MRI of CNS lymphoma with choroid plexus involvement in five dogs and one cat.

OBJECTIVES: To describe the clinical features, magnetic resonance imaging (MRI) findings, and outcome of dogs and cats with central nervous system (CNS) lymphoma that involved the choroid plexus. MATERIALS AND METHODS: A bi-institutional retrospective study of MRI of dogs and cats with CNS lymphoma, in which the choroid plexus was affected on MRI. Signalment, clinical, MRI, clinicopathologic and histopathologic findings were recorded and evaluated. RESULTS: CNS lymphoma with choroid plexus involvement on the MRI was identified in five dogs and one cat. MRI revealed diffuse enlargement and multifocal nodularity in the choroid plexus in most cases, with the fourth ventricle the most common site affected. Five of the cases had signs of extraneural involvement (including the cat), while the sixth case was not staged. Four of five CSF samples analysed provided a diagnosis of lymphoma. CLINICAL SIGNIFICANCE: We report MRI findings of CNS lymphoma involving the choroid plexus. These results show the importance of recognising novel imaging patterns and the potential utility of CSF collection in diagnosing CNS lymphoma involving the choroid plexus ante mortem.

The use of hysteroscopy in endometrial cancer: old questions and novel challenges.

Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option.

Effectiveness of different methods for polypectomy in the menopause: a retrospective study.

Introduction: Most endometrial polyps represent focal hyperplasia of the endometrium. Endometrial polyps can be diagnosed by ultrasound, hysterocontrast sonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the gold-standard method, with the greatest sensitivity and specificity and also with the opportunity for treatment at the same time.Study design: A retrospective study was conducted on 424 patients between 2006 and 2018. The polyps were verified during diagnostic hysteroscopy and were removed by resectoscopy or curettage. All samples underwent histological examination. The effectivity of the type of resection and the recurrence rate were evaluated.Results: The average age of the patients was 60.2 ± 9.3 years. Polyps were excised in 62.97% by resectoscopic polypectomy and in 37.03% by curettage. Malignancy was confirmed in 4.24% of cases. Histological verification of polyps was 79.4% in the resectoscopy group and 69.04% in the curettage group; the difference was significant (p < 0.01). The recurrence rate was 20.47% after resectoscopy and 27.12% following curettage.Conclusion: Hysteroscopy remains the best option and the gold-standard method among diagnostic procedures of endometrial pathology. In this study, there was a significant difference in matching hysteroscopic and histological findings in the two methods of polypectomy. The recurrence rate is also lower following resectoscopy.

Suspected Phenobarbital-Induced Pseudolymphoma in a Dog.

Pseudolymphoma is a drug reaction to anti-epileptics that is well recognized in humans; it has been reported in one cat but not dogs. In this report, lymphoma-like clinical signs are suspected to be secondary to phenobarbital administration in a dog. A 2.5-year-old male, neutered Shepherd mix presented for a 3-day history of progressive ataxia, dazed mentation, pyrexia, and lethargy. While hospitalized, the dog developed generalized lymphadenopathy and sustained pyrexia. The dog was receiving levetiracetam and phenobarbital for epilepsy, and serum concentrations of both were within standard therapeutic ranges. Abdominal ultrasound revealed hepatomegaly, splenomegaly, and generalized lymphadenopathy. Cytology of the peripheral lymph nodes was consistent with reactive lymph nodes, and aspirates of the liver and spleen revealed histiocytic-neutrophilic inflammation. Phenobarbital was discontinued and replaced with zonisamide. Within 24 hours, the dog was normothermic, and other clinical signs resolved within a week. This case highlights a potentially serious yet reversible adverse reaction to phenobarbital in a dog. This idiosyncratic reaction could be mistaken for neoplasia and is an important differential for lymphoma-like signs in any dog administered phenobarbital.

Optimal MRI interval for detection of asymptomatic recurrence in surgically treated early cervical cancer by use of a mathematical model.

