Septic hip abscess due to Fusobacterium nucleatum and Actinomyces turicensis in an immunocompetent SARS-CoV-2 positive patient.

A 42-year-old man was referred to the Department of Orthopedic Surgery with pain over his right greater trochanter and signs of systemic infection. CT showed an enhanced mass in his gluteus maximus as well as gas in the biceps femoris over the underlying hip joint. Tissue biopsy yielded Fusobacterium nucleatum and Actinomyces turicensis. The patient was successfully treated for 6 weeks with amoxicillin/clavulanic acid 875mg/125mg and metronidazole 500mg.

[Detection of lung nodules. New opportunities in chest radiography]. / Detektion pulmonaler Rundherde. Neue Möglichkeiten der Thoraxradiographie.

BACKGROUND: Chest radiography still represents the most commonly performed X-ray examination because it is readily available, requires low radiation doses and is relatively inexpensive. However, as previously published, many initially undetected lung nodules are retrospectively visible in chest radiographs. STANDARD RADIOLOGICAL METHODS: The great improvements in detector technology with the increasing dose efficiency and improved contrast resolution provide a better image quality and reduced dose needs. METHODICAL INNOVATIONS: The dual energy acquisition technique and advanced image processing methods (e.g. digital bone subtraction and temporal subtraction) reduce the anatomical background noise by reduction of overlapping structures in chest radiography. Computer-aided detection (CAD) schemes increase the awareness of radiologists for suspicious areas. RESULTS: The advanced image processing methods show clear improvements for the detection of pulmonary lung nodules in chest radiography and strengthen the role of this method in comparison to 3D acquisition techniques, such as computed tomography (CT). ASSESSMENT: Many of these methods will probably be integrated into standard clinical treatment in the near future. Digital software solutions offer advantages as they can be easily incorporated into radiology departments and are often more affordable as compared to hardware solutions.

Musculoskeletal imaging with a prototype photon-counting detector.

OBJECTIVE: To test a digital imaging X-ray device based on the direct capture of X-ray photons with pixel detectors, which are coupled with photon-counting readout electronics. METHODS: The chip consists of a matrix of 256 × 256 pixels with a pixel pitch of 55 µm. A monolithic image of 11.2 cm × 7 cm was obtained by the consecutive displacement approach. Images of embalmed anatomical specimens of eight human hands were obtained at four different dose levels (skin dose 2.4, 6, 12, 25 µGy) with the new detector, as well as with a flat-panel detector. RESULTS: The overall rating scores for the evaluated anatomical regions ranged from 5.23 at the lowest dose level, 6.32 at approximately 6 µGy, 6.70 at 12 µGy, to 6.99 at the highest dose level with the photon-counting system. The corresponding rating scores for the flat-panel detector were 3.84, 5.39, 6.64, and 7.34. When images obtained at the same dose were compared, the new system outperformed the conventional DR system at the two lowest dose levels. At the higher dose levels, there were no significant differences between the two systems. CONCLUSION: The photon-counting detector has great potential to obtain musculoskeletal images of excellent quality at very low dose levels.

[Dose reduction and adequate image quality in digital radiography: a contradiction?]. / Dosisreduktion und adäquate Bildqualität in der digitalen Radiographie: ein Widerspruch?

CLINICAL/METHODICAL ISSUE: Dose reduction and adequate image quality in digital radiography - a contradiction? STANDARD RADIOLOGICAL METHODS: Digital radiography has already replaced traditional screen-film systems. METHODICAL INNOVATIONS: Substantial improvements in both dose efficiency and spatial resolution demonstrate the rapid developments in digital radiography. PERFORMANCE: Needle-detector systems have shown up to a 50% dose reduction compared to traditional screen-film systems. There is also a dose reduction capability of up to 50% comparing direct radiography (DR) systems to computed radiography (CR) systems for chest X-rays. However, despite the most recent achievements of CR technology, the dose efficiency of DR systems (caesium iodide flat-panel detector) is unparalleled. ACHIEVEMENTS: The progress in detector technology has contributed to dose reduction and improved image quality, while saving time and providing a higher examination rate. PRACTICAL RECOMMENDATIONS: The use of dose indicators and longitudinal dose control are important to avoid substantial accidental dose increase. The dose applied to patients should fall markedly below the defined diagnostic reference levels within the European Union. Regular quality control, as well as continuous education and training of medical and technical personnel, contribute to ensure that the ALARA (as low as reasonably achievable) principle is consistently followed.

