Joachim Brade

Congenital Diaphragmatic Hernia: Predictive Value of MRI Relative Lung-to-Head Ratio Compared with MRI Fetal Lung Volume and Sonographic Lung-to-Head Ratio

OBJECTIVE The purpose of this study was to evaluate the prognostic accuracy of a new MRI-based relative lung-to-head ratio in regard to neonatal survival and need for extracorporeal membrane oxygenation (ECMO) in the care of fetuses with congenital diaphragmatic hernia (CDH) and to compare it with the previously described sonographic relative lung-to-head ratio and relative fetal lung volume assessed at antenatal MRI. MATERIALS AND METHODS Sonographic lung-to-head ratio and MRI fetal lung volume were measured in 90 fetuses (mean gestational age, 31.4+/-4.1 weeks) with CDH. Sonographic relative lung-to-head ratio and MRI relative fetal lung volume were assessed by expressing the observed sonographic lung-to-head ratio and MRI fetal lung volume as a percentage of the expected parameter value. The new MRI relative lung-to-head ratio was assessed as a percentage of the expected MRI lung-to-head ratio based on MRI fetal lung volume and MRI head circumference measurements. Measurements for survival and ECMO requirement were determined with the area under the curve (AUC). Data were analyzed for left-sided defects, right-sided defects, and associated liver herniation. RESULTS Among fetuses with left-sided CDH, all parameters were excellent in determining neonatal survival and need for ECMO therapy (p <or= 0.0027). Prognostic accuracy was best for the newly devised MRI relative lung-to-head ratio (AUC, 0.816 and 0.807) and lowest for sonographic relative lung-to-head ratio (AUC 0.783 and 0.703). Among fetuses with right-sided defects, the predictive value was lower for all parameters (AUC, 0.788-0.560). All neonates without liver herniation survived. CONCLUSION Among fetuses with left-sided CDH, assessment of pulmonary hypoplasia based on MRI relative fetal lung volume and MRI relative lung-to-head ratio is excellent in prediction of neonatal survival and ECMO requirement. The prognostic accuracy is slightly better than that of sonographic relative lung-to-head ratio. Among fetuses with right-sided CDH, the prognostic value of all parameters is lower than those among fetuses with left-sided defects.

Tinnitus: distinguishing between subjectively perceived loudness and tinnitus-related distress.

Objectives Overall success of current tinnitus therapies is low, which may be due to the heterogeneity of tinnitus patients. Therefore, subclassification of tinnitus patients is expected to improve therapeutic allocation, which, in turn, is hoped to improve therapeutic success for the individual patient. The present study aims to define factors that differentially influence subjectively perceived tinnitus loudness and tinnitus-related distress. Methods In a questionnaire-based cross-sectional survey, the data of 4705 individuals with tinnitus were analyzed. The self-report questionnaire contained items about subjective tinnitus loudness, type of onset, awareness and localization of the tinnitus, hearing impairment, chronic comorbidities, sleep quality, and psychometrically validated questionnaires addressing tinnitus-related distress, depressivity, anxiety, and somatic symptom severity. In a binary step-wise logistic regression model, we tested the predictive power of these variables on subjective tinnitus loudness and tinnitus-related distress. Results The present data contribute to the distinction between subjective tinnitus loudness and tinnitus-related distress. Whereas subjective loudness was associated with permanent awareness and binaural localization of the tinnitus, tinnitus-related distress was associated with depressivity, anxiety, and somatic symptom severity. Conclusions Subjective tinnitus loudness and the potential presence of severe depressivity, anxiety, and somatic symptom severity should be assessed separately from tinnitus-related distress. If loud tinnitus is the major complaint together with mild or moderate tinnitus-related distress, therapies should focus on auditory perception. If levels of depressivity, anxiety or somatic symptom severity are severe, therapies and further diagnosis should focus on these symptoms at first.

