect that needs to be taken into consideration when planning the auditory rehabilitation of patients after acoustic neuroma surgery.

Existence of bovine neonatal pancytopenia before the year 2005? Retrospective evaluation of 215 cases of haemorrhagic diathesis in cattle.

Haemorrhagic diathesis (HD) in cattle is a relatively rare syndrome that can have many different causes. With the occurrence of bovine neonatal pancytopenia (BNP) in 2007, the number of cases of HD in cattle has increased. This led to an enhanced interest in diseases presenting with bleeding disorders. The possible causes of HD in cattle, the clinical findings, and the course of various diseases are described and evaluated. Furthermore, we determined whether cases of BNP occurred before the introduction of the vaccine Pregsure BVD since its widespread use was associated with the syndrome. Records of 215 cases of HD in cattle that had been referred to the Clinic for Ruminants with Ambulatory and Herd Health Services at the Centre for Clinical Veterinary Medicine, Ludwig Maximilian University, Munich, between 1982 and 2014 were evaluated. The two most commonly diagnosed diseases were BNP (n = 95) and septicaemia (n = 35), with fatality rates of 82% and 66%, respectively. In 27 (13%) cases, no clear cause for the HD could be designated. Statistically significant differences were found with regard to the course of the various disorders and the clinical findings. A receiver operating characteristic analysis of thrombocyte counts of affected animals at the time of arrival at the clinic did not provide any predictive information on disease outcome. Two cases of HD occurred before the introduction of Pregsure BVD (1989, 1991). In both cases, clinical, haematological, and pathological findings were identical to BNP. The cause of HD in these two cases could not be determined retrospectively.

Electrophysiological detection of scalar changing perimodiolar cochlear electrode arrays: a long term follow-up study.

The position of the cochlear electrode array within the scala tympani is essential for an optimal hearing benefit. An intraoperative NRT-ratio was established, which can provide information about the intraoperative intracochlear electrode array position for perimodiolar electrodes. The aims of this study were to verify the longterm reliability for the NRT-ratio in perimodiolar electrodes. In a retrospective controlled study in a Tertiary Referral Center the electrophysiological data sets of 123 patients with implanted Nucleus Contour Advance electrodes were enclosed. Intraoperative and up to 1 year follow-up Auto-NRTs were evaluated. A NRT-ratio was calculated by dividing the average Auto-NRT data from electrode 16 to 18 with the average from electrode 5 to 7. Using a flat panel tomography system, the position of the electrode array was certified radiological. 31 patients with perimodiolar electrodes with 1 year follow-up data were included in the study. Eleven patients showed regular follow-up NRT-ratio with a correlated and radiologically confirmed electrode position. 20 patients showed mismatches between the NRT-ratio and the radiological position. These patients were highly variable in terms of duration of deafness and neural spectrum disorders. The NRT-ratio can be used to determine the intracochlear position of the electrode array for perimodiolar electrodes. Intraoperatively the NRT-ratio predicts the array position within the cochlea highly reliable for perimodiolar electrodes. We showed that after 6 months and a year, the NRT-ratio remains unchanged in most of the cases and shows a good correlation to the radiological determined position of the array. Nevertheless, the condition of the neural structures is highly important for reproducible responses. Limited validity is given in patients with degenerative and structural neural disorders.

Radiological control of the floating mass transducer attached to the round window.

The surgical rehabilitation of mixed hearing losses can be performed by coupling the floating mass transducer of the Vibrant Soundbridge to the round window. The quality of coupling the floating mass transducer to the round window is crucial for the audiological outcome. It was the aim of this study to further observe the different patterns of floating mass transducer position at the round window. We compared twenty patients with mixed hearing loss implanted with a floating mass transducer attached to the round window and 24 surgeries between 5/2007 and 6/2010. An evaluation of the chronological observation of the flat panel angiography-controlled position of the floating mass transducer at the round window with relation to the surgical report and the audiological outcome was done. We observed no changes in the mean pre- and postbone conduction thresholds. The floating mass transducer position was variable and could be radiologically classified and correlated with the audiologically outcome. A learning curve was observed from the earlier to later implantations. Postoperative, radiological evaluation of the location and angle of the floating mass transducer by means of flat panel tomography allowed us to classify the floating mass transducer position at the round window into 4 groups.

[High incidence of jaundice in young calves in Southern Germany]. / Häufung von Ikterus bei jungen Kälbern in Süddeutschland.