INTRODUCTION: Applications of mathematical modeling may provide an insight into the timing of surveillance modalities. We aimed to determine the optimal magnetic resonance imaging (MRI) interval for the detection of surgically treated early cervical cancer asymptomatic recurrence by using a mathematical model for volumetric tumor growth time. METHODS: We assumed that tumor volume increases by a factor equal to the basis of natural logarithms (e~2.718) at constant time intervals. Using a mathematical formula, the tumor volume (V) was converted to diameter (D), which could be expressed as a function of time (t), given an initial diameter Di (corresponding to initial volume Vi) and a constant DT, where DT is the time required for volumetric tumor growth by a factor (e). Three different DTs were used for demonstration of the model, i.e. 20, 100 and 400 days. RESULTS: Assuming complete surgical clearance, a worst-case scenario for a 20-day DT indicated that a 20 µm cervical tumor would need at least 12 months to reach 10 mm in diameter, which would be detected with an annual surveillance interval MRI. Over a 5-year (60 months) follow-up, nearly five surveillance MRIs would be required if the threshold of 10 mm was desired. For a 100-day DT over a 5-year (60 months) follow-up, a single only MRI would be required, if the threshold of 10 mm was desired. In the case of an indolent tumor (DT is 400 days), the model would not recommend a surveillance MRI to detect asymptomatic recurrence. A positive linear association between optimal MRI intervals and volumetric tumor DTs was demonstrated. CONCLUSION: In the absence of evidence, we postulate annual MRI scanning is probably the shortest interval, which can be clinically useful for optimization of routine surveillance follow-up protocols in surgically treated early cervical cancer. This mathematical model requires proper verification in prospective clinical studies. Hippokratia 2016, 20(1): 4-8.

Function of the extensor mechanism of the knee after using the 'patellar-loop technique' to reconstruct the patellar tendon when replacing the proximal tibia for tumour.

The aim of this study was to analyse the gait pattern, muscle force and functional outcome of patients who had undergone replacement of the proximal tibia for tumour and alloplastic reconstruction of the extensor mechanism using the patellar-loop technique. Between February 1998 and December 2009, we carried out wide local excision of a primary sarcoma of the proximal tibia, proximal tibial replacement and reconstruction of the extensor mechanism using the patellar-loop technique in 18 patients. Of these, nine were available for evaluation after a mean of 11.6 years (0.5 to 21.6). The strength of the knee extensors was measured using an Isobex machine and gait analysis was undertaken in our gait assessment laboratory. Functional outcome was assessed using the American Knee Society (AKS) and Musculoskeletal Tumor Society (MSTS) scores. The gait pattern of the patients differed in ground contact time, flexion heel strike, maximal flexion loading response and total sagittal plane excursion. The mean maximum active flexion was 91° (30° to 110°). The overall mean extensor lag was 1° (0° to 5°). The mean extensor muscle strength was 25.8% (8.3% to 90.3%) of that in the non-operated leg (p < 0.001). The mean functional scores were 68.7% (43.4% to 83.3%) (MSTS) and 71.1 (30 to 90) (AKS functional score). In summary, the results show that reconstruction of the extensor mechanism using this technique gives good biomechanical and functional results. The patients' gait pattern is close to normal, except for a somewhat stiff knee gait pattern. The strength of the extensor mechanism is reduced, but sufficient for walking.

[Determination of activity levels in patients with cerebral palsy]. / Ermittlung des Aktivitätslevels bei Patienten mit infantiler Zerebralparese.

AIM: The aim of this study is the determination of physical activity in everyday life of handicapped persons due to cerebral palsy using standardised testing procedures. METHOD: The subjects were examined according to the Conconi test on a treadmill at increasing speeds for their fitness. We used a continuous heart rate monitoring, 3-axis acceleration sensors, lactate measurements and pedography. RESULTS: Three groups of subjects could be differentiated. In one group, a rapid rise in heart rate even at lower walking speed was observed. In a second group of persons with poor motor coordination, the maximum walking speed was limited. Single subjects were not limited neither in their physical performance nor in their condition. CONCLUSION: In the physical therapy for patients with cerebral palsy one should not lose sight of possible cardiovascular limitations additional to the physical disabilities.

Clinical, radiological and pathological correlates of leukoaraiosis.

