Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia

To evaluate the level of concurrence between radiologist reports and the diagnosis of community-acquired pneumonia (CAP) in patients discharged from an emergency department (ED), a retrospective chart audit of patients discharged with a diagnosis of pneumonia or possible pneumonia from the ED during a 2-year period was conducted. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as pneumonia, possible pneumonia, non-pneumonia and normal, and categories from each were compared. 815 charts were analyzed. Of 671 EP diagnoses of pneumonia, 304 (45.3%) RRs reported pneumonia and 82 (12.2%), possible pneumonia. Of 815 EP diagnoses of pneumonia or possible pneumonia, 426 (52.3%) RRs were in agreement, while 216(26.5%) were of diagnoses other than pneumonia and 173 (21.1%) were read as normal. EPs and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time to revisit the gold standard status of plain chest X-ray.Presented at the 9th International Conference of Emergency Medicine, Edinburgh, Scotland, 17–21 June, 2002.     

Evaluation of an ACTBP2 ladder composed of 26 sequenced alleles

A total of 90 alleles found in white Caucasians from North-West Germany were sequenced and 26 alleles chosen to construct a uniform and reliable allelic ladder for the STR system ACTBP2 (SE33). In addition 3 new aspects concerning the sequence structure were observed. Population studies were carried out on white Caucasians (n = 278) from North-West Germany using the new improved ladder. A total of 24 alleles and 14 interalleles were found and reproducible results obtained. No significant deviation from Hardy-Weinberg-equilibrium could be observed.Dedicated to Prof. Dr. U. Heifer on the occasion of his 65th anniversary     

Technical parameters influencing the severity of injury of front-seat,belt-protected car passengers on the impact side in car-to-car side collisions with the main impact between the front and rear seats (B-pillars)

Summary Authentic car-to-car side collisions (n = 30) with the main impact area at the B-pillar were analyzed to find technical parameters corresponding with the injury severities of the front seat, belt-protected car passengers on the impact side. EES (Energy Equivalent Speed) and Av (delta v, change in velocity) were highly significant predictors of the severity of thoracic and abdominal injuries and total injury severity coded according to the Abbreviated Injury Scale (AIS). At an EES or v 40 km/h all front-seat car passengers on the impact side sustained a total injury severity of Maximum AIS (MAIS) 4 and died. Although a passenger could survive the crash without injury to one or more body regions up to the highest EES- and Av-values, at EES or v 40 km/h fatal injuries were sustained in at least one body region. At an EES 35 km/h or a Av 15 km/h no front-seat car passenger on the impact side remained uninjured.     

Evaluation of knee ligament injuries with the IKDC form

Various scoring systems have been proposed to quantify the disability caused by knee ligament injuries and to evaluate the results of treatment. None of these systems has found worldwide acceptance, mainly because all scoring systems attribute numerical values to factors that are not quantifiable, and then the arbitrary scores are added together for parameters not comparable with each other. For these reasons a group of knee surgeons from Europe and America met in 1987 and founded the International Knee Documentation Committee (1KDC). A common terminology and an evaluation form was created. This form is the standard form for all publications on results of treatment of knee ligament injuries. It is a concise one-page form. It includes a documentation section, a qualification section and a evaluation section. For evaluation there are four problem areas (subjective assessment, symptoms, range of motion and ligament examination). These are supplemented with four additional areas that are only documented but not included in the evaluation (compartmental findings, donor site pathology, X-ray findings and functional tests). The form can be used pre- and postoperatively and at follow-up. It has been specified that in any publication the minimum follow-up time for shortterm results should be 2 years, for medium-term results 5 years and for long-term results 10 years. The largest part of the sheet is the qualification section. It is called qualification section rather than scoring section because no scores are given. Each parameter is qualified as normal, nearly normal, abnormal or severely abnormal. This qualification is less subjective and emotional than very good, good, fair and poor. No knee and no knee function can be better than normal, and it is rather doubtful whether any knee, once operated on, can ever be normal again. For evaluation, the parameters of the four problem ares subjective assessment, symptoms, range of motion and ligament examination, are qualified for the group qualification. The worst qualification within the group gives the group qualification. The worst group qualification gives the final evaluation. If the knee is abnormal in any of the problem areas, it cannot be a normal knee. For chronic knee conditions there is also the possibility of evaluating the sum of levels of improvement or deterioration of all groups compared with the preoperative evaluation. The committee also recommends that terms describing knee ligament problems should be used according to the definitions of Noyes et al. [32]. The use of the IKDC evaluation form will reveal less favourable results than those evaluated with other current evaluation forms, because a still existing knee problem cannot be hidden with a high numerical score that is added up from other, unrelated parameters. It is to be hoped, however, that the use of this new form will enable us to compare treatment methods in various publications with each other.     