OBJECTIVE: Between September, 2010, and August, 2011, a series of cases of jaundice of unknown origin in young calves was detected in a number of farms in Southern Germany. This paper describes the syndrome on the basis of 57 cases, and the approach taken to discover the cause. MATERIAL AND METHODS: The clinical course of the disease is described in 19 patients. Using a case definition (calves aged 1-3 weeks, total serum bilirubin > 20 µmol/l and/or serum glutamate dehydrogenase [GLDH] activity >50U/l and/or autopsy findings with striking liver pathology [jaundice, liver dystrophy, cirrhosis]), 36 farms were included in an epidemiological survey. In a feeding trial, two batches of a dietary supplement feed, previously used in diseased calves on farms, were fed at the dosage recommendations of the manufacturer to four clinically healthy calves over 5days. Four other calves served as controls. The calves were clinically monitored daily, and blood samples were investigated using clinical chemistry and haematology. RESULTS: Clinical examination revealed behavioural alterations (weakness, tonic-clonic seizures and bawling just before death), recumbency, jaundice and discolouration of faeces. In less severe cases without clinical signs, there was an increase in serum bilirubin concentration and/or GLDH activity. In the epidemiological survey of affected farms, the feeding of a diet supplement feed was registered in 54 of 57 cases. The feeding of two batches of that diet supplement feed to four clinically healthy calves resulted in a significant (p<0.05) increase in bilirubin and lactate concentrations, as well as the GLDH activity in serum, but without serious impairment of the general condition, whereas in control calves, no comparable changes were observed. CONCLUSION: The results of the epidemiological survey and the feeding trial suggest a causal involvement of a dietary supplement feed. The toxic principle is unknown. CLINICAL RELEVANCE: Knowledge of the clinical picture and the probable feed-related context is important to detect this disease early. The suspected dietary supplement feed has been taken off the market, but with other products similar problems may arise.

[Cochlear implants in isolated temporal bones: evaluation of electrode position with 64-slice computed tomography]. / Kochleaimplantate im Felsenbeinpräparat : Evaluation der Elektrodenlage mittels 64-Zeilen-Computertomographen.

BACKGROUND: For the functional outcome after cochlear implant surgery, the electrode position is of essential importance. Therefore, radiological techniques to localize the electrode within the cochlea are becoming increasingly important. In our study, we used multi-slice computed tomography (CT) to find radiological criteria to allocate the electrode within the cochlea. METHODS: Ten Nucleus 24 RCA electrodes were implanted into isolated human temporal bones using an extended cochleostomy and the Advance Off-Stylet technique. Five electrodes were implanted into the scala tympani and five into the scala vestibuli. After implantation, the temporal bones were blinded to the radiologist, and 64-slice CT scans were performed and analysed. RESULTS AND CONCLUSIONS: In all 10 cases, the surgical positioning of the electrode was equal to the radiological analysis of the CT scans. Radiological criteria were found that permit correct identification of the electrode within the cochlea. We think that this technique is sufficient for most questions concerning quality control and is widely available.

The role of cerebrospinal fluid flow study using phase contrast MR imaging in diagnosing idiopathic normal pressure hydrocephalus.

BACKGROUND: The purpose of this prospective study was to identify the ability of cerebrospinal fluid flow study using phase contrast MR imaging to replace the invasive methods currently used to establish the diagnosis of idiopathic normal pressure hydrocephalus (iNPH). MATERIALS AND METHODS: Between January 2003 and April 2005, 61 patients with clinical symptoms fitting the Hakim triad and a dilated ventricular system on CT underwent a intrathecal infusion test and cerebrospinal tap test. All patients also had a phase contrast MRI to determine the CSF flow rate in the aqueduct. Shunted patients were followed postoperatively up to 12 months. The pre- and postoperative symptomatic condition was evaluated using the clinical Kiefer score. The outcome was calculated by the NPH Recovery Rate. FINDINGS: Patients were classified into 41 with iNPH and 20 patients with brain atrophy. Thirty-nine iNPH patients were shunted and two patients refused surgery. The mean Kiefer score of the shunted patients was statistically significantly lower after surgery. In patients screened for clinical symptoms and ventriculomegaly on CT imaging, an aqueduct-CSF flow rate greater than 24.5 ml/min was found to be statistically specific for a diagnosis of iNPH. CONCLUSIONS: The measurement of the CSF flow rate in the aqueduct by using the phase contrast MRI technique is a highly specific pre-selective method for diagnosing iNPH.

Application of the glutaraldehyde test in cattle.