[Diseases of the peritoneum and mesenterium]. / Erkrankungen von Peritoneum und Mesenterium.

Peritoneal diseases can be seen in the different imaging modalities either as fluid collections or solid tumors along the ligaments, mesenteries, and spaces of the peritoneal cavity. The broad spectrum of different abnormalities includes inflammatory, infectious, traumatic, and neoplastic diseases. In this article, a large variety of peritoneal abnormalities such as ascites, peritonitis, intraperitoneal hemorrhage, and both primary and secondary peritoneal tumors are discussed. The different imaging modalities, characteristic radiological features, and typical pathways of anatomic spread are explained.

[Peritoneum and mesenterium. Radiological anatomy and extent of peritoneal diseases]. / Peritoneum und Mesenterium: Radiologische Anatomie und Ausbreitungswege intraabdomineller Erkrankungen.

The abdominal cavity is subdivided into the peritoneal cavity, lined by the parietal peritoneum, and the extraperitoneal space. It extends from the diaphragm to the pelvic floor. The visceral peritoneum covers the intraperitoneal organs and part of the pelvic organs. The parietal and visceral layers of the peritoneum are in sliding contact; the potential space between them is called the peritoneal cavity and is a part of the embryologic abdominal cavity or primitive coelomic duct. To understand the complex anatomical construction of the different variants of plicae and recesses of the peritoneum, an appreciation of the embryologic development of the peritoneal cavity is crucial. This knowledge reflects the understanding of the peritoneal anatomy, deep knowledge of which is very important in determining the cause and extent of peritoneal diseases as well as in decision making when choosing the appropriate therapeutic approach, whether surgery, conservative treatment, or interventional radiology.

Assessment of bone mineral at appendicular sites in females with fractures of the proximal femur.

The prediction of hip fractures by measurements at remote sites or the improvement of predictive power by measurements at multiple sites could potentially increase the success of osteoporosis screening programs. In a cross-sectional study on 137 postmenopausal women, we tested the hypothesis that bone assessment at the hip, the forearm, and the tibia are independently associated with osteoporotic fractures of the hip. Bone mineral densities, geometric features, and ultrasound properties were determined with hip dual X-ray absorptiometry, forearm peripheral quantitative computed tomography (QCT), and tibia speed of sound measurement. While the odds ratios for fracture discrimination per standard deviation decrease ranged between 3 and 4 for measurements at the hip, they were only 1.8 at the forearm and 1.4 at the tibia. Measurements at the tibia or the forearm were neither independently associated with osteoporotic hip fractures (p > 0.05) nor could any combination of measurements significantly increase the power for the identification of fractures as measured with receiver operating curves. Women who sustained trochanteric fractures were characterized by a generalized loss of bone mineral. Cervical fractures were associated with a decrease of bone mineral density at the hip, but no significant alterations in bone mass or geometric properties were observed at the tibia or at the forearm. Fracture risk prediction at the hip is therefore preferably performed by measurements at the hip itself. Peripheral QCT at the distal radius and tibial ultrasound seem capable of depicting women with an increased risk for trochanteric but not for cervical fractures. The risk assessment appears not to be improved by including information of cortical or geometric properties of the forearm.

High resolution MRI of small joints: impact of spatial resolution on diagnostic performance and SNR.