Cancer radioimmunotherapy with alpha-emitting nuclides

In lymphoid malignancies and in certain solid cancers such as medullary thyroid carcinoma, somewhat mixed success has been achieved when applying radioimmunotherapy (RIT) with -emitters for the treatment of refractory cases. The development of novel RIT with -emitters has created new opportunities and theoretical advantages due to the high linear energy transfer (LET) and the short path length in biological tissue of -particles. These physical properties offer the prospect of achieving selective tumoural cell killing. Thus, RIT with -emitters appears particularly suited for the elimination of circulating single cells or cell clusters or for the treatment of micrometastases at an early stage. However, to avoid non-specific irradiation of healthy tissues, it is necessary to identify accessible tumoural targets easily and rapidly. For this purpose, a small number of -emitters have been investigated, among which only a few have been used for in vivo preclinical studies. Another problem is the availability and cost of these radionuclides; for instance, the low cost and the development of a reliable actinium-225/bismuth-213 generator were probably determining elements in the choice of bismuth-213 in the only human trial of RIT with an -emitter. This article reviews the literature concerning monoclonal antibodies radiolabelled with -emitters that have been developed for possible RIT in cancer patients. The principal radio-immunoconjugates are considered, starting with physical and chemical properties of -emitters, their mode of production, the possibilities and difficulties of labelling, in vitro studies and finally, when available, in vivo preclinical and clinical studies.     

Das Problem der a-priori-Wahrscheinlichkeit bei Verwendung der Essen-Möller-Formel zur Berechnung der Vaterschaftswahrscheinlichkeit

Zusammenfassung Die Annahme der a-priori-Wahrscheinlichkeit, daß Nichtväter und wahre Väter gleichhäufig zur Begutachtung gelangen, wird an Hand von 408 Aktenfällen bestätigt.Die Berechnung der Vaterschaftswahrscheinlichkeit bietet, insbesondere bei Mehrverkehrsfällen, wertvolle Hinweise für die Vaterschaft oder Nichtvaterschaft eines Probanden, Hinweise, die durch die Angabe der Vaterschaftsausschlußchance aufgrund der Mutter-Kind-Konstellation nicht erbracht werden können. Auf Beziehungen zwischen der Vaterschaftsausschlußchance und der Vaterschaftswahrscheinlichkeit wird hingewiesen.

---

The assumption of prior probability computing the plausibility of paternity by the Essen-Möller equation and its problem

Summary Among objectivists the assumption of firsthand probability, that non-fathers and true-fathers are being given an opinion on with equal frequency, yields to a rejection in calculating the probability of fatherhood according to Essen-Möller. By means of 408 cases it is shown, that this assumption does meet the actual situation. Non-fathers and true-fathers are observed equally frequent. Calculation of fatherhood probability renders a valuable reference to paternity or nonpaternity of a subject in cases of multiple intercourses. These references cannot be brought on by the statement of the exclusion chance of fatherhood based on the mother-child-constellation. The relationship between the exclusion chance and the probability of fatherhood is pointed out.

     

A pattern of post-traumatic demineralization of bone simulating permeative neoplastic replacement: A potential source of misinterpretation

Long bones with a prominent endosteal trabecular pattern, particularly the herringbone configuration, when immobilized, will demineralize in a striking spotty pattern which may simulate neoplastic permeative replacement of bone. The recognition of this phenomenon will obviate needless concern and investigation.     

Positive 131Cesium scanning in parathyroid adenoma

In a case of primary hyperparathyroidism, a palpable nodule, at the base of the right lobe of the thyroid, proved cool during ^99mTc scanning, but hot when scanned with radiocesium. The uptake of this tracer was higher than the uptake of ⁷⁵Se-selenomethionine after suppression with T₃.The authors discuss the possibility of cases of false-positive radiocesium uptake in extrathyroid nodules, and in particular, the use of this tracer for the detection of parathyroid adenoma by scanning.     