In a cohort study involving 62 cows from an experimental farm, the kinetics of the glutaraldehyde test (GAT) according to Sandholm (1974) was examined by testing samples of EDTA blood, lithium heparinate blood, serum, and plasma taken at various intervals. Total protein was measured in serum, and fibrinogen was determined in plasma. Gamma globulin was measured by electrophoresis. All glutaraldehyde tests were performed in duplicates, and the relation of the two results was used as measurement of precision. Optimal cut-off of the GAT time was determined as the zenith of the sum of sensitivity and specificity of various intervals for detecting combinations of gamma globulin and fibrinogen levels above 32 g/l. Precision was the best in EDTA blood. The relation between coagulation time and gamma globulin plus fibrinogen is best described by an exponential curve. The maximum value for the sum of sensitivity and specificity was found at 7 and 8 min. Seven days was the shortest interval observed between a negative test result (>15 min) and a strongly positive test result (<3 min). Twenty-one days was the shortest interval observed between a strongly positive test result and a negative test result. EDTA blood should be used for the GAT. A cut-off of 8 min yields the highest efficiency. Test results must be viewed in light of clinical findings.

[The aetiology of generalized alopecia in young calves]. / Untersuchungen zur Ursache des generalisierten Haarausfalls bei jungen Kälbern.

The objective of this study was to test for correlations between alopecia and ruminal drinking in young calves. 331 calves up to an age of 31 days were tested for evidence of generalized hair loss daily during their stay in the clinic. Incidence of diarrhoea and the results of ruminal fluid and blood analysis were compared between the groups with and without alopecia. Calves with alopecia showed a significantly higher incidence of diarrhoea and of ruminal acidosis persisting for at least 24 hours. Blood analysis revealed significant differences in degree of acidosis, in concentrations of D-lactate, urea, and creatinine in serum as well as in the activities of glutathione peroxidase, aspartate amino transferase, and creatine kinase. Alopecia in calves is correlated to longer periods of diseases, which are known to be accompanied by the production of D-lactate in the gastrointestinal tract, such as diarrhoea and ruminal drinking. The question, whether alopecia is due to formation of toxic substances or to deficiency of essential substances can not be answered.

[Idiopathic normal-pressure hydrocephalus. Flow measurement of cerebrospinal fluid using phase contrast MRI and its diagnostics importance]. / Idiopathischer Normaldruckhydrozephalus. Liquorflussmessung mittels Phasenkontrast--RT und ihre diagnostische Bedeutung.

AIM: The measurement of CSF flow in the aqueduct has been a focus of interest since the development of MR imaging (MRI) techniques for this purpose in diagnosing idiopathic normal-pressure hydrocephalus (iNPH).The purpose of this prospective study was to determine the ability of this diagnostic tool to replace invasive methods in establishing the diagnosis of iNPH. PATIENTS AND METHODS: Between January 2003 and April 2005, 61 patients with the Hakim triad of clinical symptoms and dilated ventricular systems underwent the intrathecal infusion test, cerebrospinal tap test, and phase-contrast MRI to measure CSF flow rate in the aqueduct. Shunted patients were controlled 12 months postoperatively. Pre- and postoperative clinical symptoms were evaluated with the Kiefer score. Outcome was calculated according to the NPH recovery rate. RESULTS: According to these criteria the patients were classified into groups of 41 with iNPH and 20 with brain atrophy. Of the iNPH patients, 39 were shunted and two did not agree to surgery. The mean Kiefer score of the shunted patients was statistically significantly lower after surgery. The aqueductal CSF flow rate of these patients was statistically analyzed and showed that a flow rate of more than 24.5 ml/min is 95% specific to iNPH. CONCLUSIONS: Measurement of the CSF flow rate in the aqueduct using phase-contrast MRI is a highly specific preselective method for diagnosing iNPH.

Neurotological and neuroanatomical changes in the connexin-26-related HID/KID syndrome.

The phenotype of the HID (hystrix-like ichthyosis, deafness)/KID (keratitis, ichthyosis, deafness) syndrome is primarily characterized by skin changes. However, the connexin 26 (Cx 26) autosomal dominant mutation underlying this syndrome is of special neurotological interest. In the present paper, the clinical pattern, audiovestibular and neuroimaging findings and the detailed genetic analysis of 4 patients with identical HID/KID-associated mutation D50N of Cx 26 are reported. The audiological test results demonstrated profound sensorineural hearing loss in all of the patients. Neurotological testing revealed inconsistent abnormalities in dynamic posturography (sensory organization test), but the vestibular ocular reflex upon caloric irrigation was normal in all patients. Vestibular-evoked myogenic potential testing for otolith function (saccule) showed a regular response in 1 patient and pathologic responses in 3 patients, while subjective haptic vertical (utricular function) testing was normal in all of the patients. CCT showed an extended (in length), but very thin (in diameter) bony lining between the basal portion of the internal auditory canal and the vestibule in the 3 scanned patients. Our study provides evidence for functionally intact semicircular canals and normal utricular function in subjects with the autosomal dominant D50N mutation of Cx 26, in contrast to saccular function which was generally compromised and hearing loss which was profound.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.

