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Background: The non-invasive diagnosis of cardiac sarcoidosis (CS) is difficult. Cardiovascular magnetic resonance (CMR) has become a very valuable diagnostic tool in patients with suspected CS, but usually a combination of different tests is used. Oxygen uptake efficiency slope (OUES) is a parameter of cardiopulmonary exercise testing (CPET), which is used as an indicator for cardiovascular impairment. We investigated the predictive value of OUES for the diagnosis of myocardial involvement in sarcoid patients., Methods: Retrospectively 37 consecutive patients (44.9±13.8 years) with histologically confirmed sarcoidosis and clinical suspicion of heart involvement underwent noninvasive diagnostic testing including CMR. CS was diagnosed according to the guidelines from the Japanese Society of Sarcoidosis and other Granulomatous Disorders with additional consideration of CMR findings. Furthermore, CPET with calculation of predicted OUES according to equations by Hollenberg et al. was carried out., Results: Patients with CS (11/37; 30%) had a worse cardiovascular response to exercise. OUES was significantly lower in CS-group compared to non-CS-group (59.3±19.1 vs 88.0±15.4%pred., p<0.0001). ROC curve method identified 70%pred. as the OUES cut-off point, which maximized sensitivity and specificity for detection of CS (96% sensitivity, 82% specificity, 89% overall accuracy). OUES <70%pred. was the single best predictor of CS (Odds ratio: 100.43, 95% CI: 1.99 to 5064, p<0.001) even in multivariate analyses., Conclusion: OUES assessed in CPET may be helpful in identifying patient with cardiac involvement of sarcoidosis. Patient selection for CMR may be assisted by CPET findings in patients with sarcoidosis.

Background: Clinicians are frequently confronted by thromboembolic events in patients with lung cancer, yet few data are available about their incidence. In order to obtain data on the frequency of thromboembolic events in the venous and arterial systems, all patients with lung cancer diagnosed in our hospital were retrospectively evaluated with regard to such an event., Patients/methods: All patients with a primary diagnosis of lung cancer between January 2008 and December 2010 were prospectively recorded within our tumour registry and retrospectively evaluated with regard to tumour stage, histology and platinum-based chemotherapy. Thromboembolic complications of the arterial and the venous system were included (pulmonary embolism, deep venous thrombosis, myocardial infarction, mesenterial ischaemia, acute limb ischaemia, ischaemia of the renal artery and ischaemic stroke)., Results: Within those 36 months 1940 patients (1209 men, 731 women) were diagnosed with lung cancer. SCLC and NSCLC in 156 (8 %) and 1784 cases (92 %), respectively. Thromboembolic events were documented in 190/1940 (9.8 %) cases, venous thromboembolic complications in 148/190 patients (78 %), arterial thromboembolic complications in 51/190 patients (27 %). We documented 82/148 (55 %) deep venous thrombosis, 98/148 (66 %) pulmonary embolisms and arterial thromboembolic events: ischaemic stroke 23/51 (45 %), coronary arteries 14/51 (28 %), peripheral arteries 12/51 (24 %), mesenterial arteries 4/51 (7.8 %), extracranial cerebral arteries 3/51 (5.9 %)., Conclusions: Thromboembolic complications are a common event in patients with lung cancer. Thus, the benefit of primary prevention anticoagulation in lung cancer patients should be prospectively evaluated., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: PET/CT investigation with 18F-fluorodeoxyglucose (FDG) has a high sensitivity (89 - 100 %) and good specificity (79 - 95 %) for the diagnosis of NSCLC. Currently, it is mainly used in preoperative staging. This leads in approximately 15 % of these cases to the diagnosis of metastatic disease that was neither clinically suspected nor seen in previously performed conventional imaging. We hypothesised that including these cases in the palliative stage IV group would have an influence on overall survival., Aim: The aim of this study was to compare the overall survival (OS) of patients with stage IV NSCLC who underwent FDG-PET/CT staging with patients in whom conventional imaging procedures were performed., Methods: We analysed the OS of all stage IV NSCLC patients diagnosed in our clinic in 2009 (n = 254), 96/254 (38 %) patients were staged with PET/CT and 158/254 (62 %) with conventional imaging (CT group). Survival data were compared by Kaplan-Meier statistics., Results: Patients in the PET/CT group were younger (65 ± 11) than in the CT group (68 ± 10 years; p = 0.008). The median OS of all patients was 246 (range: 217 - 275) days; 338 (range: 247 - 429) days in the PET/CT group and 207 (range: 161 - 253) days in the CT group (p = 0.001), stating a difference of 131 days (4.4 months) in median OS., Conclusion: The use of FDG-PET/CT staging mainly in the preoperative setting leads to stage migration of patients with a better prognosis into the worst stage (IV) and thus longer survival within this subgroup. This survival benefit is unrelated to treatment and needs to be addressed in future studies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Patients with cystic fibrosis (CF) frequently experience pulmonary exacerbations that may lead to a faster subsequent decline in pulmonary function; however, this relationship has not been clearly established. The purpose of this study was to determine the association between the frequency of pulmonary exacerbations and subsequent forced expiratory volume in 1 sec (FEV(1) ) decline in adults and children with CF., Methods: Cohort study of subjects followed in the Cystic Fibrosis Foundation Patient Registry from 2003 through 2006. Mixed effects modeling was used to estimate differences in rates of decline in FEV(1) in 2004-2006 for patients with 0, 1, 2, or 3+ pulmonary exacerbation(s) in 2003., Results: Of 8,490 subjects who met inclusion criteria, 60% had 0 exacerbations, 23% had 1, 10% had 2, and 7% had 3+ exacerbations in 2003. Compared to children with no pulmonary exacerbations in 2003, children with one or more exacerbations experienced a significantly (P < 0.001) greater rate of FEV(1) decline in 2004-2006. In contrast, among adults, only those with 3+ exacerbations in 2003 had a significantly (P = 0.01) greater rate of FEV(1) decline in 2004-2006 than those with no exacerbations in 2003., Conclusions: There is a strong association between the frequency of pulmonary exacerbations and subsequent decline in pulmonary function. In adults, having 3+ exacerbations, and among children, having any exacerbations is associated with a greater rate of decline in the ensuing 3 years. Improved prevention, identification, and treatment of pulmonary exacerbations are likely to have long-term benefits for patients with CF, especially children., (Copyright © 2010 Wiley-Liss, Inc.)