Esthesioneuroblastoma in Maffucci’s syndrome

Maffuccis syndrome consists of multiple cutaneous hemangiomas, dyschondroplasia, and enchondromas with potential for malignant change. We report a case of a 33-year-old man with Maffuccis syndrome who presented with a several month history of nasal congestion, facial pain, and diminished vision in his left eye. Radiological studies showed a large soft tissue mass centered in the sinonasal area, extending bilaterally into maxillary sinuses and orbits with compression of left optic nerve. Biopsy of the mass showed esthesioneuroblastoma (olfactory neuroblastoma). Chemotherapy resulted in initial improvement, but the tumor recurred and did not respond to further treatment, resulting in his death. Sarcomatous tumors are reported in Maffuccis syndrome, but this is a rare case of a neuroendocrine tumor in a patient with Maffuccis syndrome.     

Genetic polymorphism of Alpha-2-HS glycoprotein in Lombardy (Italy)

Summary 2HS-subtypes have been analysed in samples from 700 unrelated individuals from the Brescia area (Italy) by the isoelectric focusing technique and immunofixation. The observed allele frequencies were: 2HS*1= 0.7472; 2HS*2 = 0.2507; 2HS*V = 0.0021.     

Frequency of D1S80 and HLA DQα alleles in a Chinese population

Allele frequency distributions for the D1S80 (MCT118) and HLA DQ loci were determined in a Chinese population sample using the polymerase chain reaction (PCR). A total of 25 alleles and 100 phenotypes were observed for D 1 S80. The frequency of allele 18 was higher than allele 24 only in this Chinese population when compared to other reported populations. A total of 6 alleles and 21 possible phenotypes were observed for HLA DQ. The power of discrimination was 0.97 and 0.93 for D1S80 and HLA DQ, respectively.     

Disco-vertebral destructive lesions (So-called Andersson Lesions) associated with ankylosing spondylitis

Radiological examination of 31 patients with established ankylosing spondylitis revealed 58 disco-vertebral destructive lesions. Careful assessment of their radiological features permitted differentiation into two main types, (1) inflammatory and (2) non-inflammatory. The inflammatory type may represent either an active inflammatory process or a late sequel to such a lesion. In this series 44 lesions were included in this category, with a marked predilection for the lumbar spine. Moreover, all were observed within the first decade following the onset of the disease.The non-inflammatory type reflects an attempt of a stress fracture in the diseased spinal column to repair by connective tissue, causing a pseudoarthrosis. Eleven such lesions were obseved in this series all occurring more than 12 years after the onset of the disease. In a much smaller group of three cases-here termed the ambivalent type — differentiation between the inflammatory and non-inflammatory types could not be established on radiological grounds alone. It is of interest that all three cases occurred within the first year after the onset of the disease.It is suggested that the term Andersson lesion should be used to include all disco-vertebral destructive lesions related to ankylosing spondylitis—be they of inflammatory or non-inflammatory pathogenesis —as the better known term Romanus lesion includes all types of circumscribed marginal destructive lesions of vertebral bodies without involvement of the disc in ankylosing spondylitis.     

Zur Interpretation von postmortalen Digoxinspiegeln: Überprüfung eines „Korrekturfaktors“ für postmortal gemessene Digoxinkonzentrationen im Blut

Zusammenfassung Die Interpretation von postmortalen Serumdigoxinspiegeln wird vor allem dadurch erschwert, daß mit einem präfinalen and postmortalen Anstieg der Digoxinkonzentration im Blut zu rechnen ist. Eriksson et al. (1984) dividierten die postmortal gemessenen Digoxinspiegel im Femoralvenenblut durch 1,5, um den postmortalen Anstieg des Serumdigoxinspiegels zu berüicksichtigen; nach Meinung dieser Autoren weisen postmortale Serumdigoxinspiegel, die nach Division durch 1,5 noch über dem therapeutischen Bereich liegen, auf eine Digoxinüberdosierung hin. Der diagnostische Wert des von Eriksson et al. (1984) vorgeschlagenen Korrekturfaktors wurde überprüft. In 56 Fällen mit dokumentierter Digoxin-Medikation wurde postmortal Femoralvenenblut asserviert und eine Serumdigoxinspiegelbestimmung durchgeführt. In keinem der untersuchten Fälle war klinisch eine Digoxin-Intoxikation diagnostiziert worden. 50% der gemessenen Werte lager oberhalb des therapeutischen Bereichs (0,7 ng/ml bis 2,2 ng/ml). Nach Division der gemessenen Werte durch 1,5 lagen noch immer ca. 20% über 2,2 ng/ml, der höchste korrigierte Wert betrug 4,44 ng/ml. Unter Berücksichtigung des Zeitraums zwischen letzter Gabe und Tod, der individuell unterschiedlichen Digitalisglykosidempfindlichkeit sowie der Komplexität präfinaler und postmortaler Verteilungsvorgänge wurde für unser Untersuchungskollektiv festgestellt, daß eine (unerkannte) Digoxinüberdosierung auch darn nicht wahrscheinlich war, wenn der postmortale Wert nach Division durch 1,5 noch über dem therapeutischen Bereich lag. Der vor Eriksson et al. (1984) vorgeschlagene Korrekturfaktor ist nur vor begrenztem diagnostischem Wert; die korrigierten Werte können allenfalls einen Hinweis darauf geben, in welchem Bereich sich die entsprechende antemortale Serumdigoxinkonzentration bewegt haben könnte. Vor allem korrigierte Werte, die nur wenig über dem therapeutischen Bereich liegen, können den Verdacht auf eine Digoxinüberdosierung nicht mit ausreichender Sicherheit stützen.Ausführliche Darstellung siehe Dissertation St. Ritz, Kiel, Dissertation eingereicht Sonderdruckanfragen an: S. Ritz     