BACKGROUND: Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs. OBJECTIVES: To assess the efficiency and effectiveness of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CENTRAL, CCMED, publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and congress abstracts were handsearched. Trials were obtained from the Cochrane Injuries Group's trials register. Authors were contacted for further information and individual patient data. PARTICIPANTS: patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury. INTERVENTIONS: diagnostic algorithms comprising emergency ultrasonography (US). CONTROLS: diagnostic algorithms without US ultrasound examinations (e.g. primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]). OUTCOME MEASURES: mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life. STUDIES: randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs). DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate. MAIN RESULTS: We identified two RCTs with US in the experimental arm and another with US in the control group. We also considered two qRCTs. Overall, trials were of moderate methodological quality. Few authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We were able to pool data from two trials comprising 1037 patients for primary endpoint analysis (i.e. mortality). The relative risk in favour of the no-US arm was 1.4 (95% CI 0.94 to 2.08). Because of a lack of details, the meaning of this observation remains unclear. There was a marginal benefit with US-based pathways in reducing CT scans (random-effects RD -0.46; 95% CI -1.00 to 0.13), offset by trials of higher methodological rigour. No differences were observed in DPL and laparotomy rates. AUTHORS' CONCLUSIONS: There is insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

D-Lactic acidosis in calves as a consequence of experimentally induced ruminal acidosis.

In order to test the hypothesis that ruminal drinking in calves can lead to D-lactic metabolic acidosis, ruminal acidosis was induced in nine calves by intraruminal application of untreated whole milk via a stomach tube. The amount of the daily force-fed liquid was 3 x 1 l. The experimental design called for an end of intraruminal applications if two or more of the following signs were observed: severe depression, estimated degree of dehydration >10%, absence of sucking reflex, lack of appetite for two consecutive feedings, severe metabolic acidosis with calculated Actual Base Excess (ABE) <-15 mmol/l. The procedure was scheduled to be discontinued on the 17th day of experiment. The onset of ruminal acidification occurred rapidly, and mean pH value fell from 6.70 (+/-0.48) to 4.90 (+/-0.38) after the first application. The following days the pH values varied between 4 and 5. Rumen acidity was characterized biochemically by a significant increase in both isomers of lactic acid. The effects of the intraruminal administration on the calves were detrimental; eight of nine calves showed an acute disease process. According to the pre-established clinical standard, seven of nine calves were removed from the intraruminal feeding schedule. All but one of the calves developed severe systemic acidosis. The increase in anion gap demonstrated the net acid load. In all the calves D-lactate levels were found to show a significant and rapid increase. On the contrary, L-lactate never deviated from physiological levels. These observations confirm that, in young calves as in adult cattle, ruminal acidosis may lead to a clinically manifested D-lactic metabolic acidosis.

[Diagnostic efficacy of gadodiamide-enhanced dynamic examination technique in comparison to conventional magnet resonance tomography in exacerbated chronic osteomyelitis]. / Diagnostische Effektivität der Gadodiamid-verstärkten dynamischen Untersuchungstechnik im Vergleich zur konventionellen Magnetresonanztomographie bei exazerbierter chronischer Osteomyelitis.