Objective: Findings from studies investigating optimal techniques for attenuating propofol-related injection pain are inconsistent. In previous studies, lidocaine pretreatment using a tourniquet has been reported to be superior, inferior, or equivalent to a lidocaine-propofol admixture for reducing pain. This discordance could represent either no meaningful difference in the treatments or underlying methodological differences in the previous studies. We hypothesized that tourniquet-controlled pretreatment with lidocaine would be superior to lidocaine-propofol admixture for reducing propofol injection pain., Methods: This randomized controlled trial compared 3 groups-a control group (saline pretreatment/saline admixture; n = 50), a pretreatment group (lidocaine pretreatment/saline admixture; n = 51), and an admixture group (saline pretreatment/lidocaine admixture; n = 50). The primary outcome was verbal pain score after injection. The incidence of pain on injection was explored as a secondary outcome., Results: The median (interquartile range) verbal pain score after study solution injection were as follows-control group: 3 (0-6), pretreatment group: 0 (0-0), and admixture group: 0 (0-2). The pretreatment group had significantly lower pain scores when compared with the admixture group (P = 0.016), and both groups were superior to the control group. The pretreatment group had fewer subjects experiencing any injection pain than did the admixture group (20% vs. 44%, respectively; P = 0.024)., Conclusions: Tourniquet-controlled pretreatment with lidocaine is statistically superior to admixing lidocaine with propofol for reducing propofol injection pain intensity, but the clinical importance of this small effect is questionable. However, pretreatment more effectively eliminates injection pain.