This study focuses on the spatial resolution required for cartilage imaging. The purposes of this study were (I) to analyze the diagnostic performance in diagnosing artificially produced cartilage lesions in a small joint model using an optimized fat saturated three-dimensional gradient-echo sequence, (II) to relate the lesion size and depth as diagnosed in the magnetic resonance images with the corresponding pathologic findings and (III) to assess signal-to-noise (SNR) ratios for each of the protocols. Twenty-five artificial cartilage lesions were created in the knee joints of 10 rabbits. These specimens and seven specimens without lesions were imaged at 1.5 T using a three-dimensional gradient-echo sequence with varying slice thickness, field of view and matrix. A total of 404 corresponding images were selected, 50% with and 50% without cartilage lesions. Six radiologists scored all images according to five levels of confidence and receiver operating characteristic (ROC) analysis was performed. Lesion size and depth were compared to the corresponding pathological specimen sections. Additionally SNR ratios were calculated. ROC analysis of pooled data from all readers showed the highest area under the ROC curve for the sequence with the highest spatial resolution, while the diagnostic performance was significantly lower in the other sequences (p <0.01). Assessment of the lesion size and depth was correct in 45% and 40% respectively with the highest resolution and in 29% and 23% with the lowest resolution. SNR ratios decreased with increasing spatial resolution. In conclusion this study shows that increasing spatial resolution improves diagnostic performance in cartilage lesions, though SNR decreases substantially. Assessment of correct lesion size and depth still is limited.

[Ultrasound velocity measurement in the diagnosis of postmenopausal osteoporosis]. / Ultraschallgeschwindigkeitsmessung zur Diagnose der postmenopausalen Osteoporose.

We evaluated ultrasound transmission velocity as an indicator for osteoporosis at the os calcis of both feet and at the proximal phalanges of DII and DIII of both hands in 74 female subjects (22 premenopausal, 29 postmenopausal non-osteoporotic and 23 postmenopausal osteoporotic). In addition dual x-ray absorptiometry (DXA) of the lumbar spine was performed in 30 women and a combined cortical thickness index (CCT-index) of os metacarpale II was calculated from hand radiographs in 29 women. Ultrasound velocity at all sites slightly decreased in premenopausal women with age and declined significantly after menopause. At the hand postmenopausal osteoporotic women had significantly lower velocities than normal postmenopausal or premenopausal women while no difference could be seen at os calcis. An only poor or moderate correlation between ultrasound velocity at all sites and DXA of the lumbar spine and a good correlation between the CCT-index and velocity at the fingers indicate that ultrasound velocity is not only affected by bone density but even more by structural properties.

[Ultrasonic velocity measurements at weight-bearing and non-weight-bearing sites of the peripheral skeleton. The effect of physical activity in soccer players]. / Ultraschallgeschwindigkeitsmessungen an belastungstragenden und nicht-belastungstragenden Stellen des peripheren Skeletts. Der Einfluss körperlicher Aktivität bei Fussballspielern.

Ultrasound transmission velocity at the appendicular skeleton is determined by elastic properties of the bone as mass density. We evaluated ultrasound transmission velocity at the os calcis of both feet and at the proximal phalanges of DII and DIII of both hands in 51 male subjects. 28 of them were professional soccer players of the 1st German division, 11 subjects performed non-professional exercise in various athletic organisations regularly and 12 did not exercise at all. A significant difference in the speed of sound could be seen at os calcis, where the soccer players had higher velocities than the other groups. The differences between the groups at the upper and lower extremities suggest that changes in ultrasound transmission velocity are not only affected by structural changes in the aging skeleton, as it might be suggested by age differences, but by exercise. Physical exercise can change the properties (structure and/or density) of weightbearing bone and this can be detected by measuring ultrasound velocity.

Lung manifestation in asymptomatic patients with primary Sjögren syndrome: assessment with high resolution CT and pulmonary function tests.