PURPOSE: To evaluate the diagnostic effectiveness of dynamic gadodiamide-enhanced MRI in discriminating reparative tissue formation from florid inflammation in patients with chronic osteomyelitis. MATERIALS AND METHODS: Subjects with chronic osteomyelitis and clinically suspected exacerbation were consecutively enrolled into a prospective trial. Following conventional contrast-enhanced MRI scanning, a dynamic contrast-enhanced SE sequence was carried out in all patients (acquisition interval 58 s, 11 repetitions with a total acquisition time of 11 minutes). The relative increase of the time-dependent signal intensity was assessed in representative circular regions of interest placed over bone marrow and surrounding soft tissues. As diagnostic reference standard, histologic and intraoperative findings were obtained independently from the result of the index test. The MRI studies were evaluated by two radiologists who were blinded to the findings of the reference test. RESULTS: 30 of 51 patients were subsequently scheduled for surgery (mean age 42.6 +/- 12.7 years, 27 males). 19 cases had a florid granulocytic infection, with 6 cases showing histologic signs of putrid liquefaction. Another 11 patients had chronic-granulating, fibrosing osteomyelitis. The course of the signal-time curves differed significantly between the different pathologic processes (multiple measures ANOVA, p < 0,001) in both bone marrow and soft tissue. The areas under the receiver operating characteristics (ROC) curves of the dynamic sequence as a performance measure to distinguish between acute and chronic infection were 0.73 (95 % confidence interval 0.41 - 1.00) and 0.82 (95 % confidence interval 0.59 - 1.00), respectively. Although no overall difference was found in diagnostic efficacy between conventional and dynamic MRI, the dynamic technique provided important additional information for equivocal conventional results. CONCLUSION: Dynamic contrast-enhanced MRI scanning is a safe and potentially valuable tool to discriminate between florid and chronic inflammation in documented osteomyelitis.

Evaluation of the Merlin, Micronaut system for automated antimicrobial susceptibility testing of Pseudomonas aeruginosa and Burkholderia species isolated from cystic fibrosis patients.

Since accurate antimicrobial susceptibility testing of bacterial cystic fibrosis isolates is known to be problematic and an optimal in vitro testing method has not yet been evaluated, the study presented here was conducted to compare the performance of the reference agar dilution method and broth microdilution with a commercially available automated susceptibility test system (Merlin; Micronaut, Germany). In this pilot study, the susceptibility of 70 clinical strains of Pseudomonas aeruginosa and Burkholderia cepacia-like organisms to nine antimicrobial agents was tested using these methods. Susceptibility results generated by broth microdilution (both automated and according to the National Committee for Clinical Laboratory Standards recommendations) were demonstrated to be of good reproducibility, and they compared favourably to the time- and material-consuming standard agar dilution reference method, especially after a prolonged incubation time (48 h).

[Emergency ultrasound for blunt abdominal trauma--meta-analysis update 2003]. / Sonographische Diagnostik im Schockraum bei stumpfem Bauchtrauma--Metaanalyse Update 2003.

Emergency ultrasound has established itself as a key procedure of primary diagnostic work-up for blunt abdominal and multiple trauma. However, in a systematic review published in 2001 ultrasonography turned out to provide an unexpectedly low sensitivity. We conducted an update of this analysis to investigate if test characteristics will be maintained including recent studies. Prospective trials published between January 1957 and January 2003 were identified using the Medline/Oldmedline, Embase and Cochrane Controlled Trials Register databases. The searching strategy comprised a manual search as well as a search along the world-wide web. Qualitative rating was carried out by two investigators using criteria proposed by the Centre for Evidence-Based Medicine, Oxford. We investigated a composite endpoint (i. e., free fluid and/or organ laceration) as well as the single criteria organ injury and free intraabdominal fluid collections. After calculation of two-by-two-tables, Summary Receiver Operating Characteristics (SROC) and Q* values were determined together with their 95% confidence intervals. The Q* value was proposed as the point of intersection where sensitivity equals specificity. In addition, a random effects model was employed to compute common positive and negative likelihood ratios (LR). By assessing the title and/or abstract, 349 of 957 papers contained potentially valid information for the purpose of this review. A total of 67 studies were deemed eligible, nine of which had to be excluded from meta-analysis because of dual publication. This left 58 trials allocating 16,361 subjects for statistical analysis. Despite a trend towards improved study designs observed during the past decade, the included trials were of average methodological quality. Two-thirds of all investigations fulfilled two or less of the six possible quality criteria. The diagnostic reference standard was applied independently in only 40% of all protocols. With regard to the composite endpoint and the sonographic depiction of free fluid, the Q* value was estimated at 0.91, whereas Q* equaled 0.90 for the detection of organ injury. Q* values subsequently decreased with improving study quality and fell clearly below 0.80 in methodologically proper studies. Accounting for a negative LR of 0.23 (composite endpoint) and an assumed prevalence of 35% of intraabdominal injury, a post-test probability of 11% will remain in case of a negative sonogram. In pediatric trauma, ultrasound showed even worse test characteristics (negative LR = 0.43). Thus, in case of a 35% prevalence, the post-test probability has to estimated at 19%. Emergency ultrasound provides high specificity but insufficient sensitivity to reliably rule out intraabdominal injury.