A simple method for the quantification of benzodiazepine receptors using iodine-123 iomazenil and single-photon emission tomography

Iodine-123 iomazenil (Iomazenil) is a ligand for central type benzodiazepine receptors that is suitable for single-photon emission tomography (SPET). The purpose of this study was to develop a simple method for the quantification of its binding potential (BP). The method is based on a two-compartment model (K ₁, influx rate constant;k ₂, efflux rate constant;V _T (=K ₁/k ₂), the total distribution volumes relative to the total arterial tracer concentration), and requires two SPET scans and one blood sampling. For a given input function, the radioactivity ratio of the early to delayed scans can be considered to tabulate as a function ofk ₂, and a table lookup procedure provides the correspondingk ₂ value, from whichK ₁ andV _T values are then calculated. The arterial input function is obtained by calibration of the standard input function by the single blood sampling. SPET studies were performed on 14 patients with cerebrovascular diseases, dementia or brain tumours (mean age±SD, 56.0±12.2). None of the patients had any heart, renal or liver disease. A dynamic SPET scan was performed following intravenous bolus injection of Iomazenil. A static SPET scan was performed at 180 min after injection. Frequent blood sampling from the brachial artery was performed on all subjects for determination of the arterial input function. Two-compartment model analysis was validated for calculation of theV _T value of Iomazenil. Good correlations were observed betweenV _T values calculated by three-compartment model analysis and those calculated by the present method, in which the scan time combinations (early scan/delayed scan) used were 15/180 min, 30/180 min or 45/180 min (all combinations:r=0.92), supporting the validity of this method. The present method is simple and applicable for clinical use.     

Usefulness of <Superscript>123</Superscript>I-metaiodobenzylguanidine myocardial scintigraphy for predicting the effectiveness of β-blockers in patients with dilated cardiomyopathy from the standpoint of long-term prognosis

Purpose The usefulness of ¹²³I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy in predicting the effectiveness of -blocker therapy in dilated cardiomyopathy (DCM) was investigated from the standpoint of long-term prognosis.Methods The subjects were 53 DCM patients in whom -blockers had been successfully introduced and used for 6 months or longer. When symptoms were stable before the introduction of -blockers and for up to 1 year thereafter, MIBG myocardial single-photon emission computed tomography was performed and the images analysed to obtain the extent score (EXT), severity score (SEV) and washout rate (WR). At the same time, echocardiography was performed to measure left ventricular ejection fraction (LVEF). Thereafter, patients were placed under observation for an average of 1,314±986 days, with the occurrence of cardiac events as the endpoint.Results The degree of improvement in WR after introduction of -blockers was a significant predictor of cardiac events. In fact, none of the patients whose improvement in WR was valued at 10 or higher had cardiac events. Accordingly, using improvement in WR of 10 as the cut-off value, the patients were divided into two groups, improved and unimproved. There were significant differences between the groups in respect of early EXT, early SEV and WR before the introduction of -blockers . As regards predictors of WR improvement, multivariate logistic regression analysis demonstrated that early EXT, WR and LVEF were significant predictors.Conclusion This study shows that, from the standpoint of long-term prognosis, DCM patients who would benefit the most from -blocker therapy are those with low early EXT and early SEV and high WR before -blocker introduction regardless of LVEF values.     