The authors studied 37 consecutive patients with primary Sjögren syndrome and normal chest radiographs. Thin-section CT images were analyzed using a semiquantitative grading system. The presence, distribution, and severity of 9 morphologic parameters were assessed. In 34 patients, CT findings were correlated to pulmonary function tests (PFTs). Abnormal high resolution CT (HRCT) findings were seen in 24 of 37 patients (65%): interlobular septal thickening, n = 9; micronodules, n = 9; ground glass attenuation n = 4; parenchymal cysts, n = 5. Intralobular opacities, honey combing, bronchial wall thickening, bronchiectasis, and pleural irregularities were less frequent. Both HRCT and PFTs were normal in 10 patients. Computed tomography was normal in four patients with PFTs that indicated the presence of small airway disease. High resolution CT abnormalities were found in seven patients with normal PFT. The overall correlation between HRCT and PFTs was poor. High resolution CT and PFTs appear to be sensitive for both the early detection of parenchymal abnormalities and a decreases in lung function in asymptomatic patients with primary Sjögren syndrome. However, abnormal HRCT findings do not necessarily indicate a substantial alteration in PFTs.

Improved quality of life in patients treated with Peptide radionuclides.

Peptide receptor radionuclide therapy (PRRT) has recently been established as an important treatment modality for somatostatin receptor (SSTR)-positive tumors. The purpose of this study was to evaluate the clinical response, side-effects as well as the quality of life following (90)Y-DOTA-lanreotide (DOTALAN) and/or (90)Y-DOTA-Tyr (3)-DPhe(1)-octreotide (DOTATOC) therapy in patients with progressive metastatic disease during a 6-year follow-up period. Following dosimetric evaluation with (111)In-DOTALAN and (111)In-DOTATOC, 13 patients with estimated absorbed tumor doses of >5 Gy/GBq (carcinoid, n = 5; radioiodine-negative thyroid cancer, n = 4; gastrinoma, n = 1; insulinoma, n = 1; glucagonoma, n = 1; glomus jugularis tumor, n = 1) were assigned for PRRT. A dose of 925 MBq of (90)Y-DOTALAN (four patients) or 1.85-3.7 GBq of (90)Y-DOTATOC (10 patients) was administered intravenously and repeated every 4-8 weeks. Tumor dosimetry was performed prior to and under therapy, re-staging every 2-3 months. Pain intensity, Karnofsky score and general symptoms were evaluated in order to determine quality of life. Patients were followed until death. Altogether, 53 infusions of PRRT (1.85-14.1 GBq) were administered. After the first follow-up of 3 months of (90)Y-DOTALAN therapy, stable disease (SD) was observed in one patient and progressive disease (PD) in three patients. With (90)Y-DOTATOC therapy, SD was found in all 10 patients. During the re-evaluation period (4-27 months), one patient had to be shifted from (90)Y-DOTALAN to (90)Y-DOTATOC therapy due to reduced (111)In-DOTALAN uptake after 5.5 GBq. In the first 6 months after PRRT with DOTATOC, SD was found in nine of 10 patients and PD in one patient. Thereafter, SD was observed in two patients and PD in eight patients. Nine of 13 patients after PRRT with either DOTALAN or DOTATOC died. None of the patients had experienced severe acute hematological side-effects. Transient thrombocytopenia or lymphocytopenia was seen in 10 patients after 3.7 GBq, and a skin reaction in one patient. Total accumulated kidney dose ranged between 4 and 64 Gy, with reduced creatinine clearance in two patients. Pain relief was achieved in three of three patients after ~3.7 GBq ERT within 4-6 months. Appetite, weight, Karnofsky score and general well-being had improved in patients with SD during and after therapy. Based on the results of this study conducted on a small group of patients, we conclude that PRRT may offer an alternative treatment option for SSTR-positive tumors, with only mild transient side-effects and a marked improvement in the quality of life.

DR and CR: Recent advances in technology.