Rationale: Patients with cystic fibrosis periodically experience pulmonary exacerbations. Previous studies have noted that some patients' lung function (FEV(1)) does not improve with treatment., Objectives: To determine the proportion of patients treated for a pulmonary exacerbation that does not recover to spirometric baseline, and to identify factors associated with the failure to recover to spirometric baseline., Methods: Cohort study using the Cystic Fibrosis Foundation Patient Registry from 2003-2006. We randomly selected one pulmonary exacerbation treated with intravenous antibiotics per patient and compared the best FEV(1) in the 3 months after treatment with the best FEV(1) in the 6 months before treatment. Recovery to baseline was defined as any FEV(1) in the 3 months after treatment that was greater than or equal to 90% of the baseline FEV(1). Multivariable logistic regression was used to estimate associations with the failure to recover to baseline FEV(1)., Measurements and Main Results: Of 8,479 pulmonary exacerbations, 25% failed to recover to baseline FEV(1). A higher risk of failing to recover to baseline was associated with female sex; pancreatic insufficiency; being undernourished; Medicaid insurance; persistent infection with Pseudomonas aeruginosa, Burkholderia cepacia complex, or methicillin-resistant Staphylococcus aureus; allergic bronchopulmonary aspergillosis; a longer time since baseline spirometric assessment; and a larger drop in FEV(1) from baseline to treatment initiation., Conclusions: For a randomly selected pulmonary exacerbation, 25% of patients' pulmonary function did not recover to baseline after treatment with intravenous antibiotics. We identified factors associated with the failure to recover to baseline, allowing clinicians to identify patients who may benefit from closer monitoring and more aggressive treatment.

Objectives: We studied compliance with multiple-dose vaccine schedules, assessed factors associated with noncompliance, and examined timeliness of series completion among older children, adolescents, and adults., Methods: We conducted a large, multisite, retrospective cohort study of older children, adolescents, and adults in the Vaccine Safety Datalink population from 1996 through 2004. We quantified the rates of completion of all required doses for varicella, hepatitis A, and hepatitis B vaccines according to their recommended schedules., Results: Among those who received a first dose of varicella (n = 16 075), hepatitis A (n = 594 917), and hepatitis B (n = 590 445) vaccine, relatively few completed the series (55%-65% for hepatitis B vaccine and 40%-50% for hepatitis A and varicella vaccines in most age groups). Compliance was lowest among adolescents (35.9%) and Medicaid recipients (29.7%) who received varicella vaccine and among younger adult age groups who received hepatitis A vaccine (25%-35% across those age groups). Even among series completers, there was a relatively long interval of undervaccination between the first and last doses., Conclusions: Compliance with multiple-dose vaccine series among older children, adolescents, and adults is suboptimal. Further evaluations of strategies to improve compliance in these populations are needed.

Imaging plays a major role in the diagnosis and management of pleural diseases. Generally chest radiography remains the initial examination, however, today with digital technique. Depending on first imaging findings and the clinical aspect the diagnostic course may be followed by ultrasound, computed tomography examinations, or magnetic resonance imaging. Radionuclide imaging has not been played a significant role up to now, until positron emission tomography (PET) has gained clinical relevance. However, the role of PET in pleural diseases is not yet defined and scientific works are still in progress.

Objective: To explore the role of magnetic resonance imaging (MRI) in distinguishing malignant from benign pleural disease., Methods: All 64 patients were examined with both computed tomography (CT) and MRI. The morphologic features of pleural lesions and MR signal intensity on T1-weighted, T2-weighted and contrast-enhanced T1-weighted images were evaluated., Results: Mediastinal pleural involvement, circumferential pleural thickening, nodularity, irregularity of pleural contour, and infiltration of the chest wall and/or diaphragm were most suggestive of a malignant cause on CT and MR images. Contrary to what has been reported in the literature, pleural thickness greater than 1 cm either on CT or on MRI did not reveal a significant difference between malignant and benign pleural disease (P > 0.05, chi-square test). Using morphologic features in combination with signal intensity features, MRI had a sensitivity of 98% and a specificity of 92% in the detection of pleural malignancy., Conclusions: Compared with those on CT, the morphologic features on MRI allowed a mostly equal and in some cases superior detection and evaluation of the spread of pleural disease. In combination with signal intensity and morphologic features, MRI is very useful in distinguishing malignant from benign pleural disease.