Impact of CT in the neurosurgical management of intracranial tumors

Summary A total of 103 brain tumor patients examined with CT, radionuclide brain scan, and angiography or pneumoencephalography, and all surgically verified, were studied to evaluate the impact of CT on the neurosurgical handling of brain tumors. CT alone was usually sufficient for optimal handling of astrocytoma patients, angiography in most meningioma cases, and pneumoencephalography in cases with sellar, suprasellar, and some other midline tumors. Information obtained only through CT sometimes altered the therapy. Sometimes it led to biopsy instead of a meaningless attempt at a radical excision; in other cases it permitted a radical excision otherwise not possible.     

Vereinfachte Schädelidentifizierung nach dem Superprojektionsverfahren mit Hilfe einer Video-Anlage

Zusammenfassung Die fotografische Schädelidentifizierung durch das bekannte Superprojektionsverfahren konnte durch Verwendung einer Video-Anlage modifiziert und entscheidend verbessert werden. Das auf elektronischer Bildmischung beruhende Identifizierungsverfahren ist methodisch einfach zu handhaben und bietet dem Untersucher die Möglichkeit, in wesentlich größerem Umfang die Beziehungen zwischen Knochen- und Weichteil-proportionen und den Strukturen der Knochenoberfläche und den Einzelheiten der Weichteilform als konkret faßbare Identitätsmerkmale zu erkennen. Die große Anzahl an kontrollierbaren Merkmalen gestattet es, bei dem hohen Maß an Individualität, das der Kopf bietet, nicht nur entweder ein gutes Hineinpassen oder Nichthineinpassen eines Schädels in eine Fotografie, sondern einen Identitäts-beweis oder-ausschluß zu erreichen.

---

Summary The photographic identification of a skull through the well-known superprojection technique can be modified and decisively improved by the use of a video-tape system. The identification method based on electronic photo composition is methodically simple to use. It offers the examiner the possibility to recognize the relationship between bone and soft part proportions, and the structure of the bone surface and the details of the soft part shape, as a concrete, tangible characteristic of identity to a substantially greater extent. The large number of controllable characteristics inherent in the high degree of individuality of the skull offers not just an either/or The skull fits/ It does not fit into a photograph, but achieves proof or disproof of identity.

Für die sorgfältige technische Assistenz danken wir Herrn A. Suhl     

Sclerotic changes of the manubrium sterni

Six females with nearly identical sclerotic and hyperostotic changes of the manubrium sterni are reported. Malignancies, bacterial inflammatory processes, and Paget disease, which were first suspected, could be excluded. The youngest patients also had sclerotic changes of other bones, including the lumbar spine, the pubic bone, and the clavicle, and may be classified as having chronic recurrent multifocal osteomyelitis (CRMO). The two oldest patients had ossification of the costoclavicular ligament(s) and may be classified as having inter-sterno-costo-clavicular ossification (ISCCO). One had only hyperostotic and sclerotic changes as seen in sterno-costo-clavicular hyperostosis (SCCH). The pathogenesis of these uncommon diseases is unknown, but they are all frequently associated with pustulosis palmoplantaris and have similar clinical courses and laboratory abnormalities. None of the present patients had HLA-B₂₇. The similarity of the radiological abnormalities of the manubrium sterni suggests that the diseases themselves may be similar, but with different courses depending on age, CRMO being present in children and young adults and ISCCO or SCCH in older adults.     

Magnetic resonance imaging findings in Kimura’s disease

Although early diagnosis of Kimuras disease, a rare chronic inflammatory disorder most commonly presenting with asymmetric swelling in the head and neck region, is helpful in avoiding unnecessary diagnostic tests and starting prompt treatment, only a few reports emphasized radiological findings in detail. Magnetic resonance imaging findings showing the infiltrative nature of the disease and diffuse loss of fat tissue even in nonpalpable normally appearing regions of the head and neck in a young man with Kimuras disease are presented in this report.     

Dose to patients through nuclear medicine procedures in a department in northern Greece

Diagnostic nuclear medicine procedures in a large hospital in northern Greece during 1984–1988 have been surveyed in order to estimate the radiation burden to the patients. The mean effective dose equivalent (EDE) was found to be 1.96 mSv/examination and 2.46 mSv/patient, allowing for the fact that a number of patients underwent more than one examination. Apart from EDE, absorbed dose has been calculated for bone marrow, thyroid, gonads, kidneys and bladder. Patients undergoing multiple examinations have been used to calculate true patient dose distribution as well as patient time-weighted dose distribution. Because of the predominance of renal examinations, 8.5 fatal renal malignancies are expected per 100000 patients.