After some initial reluctance, nowadays transition from conventional analogue-to-digital radiographic technique is realized in the vast majority of institutions. The eventual triumph of digital over conventional technique is related to its undoubted advantages with respect to image quality and improved image handling in the context of a picture archiving and communication system. CR represents the older system, which matured over decades and experienced some important recent improvements with respect to dose efficiency and work-flow efficiency that strengthened its position. It represents a very versatile, economically attractive system that is equally suited for integrated systems as well as for cassette-based imaging at the bedside. DR systems offer superb image quality and realistic options for dose reduction based on their high dose efficiency. While for a long time only integrated systems were on the market suited for a large patient throughput, also mobile DR systems became recently available. While for the next years, it is likely that DR and CR systems will coexist, the long term perspective of CR will depend on further innovations with respect to dose efficiency and signal-to-noise characteristics while for DR economical aspects and broader availability of mobile systems will play a role.

Computer-aided detection (CAD) of lung nodules and small tumours on chest radiographs.

Detection of focal pulmonary lesions is limited by quantum and anatomic noise and highly influenced by variable perception capacity of the reader. Multiple studies have proven that lesions - missed at time of primary interpretation - were visible on the chest radiographs in retrospect. Computer-aided diagnosis (CAD) schemes do not alter the anatomic noise but aim at decreasing the intrinsic limitations and variations of human perception by alerting the reader to suspicious areas in a chest radiograph when used as a 'second reader'. Multiple studies have shown that the detection performance can be improved using CAD especially for less experienced readers at a variable amount of decreased specificity. There seem to be a substantial learning process for both, experienced and inexperienced readers, to be able to optimally differentiate between false positive and true positive lesions and to build up sufficient trust in the capabilities of these systems to be able to use them at their full advantage. Studies so far focussed on stand-alone performance of the CAD schemes to reveal the magnitude of potential impact or on retrospective evaluation of CAD as a second reader for selected study groups. Further research is needed to assess the performance of these systems in clinical routine and to determine the trade-off between performance increase in terms of increased sensitivity and decreased inter-reader variability and loss of specificity and secondary indicated follow-up examinations for further diagnostic workup.

[Balance of required dose and image quality in digital radiography]. / Abwägen von Dosisbedarf und Bildqualität in der digitalen Radiographie.

Projection radiography is in an advanced stage of progressive transition from conventional screen-film imaging to digital image acquisition modalities. The radiographic technique, including examination parameters such as tube voltage, tube current and filtration has frequently been adopted from screen-film technology. Digital systems, however, are characterized by their flexibility as the dose can be reduced at the expense of image quality and vice versa. The imaging parameters need to be individually optimized according to the best performance of a system. The traditional means of dose adjustment, such as positioning and collimation, are as valid for digital techniques as they were for conventional techniques. Digital techniques increasingly offer options for dose reduction. At the same time there is a risk to accidentally substantially increase patient dose due to the lack of visual control. Therefore, the implementation of dose indicators and dose monitoring is mandatory for digital radiography. The use of image quality classes according to the dose requirements of given clinical indications are a further step towards modern radiation protection.

[Overuse syndromes of the foot]. / Uberlastungssyndrome des Fusses.

Overuse syndromes due to lifestyle problems or sporting activities commonly lead to foot abnormalities. The tendons of the long flexor and extensor muscles are specifically prone to degeneration. The various disorders may be classified by a grading system that includes peritendinous inflammation, degenerative tendon disease, and ruptures. Bone marrow edema is another typical manifestation of overuse. It may be differentiated from inflammatory or traumatic forms of edema by its anatomic distribution. Systematic pattern recognition is based on the concept of musculotendinous and osseous kinetic chains.

Very recent onset rheumatoid arthritis: clinical and serological patient characteristics associated with radiographic progression over the first years of disease.