INTRODUCTION: Leukoaraiosis is characterized by an abnormal appearance of the brain white matter on imaging. Its pathogenesis is still a matter of investigation. The purpose of this study was to investigate the radiological, clinical and pathological correlates of leukoaraiosis. METHODS: The study population consisted of 93 deceased patients. The pre-mortem T2W magnetic resonance images were evaluated for the presence and grading of leukoaraiosis. The clinical and pathological characteristics based on the clinical charts and autopsy reports were evaluated. Tissue specimens of the blocks of 19 brains that demonstrated severe leukoaraiosis and those of five control brains were excised and stained. RESULTS: The variables found to be significantly associated with leukoaraiosis were age and a clinical history of Parkinson's disease. Other risk factors and pathological markers of atherosclerosis were not significantly correlated with leukoaraiosis. No significant difference was found between the scoring of the myelin integrity, glial fibrillary acidic protein, cluster of differentiation 68 and smooth muscle actin. There was a significant difference with respect to thickening of vessels walls. CONCLUSIONS: Our pathological results indicate that structural vascular abnormalities characterized by vessel wall thickening are associated with leukoaraiosis, supporting the assertion that vascular changes and ischemia generate leukoaraiosis. The relations between parkinsonism and leukoaraiosis may be explicable through vascular effects on the circuitry of the basal ganglia.

[Calculation of functional kinetic parameters from the plantar pressure distribution measurement]. / Ermittlung funktioneller kinetischer Parameter aus der plantaren Druckverteilungsmessung.

PURPOSE: The aim of this study was the development of a simple procedure to calculate functional kinetic parameters from the plantar pressure distribution measurement which is used in many orthopaedic practices and clinics as a standard measurement device. The special purpose is the comparison of functional parameters between datasets taken before and after a surgical operation, for example the correction of a hallux valgus. METHOD: In the gait laboratory, pressure distribution measurements were recorded from healthy test subjects and patients with different foot diseases. The test subjects walked barefoot over the measurement plate which is integrated in a gangway. The device records a "movie" of the pressure distribution in the unrolling of the foot. It takes 72 pressure distribution pictures per second. By integrating the pressure over all segmental areas, i. e., pressure distribution picture for pressure distribution picture, the temporal progress of the total ground force can be calculated. By integration of the pressure only over a certain part of the foot, the ground force on that certain anatomic structure can be calculated, for example, the ground reaction force upon then hallux. By integration of the pressure over the same segmental areas considering their lever distance to the axes of the ankle joint, the external joint moment can be calculated. For this, the musculature of the lower leg must generate an internal moment, which exactly compensates the external moment. RESULTS: In the case of a correction of a hallux valgus, the percentage of the total external moment with regard to the upper ankle joint can be measured which is taken on by the hallux and metatarsal I. This allows us to verify a functional improvement through the operative treatment. With patients after one-sided injuries of the foot and ankle joints, the functional success of a treatment can be quantified by means of a comparison of sides, for example, after a fracture of the calcaneus. CONCLUSION: The determination of muscular ankle joint moments from the pressure distribution measurement improves the objectivity when reviewing the functional success of a therapy in different orthopaedic or surgical interventions at the foot and ankle joint.

[Plantar pressure measurement in children and youths during sports activities]. / Bodendruckmessungen am Kinder- und Jugendfuss bei sportlicher Aktivität.

The aim of this study was to consider whether changes occur in the foot area while under repeated physical stress and if they are age related. In addition it interests what consequences this might have in regard to proper shoe wear. The subjects for this study consisted of 15 children and youths aged between 4 and 16 years. The plantar pressure distribution and vertical ground reaction forces were measured before and after physical exercise. The subjects first ran a given distance wearing sport shoes, had a rest and then ran the same distance barefoot. The results showed marked age related differences after exercise. The pressure values were increased in all of the youths in the middle foot region. In comparison young children always exhibited an unbound gait pattern without any dynamic foot roll during heel strike or toe-off. The forefoot had ground contact from the beginning of the stance phase. To compensate for the lack of dynamic foot roll it is recommended that children wear a shoe with a soft sole and with sufficient space for toe movement. The sports shoe for youths should grip the heel and support the longitudinal arch to prevent an incorrect weight distribution.

[Chronic radiculopathy. Use of minimally invasive percutaneous epidural neurolysis according to Racz]. / Chronische Radikulopathie. Einsatz der minimal-invasiven perkutanen epiduralen Neurolyse nach Racz.

Treatment of chronic low back pain exhibiting radicular symptoms poses a clinical problem that has not yet been solved. The technique of percutaneous minimally invasive neurolysis described by Racz is being performed increasingly to treat chronic radiculopathy. A total of 61 patients with corresponding symptomatology after screening for inclusion and exclusion criteria in the region of the lumbar spinal nerve were treated with the Racz catheter technique. Distinct clinical improvement was observed at the 3- and 6-month follow-ups after percutaneous minimally invasive epidural neurolysis. Subjective pain perception, quantified by the McNab score, clearly improved after 3 as well as 6 months. With the exception of partial catheter shearing in two cases and one occurrence of infection, no relevant side effects were noted. The Racz catheter technique for treatment of chronic radiculopathy following disk surgery is suitable with minimal side effects.