Aim: The quality of segmentation and three-dimensional reconstruction of anatomical structures in tomographic slices is often impaired by disturbances due to partial volume effects (PVE). The potential for artefact reduction by use of the morphological image processing operators (MO) erosion and dilation is investigated., Design: The CT examinations of 31 patients with pathological alterations in lung or brain were segmented using automatic region growing and the MO were applied in a different number of iterations. The processed regions were 3D-reconstructed (shaded surface display, MIP, volume rendering) and the occurrence of PVE-related artefacts using the signal-to-background ratio (SBR) prior to and after MO application was compared., Results: For all patients under review, the artefacts caused by PVE were significantly reduced by erosion (lung: mean SBRpre = 1.67, SBRpost = 4.83; brain: SBRpre = 1.06, SBRpost = 1.29) even with only a small number of iterations. Region dilation was applied to integrate further structures (e.g. at tumor borders) into a configurable neighbourhood for segmentation and quantitative analysis., Conclusions: The MO represent an efficient approach for the reduction of PVE artefacts in 3D-CT reconstructions and allow optimized visualization of individual objects.

Aim: To improve the pre-operative planning of interventional procedures in thorax surgery different methods of computer-graphical visualization of intrapulmonary lesions and adjacent anatomical structures based on CT and MR data were realized and compared to each other., Design: In 21 patients with intrapulmonary lesions the image data was segmented by interactive and automatic algorithms and different reconstruction techniques were applied (maximum intensity projection; color-encoded and transparent surfaces; volume rendering). Based on these three-dimensional reconstructions, different views from arbitrary perspectives (including simulated endoscopic images) were generated and animated film sequences of the 3D scene were displayed with 30 frames/second., Results: For all patients under review, a high-quality presentation of the relevant structures was obtained by use of the applied computer-graphical techniques. Even combinations of different visualization methods in one image can be generated with the software we developed., Conclusions: The various methods for image segmentation allow a fast and comfortable processing even of large data sets. The calculated values of tumor surface and volume can be used for quantitative studies and therapy control. The planning of surgical and interventional procedures can be supported by the simultaneous visualization of the intrathoracic lesion and the surrounding structures.

In a 58-year-old man, a leiomyosarcoma was found to be the cause of unclear thoracal pain on the right side. The initial diagnose was an embolus of the pulmonary artery. The MRI showed a suspicious area similar to an intravasal tumor.

Aim: In cooperation with the thoracic surgery department 3-D visualizations of tumors were generated to support the surgeons in preoperative planning. As opposed to 3-D reconstructions of CT data, those representations based on MRI images remain an exception. In this paper different methods of three dimensional visualization of lung tumors are presented and compared to each other., Design: These methods are 1. contour based surface models, 2. threshold based surface models and 3. rendered scenes of segmented volume data with transparent, color-coded display., Results: Combinations of all three methods in one single image are possible as well with the software we developed. Furthermore, cut planes through the original data can be integrated into the 3-D scene. The segmentation of anatomical objects is performed either manually or automatically with various procedures., Conclusions: Adequate possibilities of manipulation and archiving allow a fast handling and processing even of large data sets. The calculated volumes of the anatomical objects can be used for quantitative studies. Arbitrary views of the three dimensional reconstructions can be generated within a few seconds. Even animation can easily be calculated and displayed with 30 frames/second.

The discovery of the x-rays by W. C. Roentgen 100 years ago significantly improved the diagnosis and follow-up of tuberculosis, therapy control became possible, and the basis for prevention was set by early detection. Within few years, the "Roentgen" rays had been made a triumphant progress around the world, and Roentgenology was established as an independent medical discipline. Even after a century of developments like tomography, ultrasound, conventional/-high resolution and spiral computed tomography, digital radiography, digital subtraction angiography, and magnetic resonance imaging, innovations in the field of medical imaging appear to be unlimited, an evolution, which had been initiated by Roentgen. Today, therapists and radiologists are again challenged by the renaissance of tuberculosis, partially in new "clothes" by increasing numbers of HIV-patients. These specific changes clinically and radiological often appear atypical, and require subtile radiological diagnostics with the use of new imaging modalities. CT and MRI allow for follow-up of chemotherapy in mediastinal lymph node disease, significantly improve pleural diagnosis, and both are methods of choice in vertebral and cerebral tuberculous disease. Digital radiography and digital net-work allow for x-rays at the lowest dose, improved comparison in the follow-up, as well as for "online"-evaluation of images on the department's screen. Today, optimal diagnosis of tuberculosis includes the bacteriologic and clinical diagnosis and radiological imaging. To face the challenge of recurrent tuberculosis in in the second century after after Roentgen successfully, an intensive interdisciplinary cooperation of therapists and radiologists is necessary.