OBJECTIVES: Despite early recognition and disease modifying anti-rheumatic drug (DMARD) treatment, a sizable proportion of early rheumatoid arthritis (RA) patients show radiological progression. This study was performed to determine the frequency of erosive arthritis and the pace of radiological progression in an inception cohort of patients with very early RA (

[Systemic manifestations of rheumatoid arthritis]. / Systemische Manifestationen der rheumatoiden Arthritis.

Extra-articular manifestations of rheumatoid arthritis are gaining in importance both in rheumatology and other specialities. This report provides information on various organ manifestations and interactions between mere disease-related symptoms and therapeutic effects. Diagnostic radiology plays a crucial role in finding the diagnosis, planning and monitoring of treatment, early detection of complications and drug-related adverse events.

Does marathon running cause acute lesions of the knee? Evaluation with magnetic resonance imaging.

An investigation was conducted into whether running a marathon causes acute alterations in menisci, cartilage, bone marrow, ligaments, or joint effusions, which could be evaluated by magnetic resonance imaging (MRI). Twenty-two non-professional marathon runners underwent MRI of the knee before and immediately after running a marathon. Lesions of menisci and cartilage (five-point scale), bone marrow, ligaments (three-point scale), joint effusion, and additional findings were evaluated and a total score was assessed. Before the marathon, grade 1 lesions of the menisci were found in eight runners, and grade 2 lesions in five runners. After the marathon, an upgrading from a meniscal lesion grade 1 to grade 2 was observed in one runner. Before the marathon, grade 1 cartilage lesions were found in three runners, and grade 2 lesions in one runner, all of which remained unchanged after the marathon. Before and after the marathon, unchanged bone marrow edema was present in three runners and unchanged anterior cruciate ligament lesions (grade 1) were seen in two runners. Joint effusions were present in 13 runners in the pre-run scans, slightly increased in four runners after the marathon, and newly occurred in one runner after the marathon. A total score comprising all knee lesions in each runner showed an increase after the marathon in two runners, whereas no runner showed an improvement of the radiological findings (Wilcoxon signed-rank test, P>0.05). The evaluation of lesions of the knee with MRI shows that marathon running does not cause severe, acute lesions of cartilage, ligaments, or bone marrow of the knee in well-trained runners. Only subtle changes, such as joint effusions or increased intrameniscal signal alterations, were imaged after running a marathon.

Autoantibody profiling as early diagnostic and prognostic tool for rheumatoid arthritis.

BACKGROUND: Early treatment prevents progression of joint damage in rheumatoid arthritis (RA), but diagnosis in early disease is impeded by lack of appropriate diagnostic criteria. OBJECTIVE: To study the value of rheumatoid factor (RF), anti-cyclic citrullinated peptide autoantibodies (anti-CCP), and anti-RA33 autoantibodies for diagnosis of RA and prediction of outcome in patients with very early arthritis. METHODS: The prospective follow up inception cohort included 200 patients with very early (<3 months) inflammatory joint disease. Autoantibodies were measured at baseline and analysed in a tree based model which aimed at determining the added diagnostic value of testing for anti-CCP and anti-RA33 as compared with RF alone. RESULTS: RA was diagnosed in 102 patients, while 98 developed other inflammatory arthropathies. Receiver operator curve analysis showed an optimum cut off level for RF at 50 U/ml, above which anti-CCP and anti-RA33 had no additional diagnostic value. Remarkably, RF >or=50 U/ml and anti-CCP showed similar sensitivity and high specificity for RA, but overlapped considerably. Anti-RA33 was less specific and did not correlate with RF or anti-CCP. Among patients with RA, 72% showed at least one of these three autoantibodies, compared with 15% of non-RA patients. RF >or=50 U/ml and anti-CCP were predictors of erosive disease, whereas anti-RA33 was associated with mild disease. CONCLUSIONS: Stepwise autoantibody testing in early inflammatory joint disease, starting with RF, followed by anti-CCP (in patients with RF <50 U/ml), and finally anti-RA33, should be used as a sensitive and effective strategy for distinguishing patients with RA at high risk for poor outcome.