[Using the gait laboratory for the investigation of orthopaedic clinical problems in children]. / Einsatz des Ganglabors bei klinisch-orthopädischen Fragestellungen in der Kinderorthopädie.

AIM OF THE STUDY: We point out multiple applications of a gait laboratory in solving different problems in the children's orthopaedic field. With typical examples we show how biometrical data of the gait laboratory can be helpful to solve problems in orthopaedic examinations. MATERIAL AND METHOD: The range of questions to be solved in the gait laboratory differs from individual diagnostic examinations of a patient up to the control of devices in the functional use at the patient. As a typical example for the individual examination we show the gait analysis in a 14-year-old girl with idiopathic chondrolysis of the hip joint. The functional use of orthopaedic devices will be shown in youths with neuroorthopaedic diseases. As a very special question to the gait lab we describe the supply of children and youths with optimal sport shoes for running. RESULTS: The biometrical measurement techniques generate exact data to solve individual diagnostic and therapeutic questions. Orthopaedic devices can be tested in their functional efficiency and quality. Special questions can be answered very flexible. CONCLUSION: Diagnosis and therapy in orthopaedics and children's orthopaedics rely on exact data. However, details of the dynamics during movement are neither visible to the most experienced orthopaedic surgeon nor can they be documented by conventional diagnostic imaging procedures. The present technical potential of biometric assessment methods allow to precise and correct some empirical knowledge, they open a wide field of new applications in diagnostic and therapeutic examinations.

[Leading symptom elbow pain. Differential diagnosis]. / Differenzialdiagnosen beim Ellenbogenschmerz. Denken Sie nicht nur an den Tennisarm.

Pain affecting the elbow joint may be caused by a number of different pathologies. In principle, these can be grouped by causality criteria into degenerative causes, inflammatory causes, tumor disease, congenital disease and the sequelae of trauma. The majority of these latter are associated with typical clinical symptoms that can be established with the aid of a systematic clinical examination, history-taking, inspection, palpation, an examination of joint mobility, and finally radiography. In this way, the diagnosis can rapidly be established.

[Minimally invasive percutaneous epidural neurolysis in chronic radiculopathy. A prospective controlled pilot study to prove effectiveness]. / Die minimal-invasive perkutane epidurale Neurolyse beim chronischen Nervenwurzelreizsyndrom. Eine prospektive kontrollierte Pilotstudie zum Wirksamkeitsnachweis.

The treatment of chronic back pain with sciatica is still an unsolved therapeutic challenge. Percutaneous minimally invasive neurolysis according to the Racz technique is increasingly applied and discussed controversially. So far there is no prospective randomized controlled study for evaluation of a possible treatment effect. In a prospective pilot study, 25 patients with monosegmental radiculopathy of the lumbar spine were treated with minimally invasive percutaneous epidural neurolysis according to Racz's technique. They all suffered from chronic disc herniations or failed back syndromes after surgery, all with radiculopathy. The average age of the patients was 51+/-16 years, the average duration of the symptoms was 28 months. Twelve weeks after the procedure patients had significant clinical improvement. The Oswestry score increased from 64+/-17 to 22+/-12 points. Subjective pain sensation according to the McNab score showed improvement too. None of the patients had worsening of the situation compared to preoperative findings. No clinically relevant complications were observed. The results are being used to design a clinical trial in accordance with good clinical practice guidelines to analyze the therapeutic efficacy of the procedure. The described technique is still a clinically experimental procedure. However, due to a low probability of side effects and due to the good results reported so far by most authors, the Racz catheter technique may be applied in certain patients with chronic radiculopathy refractory to conservative treatment.

[Calculation of hallux bending moments from plantar pressure distribution measurement]. / Ermittlung von Hallux-Biegemomenten aus der plantaren Druckverteilungsmessung.