Use of Di(2-Ethylhexyl)Phthalate–Containing Infusion Systems Increases the Risk for Cholestasis

INTRODUCTION: Most polyvinylchloride infusion systems are plasticized with up to 60% of di(2-ethylhexyl)phthalate (DEHP). DEHP is easily extracted from the tubing by total parenteral nutrition (TPN) solutions and has been shown to have toxic effects on various organ systems including the liver in animals and humans. A role was postulated for DEHP in the development of hepatobiliary dysfunction in premature and newborn infants receiving parenteral nutrition, and the incidence of cholestasis was investigated after changing from polyvinylchloride infusion systems to polyvinylchloride-free infusion systems. MATERIALS AND METHODS: Two 3-year periods from 1998 to 2004 were investigated retrospectively before and after changing from polyvinylchloride to polyvinylchloride-free infusion systems in our department. This resulted in 1 group of 30 patients treated with polyvinylchloride lines and a second group of 46 patients treated with polyvinylchloride-free lines. The 2 groups were examined for the incidence of cholestasis and other possible contributing factors. Statistics were performed by using SAS software (SAS Institute, Cary, NC). RESULTS: After changing infusion systems, the incidence of cholestasis dropped from 50% to 13%. Using DEHP-plasticized polyvinylchloride infusion systems for TPN increased the risk for cholestasis by a factor of 5.6. The use of polyvinylchloride lines correlated strongly with the development of TPN-associated cholestasis (P = .0004). CONCLUSIONS: Using DEHP-containing polyvinylchloride infusions systems contributes to the development of cholestasis. Therefore, the use of DEHP-free infusion systems for TPN is recommended, especially in premature and newborn infants.

Right- versus left-sided congenital diaphragmatic hernia: postnatal outcome at a specialized tertiary care center.

Objective: To systematically investigate the impact of the location of the defect in congenital diaphragmatic hernia on neonatal mortality and morbidity with a special focus on survival at discharge, extracorporeal membrane oxygenation requirement, and the development of chronic lung disease. Design: Retrospective tertiary care center study with a matched-pair analysis of all fetuses that were treated for congenital diaphragmatic hernia between 2004 and 2009. Setting: A specialized tertiary care center for fetuses with congenital diaphragmatic hernia. Patients: Complete sets of data were available for 106 patients with congenital diaphragmatic hernia. For 17 of 18 infants with right-sided congenital diaphragmatic hernia we were able to allocate infants with left-sided congenital diaphragmatic hernia with no relevant difference in previously described prognostic factors, such as pulmonary hypoplasia and liver herniation. Interventions: None. Measurements and Main Results: There was a strong trend toward better survival in infants with right-sided congenital diaphragmatic hernia than with left-sided congenital diaphragmatic hernia (94% vs. 70%; p = .07). More neonates with left-sided congenital diaphragmatic hernia died of severe pulmonary hypertension despite extracorporeal membrane oxygenation. Fewer neonates with right-sided congenital diaphragmatic hernia died, yet higher degrees of pulmonary hypoplasia and oxygen requirement were observed despite extracorporeal membrane oxygenation. Conclusions: In congenital diaphragmatic hernia, the location of the defect has a substantial impact on postnatal survival and the development of chronic lung disease. In left-sided congenital diaphragmatic hernia, pulmonary hypertension resistant to therapeutic management, including extracorporeal membrane oxygenation, is more common and is associated with a higher rate of neonatal demise. Right-sided congenital diaphragmatic hernia infants have an increased benefit from extracorporeal membrane oxygenation but the better survival entails a higher rate of chronic lung disease.

Impact of blood glucose, diabetes, insulin, and obesity on standardized uptake values in tumors and healthy organs on 18F-FDG PET/CT

INTRODUCTION Chronically altered glucose metabolism interferes with (18)F-FDG uptake in malignant tissue and healthy organs and may therefore lower tumor detection in (18)F-FDG PET/CT. The present study assesses the impact of elevated blood glucose levels (BGL), diabetes, insulin treatment, and obesity on (18)F-FDG uptake in tumors and biodistribution in normal organ tissues. METHODS (18)F-FDG PET/CT was analyzed in 90 patients with BGL ranging from 50 to 372 mg/dl. Of those, 29 patients were diabetic and 21 patients had received insulin prior to PET/CT; 28 patients were obese with a body mass index >25. The maximum standardized uptake value (SUV(max)) of normal organs and the main tumor site was measured. Differences in SUV(max) in patients with and without elevated BGLs, diabetes, insulin treatment, and obesity were compared and analyzed for statistical significance. RESULTS Increased BGLs were associated with decreased cerebral FDG uptake and increased uptake in skeletal muscle. Diabetes and insulin diminished this effect, whereas obesity slightly enhanced the outcome. Diabetes and insulin also increased the average SUV(max) in muscle cells and fat, whereas the mean cerebral SUV(max) was reduced. Obesity decreased tracer uptake in several healthy organs by up to 30%. Tumoral uptake was not significantly influenced by BGL, diabetes, insulin, or obesity. CONCLUSIONS Changes in BGLs, diabetes, insulin, and obesity affect the FDG biodistribution in muscular tissue and the brain. Although tumoral uptake is not significantly impaired, these findings may influence the tumor detection rate and are therefore essential for diagnosis and follow-up of malignant diseases.