MR images of 48 patients with histologically confirmed benign and malignant diseases of the pleura were retrospectively compared with CT and bioptically/surgically obtained findings. In 47/48 patients pathological changes of the pleura were visualized by increased signal intensities on T2-weighted and contrast enhanced T1-weighted MR images. This lead to a slightly improved sensitivity compared to CT, where pathological pleura findings were confirmed in 45/48 patients. MRI was able to identify 24/28 confirmed pleural effusions, whereas CT was successful in 26/28 patients. In two cases effusions not identified on CT were visible on T2-weighted MRI. 4 pleural effusions were missed with MRI.. On CT images differentiation of pleural changes vs effusions or adjacent lesions of lung parenchyma was successful in 20/28 and in 17/23 cases, respectively. Contrast enhanced T1-weighted images achieved the highest diagnostic accuracy with 22/28 and 20/23 cases, respectively. Signal intensities on MRI were unsuitable as sole criterion for the differentiation of benign and malignant diseases of the pleura. Contour and pattern of spreading of pleural changes were helpful in differential diagnosis. Nodular changes, thickening of more than 10 mm and mediastinal, circumferential and entire hemithoracic affection of the pleura were suggestive for malignant pleural disease. Infiltration of the diaphragm and the chest wall were most indicative for malignancy; here MRI (2/2 resp. 18/19 cases) was superior to CT (0/2 resp. 14/19 cases). CT was superior in the detection of pleural calcifications and osseous destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

22 patients with intrathoracic malignant tumors suspected of invading the chest wall were examined with CT and MRI. Chest wall invasion was operatively confirmed in 19 cases and excluded in the other 3 cases. CT showed tumor infiltration of the chest wall in 14/19 cases, no morphological changes in 5/19 cases. Thoracic wall invasion was demonstrated by MR in all 19 cases. Typical MR finding of malignant invasion was local lesion within the chest wall showing high signal intensity in post-Gd T1-weighted images and in T2-weighted images. Reactive inflammatory changes as well as malignant infiltration of the pleura showed high signal intensity on enhanced T1-weighted images and on T2-weighted images.

47 patients with histologic/cytologic confirmed bronchogenic carcinoma were examined with CT and MRI. Negative and contrast enhanced CT examinations were performed, MR images were obtained with ECG gated T1- and T2-weighted SE sequences in axial and coronal planes. Both methods were evaluated with respect to tumor imaging and delineating of tumor extensions. CT and MRI were generally in agreement for primary tumor and lymph node staging. 7 out of 10 patients with malignant pericardial involvement and 3 out of 27 patients with mediastinal subcarinal lymph node metastases were identified only in MR images. MRI was superior to CT in demonstration of aortic involvement, poststenotic syndrome and extension of chest wall invasion. Additionally MRI gave functional informations about blood flow in case of superior vena cava obstruction.

The purpose of this study was to assess the role of MR imaging and the paramagnetic contrast agent Gadolinium-DTPA(Gd-DTPA) in the diagnosis of pituitary macroadenomas. 44 macroadenomas were examined with MRI before and after intravenous application of Gd-DTPA. Gd-DTPA produced excellent enhancement of solid adenoma. The best contrast between adenoma and surrounding structures could be gained on post-Gd T1-weighted images. Post-Gd images were equivalent to pre-Gd images in the evaluation of supra- and infrasellar extensions of macroadenomas. Post-Gd images had advantages in the evaluation of cavernous sinus invasion by adenoma. The difference in degree of contrast enhancement between adenoma and cavernous sinus facilitated the exact evaluation of lateral extension by adenoma in 18 cases. Almost equal degree of enhancement of both structures impaired tumor-sinus contrast in 2 cases. In the other 24 cases the tumor filled the cavernous sinus completely. It is our opinion that Gd-DTPA can be used on a widespread basis because of its excellent capability to highlight and delineate pituitary adenomas.