PURPOSE: The following study aims to demonstrate the bending stress on a hallux valgus during normal gait. The bending axis was related to the position of an open wedge osteotomy. The moments were calculated from plantar pressure measurements. METHOD: In the gait analysis laboratory plantar pressure distribution measurement was done with healthy adult volunteers during barefoot gait. From the plantar pressure distribution the vertical forces were derived just for the region hallux metatarsal I. The following calculation of the bending stress regarding to the hypothetic region of the osteotomy was done by integrating the pressure distribution multiplicated with the distance to the osteotomy. The measurements are compared with theoretical values derived from the anatomy of the foot under some plausible assumptions. RESULTS: The results of the mean values of the bending stress were 15.8 +/- 4.8 Nm for the female subjects and 21.6 +/- 5.6 Nm for the male subjects. The amount of the bending moments depended with low significance on the weight. More important is the individual type of gait. CONCLUSION: The measurements show the size of bending stress the plate stabilizing the osteosynthesis has to resist under unfavorable circumstances (for example if the plantar foot muscles are not adequately activated) and if no external stabilization (for example, cast) is used.

[Congenital clubfoot]. / Mit Gips und Physiotherapie gegen die muskuläre Imbalance. Klumpfusstherapie ohne OP.

Owing to the relatively high incidence of this condition (2 in 1,000 neonates) and the poor functional outcome of inadequate treatment, clubfoot represents a major clinical problem. Although its etiology is not fully known, modern three-dimensional analyses have led to a better understanding of the pathomorphology and provide a new basis for a differentiated therapeutic strategy. Of central importance is early diagnosis and immediate postpartum initiation of primarily conservative treatment taking the form of intensive redressment measures. Depending on the residual deformity, an appropriate surgical procedure aimed at achieving complete correction should be done between the age of 4 to 6 months. To ensure a lasting positive outcome, rigorous follow-up physiotherapeutic treatment and close surveillance are essential.

Reestablishing Naturally Functioning Dunes on Developed Coasts.

/ The potential for reestablishing dune habitat is investigated in municipalities in New Jersey, USA, where natural coastal landforms and biota have been eliminated or reduced in extent. Dunes are classified using width, relationship to natural and cultural features, and changes through time, and they are assessed for their value as naturally functioning landforms in developed municipalities. The relationship between size and longevity that exists under natural conditions is altered by human activity. Small dunes on privately owned lots can survive as long as larger dunes in natural areas that are located farther inland, and foredunes repaired using sand fences and earth-moving equipment can survive where they could not under natural conditions.Common beach management practices reduce the ecological values of coastal dunes. Mechanical beach cleaning eliminates incipient dunes, habitat for nesting birds, seed sources for pioneer dune colonizers and food for fauna, and artificially small, stabilized foredunes reduce the variability in microenvironments necessary for biodiversity. Recent initiatives for reducing coastal hazards, protecting nesting birds, and encouraging nature-based tourism provide incentive for the development of a restoration program for beaches and dunes that is compatible with human use. Suggested changes in management practice include restricting or rerouting pedestrian traffic, altering beach-cleaning procedures, using symbolic fences to allow for aeolian transport while preventing trampling of dunes, and eliminating or severely restricting exotic species. Landforms will be more natural in function and appearance but will be more dynamic, smaller and in a different position from those in natural areas. Research needs are specified for ecological, geomorphological, and attitudinal studies to support and inform restoration planning.

[Recurrent Perthes disease in a 6-year-old boy]. / Rezidiv eines M. Perthes bei einem 6-jährigen Jungen.

Two episodes of avascular necrosis in the same femoral capital epiphysis have been reported in Gaucher's disease and in six cases of Legg-Calvé-Perthes disease. The present case report is an additional example of a recurrent avascular necrosis in a six years old boy two years after complete healing of the first occurrence had been documented clinically and radiologically.

[Protrusion of a calcified cervical intervertebral disk in a 5-year-old boy]. / Protrusion einer verkalkten zervikalen Bandscheibe bei einem 5-jährigen Jungen.

Herniation of the calcified nucleus pulposus is a complication of intervertebral disc calcification. The herniated nucleus pulposus may assume an intraspinal location which may lead to cord compression and produce alarming neurological symptoms and radiographic images. Surgical intervention is, however, rarely necessary as complete resorption of the calcified disc material will generally occur. We report the case of a five years old boy with the symptoms of an acute tortcollis, radiographs of the cervical spine revealed calcification of C5/C6 intervertebral disc and MRI narrowing of the spinal canal. With conservative treatment his symptoms resolved within three weeks, three months later X-rays and MRI showed complete resolution of the calcification and herniation.