Spontaneous type 1 electrocardiographic pattern is associated with cardiovascular magnetic resonance imaging changes in Brugada syndrome

BACKGROUND Patients with Brugada syndrome (BrS) and a spontaneous type 1 ECG are considered to be at greater increased risk for sudden cardiac death than are patients with an abnormal ECG only after administration of sodium channel blockers and therefore represent a more severe phenotype. Thus, it can be hypothesized that in the presence of a more severe electrical phenotype, structural and functional changes are more likely expected because electrical changes can play a causal role in producing structural changes. OBJECTIVE The purpose of this study was to investigate whether the different ECG manifestations in patients with BrS are associated with structural changes detected by cardiovascular magnetic resonance imaging. METHODS Cardiovascular magnetic resonance imaging was performed on 69 consecutive patients with proven BrS and 30 healthy controls. Twenty-six patients had a spontaneous diagnostic type 1 BrS ECG; the remainder had a type 1 response to ajmaline provocation. Left and right ventricular volumes and dimensions were assessed and compared with respect to ECG pattern. RESULTS The right ventricular outflow tract area was significantly enlarged in patients with a spontaneous type 1 ECG compared to patients with a nondiagnostic resting ECG or controls (11 cm(2), 9 cm(2), and 9 cm(2), respectively, P < .05). Patients with a spontaneous type 1 BrS ECG revealed significantly lower left ventricular ejection fraction than did patients with a nondiagnostic resting ECG and controls (56 ± 5 vs 59 ± 5 vs 60 ± 4, respectively, P < .05) and significantly lower right ventricular ejection fraction (54 ± 5 vs 59 ± 5, P = .001) as well as end-systolic volumes compared to controls (34 ± 9 mL/m(2) vs 28 ± 79 mL/m(2), P = .02). CONCLUSION Patients with a spontaneous type 1 BrS ECG reveal significantly functional and morphological alterations in both the left and right ventricles compared to patients with basal nondiagnostic ECG or controls.

Preventive antireflux surgery in neonates with congenital diaphragmatic hernia: a single-blinded prospective study

OBJECTIVE Congenital diaphragmatic hernia (CDH) is known to be a predisposing factor in gastroesophageal reflux (GER) leading to pulmonary and nutritional problems. The aim of this prospective, randomized, patient-blinded study was to evaluate the benefit of antireflux surgery at the time of CDH repair. METHODS From 2003 to 2009, 79 neonates with left-sided CDH were included. Forty-three had regular hernia closure. Thirty-six patients additionally had fundoplication at hernia repair. Follow-up was at 6, 12, and 24 months after birth with a standardized questionnaire and a thorax radiograph. Patients with clinical signs for GER were evaluated with upper gastrointestinal series and 24-hour pH-metry. RESULTS Seventy-nine of 263 patients participated in this prospective trial. Survival rate was 88.61%. The GER symptoms were almost significantly more frequent in the group without concomitant fundoplication at the age of 6 months. At 24 months, the difference between both groups was not significant anymore. Development of body weight in the first 2 years of life was similar in both groups. No complications related to initial antireflux surgery were noted. CONCLUSION Patients profit from fundoplication at CDH repair only within the first year of life. At the present point of this study, simultaneous fundoplication at the time of primary CDH repair cannot be recommended as a standard procedure in all patients with left-sided CDH.

Long-term follow-up-findings in mammography and ultrasound after intraoperative radiotherapy (IORT) for breast cancer

The purpose of this study was to assess mammographic and sonographic findings in a long-term follow-up (>or=3 years) after breast-conserving surgery (BCS) and IORT, either applied as boost or exclusively. Follow-up-findings of 54 patients were retrospectively evaluated and compared to a control group of 48 patients, treated with BCS and whole-breast radiotherapy. After IORT patients had a higher incidence of fat necroses manifesting as oil cysts in the late follow-up mammograms (n = 31 vs n = 8); furthermore, oil cysts were larger in the IORT group (median 4.5 vs 1.4 cm(2)). In 25 IORT patients the oil cysts arose from partially organized hematomas/seromas, which in this group were generally more frequent (n = 38 vs n = 9) and larger (median 3.6 vs 1.8 cm(2)). After IORT a decreasing incidence of hematomas/seromas was reciprocal to an increasing incidence of oil cysts, and the size of both entities correlated with each other. Liquid lesions with polypoid inner wall thickening on ultrasound, attributed to organized hematomas/seromas or fat necroses, appear more frequently after IORT (n = 15 vs n = 1). In conclusion, IORT is associated with a high incidence of large oil cysts, which arise from likewise large partially organized wound cavities. On ultrasound pronounced partial organization with polypoid inner wall thickening is a frequent finding in those cavities.

Postoperative Seroma Formation After Intraoperative Radiotherapy Using Low-Kilovoltage X-Rays Given During Breast-Conserving Surgery

PURPOSE To determine the frequency and volume of seroma after breast-conserving surgery (BCS) with or without intraoperative radiotherapy (IORT). METHODS AND MATERIALS Seventy-one patients with 73 breast cancers (IORT group) treated with IORT (20 Gy Intrabeam) as a boost during BCS were compared with 86 patients with 88 breast tumors (NO-IORT group) treated without IORT. Clinical examination and measurement of seroma volume on treatment-planning CT (CT-seroma) was done at median interval of 35 days after BCS. RESULTS Seroma were found on palpation in 37 patients (23%) and on CT in 105 patients (65%; median volume, 26.3 mL). Interval between BCS and CT was significantly shorter in patients with palpable seroma (median, 33 days) or CT-seroma (33 days) compared with those with no palpable seroma (36.5 days; p = 0.027) or CT-seroma (52 days, p < 0.001). The rate of palpable seroma was not different (IORT n = 17, 23%; NO-IORT n = 20, 23%; p = 0.933), whereas fewer patients required puncture in the IORT group [3 (4%) vs. 10 (11%)]. In contrast, more patients showed CT-seroma after IORT (IORT n = 59, 81%; NO-IORT n = 46, 52%; p < 0.001). The interval between BCS and CT was significantly shorter in patients with IORT as compared with the NO-IORT patients (median, 33 days vs. 41.5 days; p = 0.036). CONCLUSION Intraoperative radiotherapy with low-kilovoltage X-rays during BCS is not associated with an increased rate of palpable seroma or seroma requiring treatment. The rate of seroma formation on CT was higher after IORT compared with the NO-IORT group, which might be because of the shorter interval between BCS and CT.

Do structural changes in the tumour bed after intraoperative radiotherapy (IORT) of breast cancer complicate the evaluation of mammograms in a long-term follow-up?

The purpose of the study was to assess whether postoperative changes in the tumour bed after intraoperative radiotherapy (IORT) with low-energy X-rays complicate the mammographic evaluation. 54 patients receiving breast-conserving surgery and IORT were compared to a control group of 48 patients with conventional breast-conserving treatment. All patients were included in routine follow-ups (≥3 years) with mammography accompanied by ultrasound. By retrospective consensus reading the mammographic changes in the tumour bed were classified as absent, low or distinct. Using the same grading it was classified whether mammographic evaluation was complicated due to postoperative changes. Focusing the yearly follow-ups within a period of four years, distinct changes were found significantly more often after IORT (52-62% vs. 7-30%). After IORT the evaluation was significantly more often distinctly complicated in each follow-up, except for year 1 (16-21% vs. 0-8%). In the IORT group the distribution of findings was nearly stable over time. In the control group it changed over time and a distinctly complicated evaluation was no longer seen in the follow-ups of years 3 and 4. Overall, further non-routine diagnostic procedures due to unclear findings in the tumour bed became necessary in 7% (IORT) vs. 8% (control group) of the patients (p=0.86). Evaluation of mammograms is complicated after IORT. In contrast to conventionally treated patients postoperative changes and difficulties of evaluation do not decrease over time. Overall, after IORT the diagnostic uncertainty does not seem to be increased in ultrasound supported mammographic follow-ups. The topic needs further evaluation with larger study samples.