The influence of orthoses on the proprioception of the ankle joint

The ankle joints of 14 healthy volunteers and 16 patients with unstable ankle joints were tested regarding their functional and proprioceptive capabilities. All of them were active athletes. Three tests were used of the study: single-leg stance test, single-leg jumping course test, angle-reproduction test. The influence of three stabilization devices (lace-on-brace/Mikros, stirrup-brace/ Aircast, taping) on the proprioceptivity of stable and unstable ankle joints was evaluated. The scores of the singleleg jumping course without any stabilizing device (category standard) ranged between 8.06 and 13.68 (10.65±1.29). In the categories Mikros (9.85±0.99), and Aircast (9.99±1.14) as well as with the tape bandage (10.27±0.81) better scores were achieved. The differences standard vs. Mikros and standard vs. Aircast revealed a significant reduction of the scores with orthoses (P<0.01). The error rate in the single-leg stance test was within the range of 0–16 (5.12±2.85) for the category standard. It was lower for the categories Mikros (3.65±2.65) and Aircast (4.17±2.59). The error rate was highest in the group with a tape bandage (5.79±3.53). The differences standard vs Mikros as well as standard vs. Aircast were significant (P<0.01). There was also a significant difference between these categories regarding injured and not injured ankle joints (P<0.01). The angle-reproduction-test showed higher values for the category standard (2.36°±0.97) in comparison to the categories Mikros (1.46°±0.72), Aircast (1.62°±0.91) and taping (1.84°±0.41). In the category standard the reproduction error was lower testing not injured ankle joints (2.30°±1.04) than testing the group of unstable ankle joints (2.44°±0.81), whereas in all other categories the reproduction error was higher in the group of not injured joints. The differences in all measurements between standard vs. Mikros and standard vs. Aircast were significant (P<0.01). The results of the three tests showed a highly significant difference between injured and not injured ankle joints (P<0.01).     

The “dural tail” adjacent to meningiomas studied by dynamic contrast-enhanced MRI: a comparison with histopathology

We examined 32 patients with intracranial tumors (17 meningiomas, 8 neuromas, 7 pituitary adenomas) by conventional and dynamic contrast-enhanced MRI. Our aim was to clarify whether the pathological dural contrast enhancement adjacent to meningiomas (the dural tail) is specific to meningiomas and, more important, whether it represents neoplastic dural infiltration or hypervascularization as a tumor accompanying reaction. A dural tail was found in 9 of 17 meningiomas. None of the other extra-axial tumours (neuromas, pituitary adenomas) showed comparable dural enhancement. Dynamic examinations with an ultrafast single slice imaging technique (snapshot-FLASH) after a bolus injection of contrast medium showed a dural tail in seven out of these nine meningiomas, while in two cases the dural tail turned out to be a cortical vein with a characteristic dynamic contrast enhancement pattern. In the dynamic study all seven dural tails were found to have earlier, steeper contrast enhancement than the corresponding tumours. All the tumours and part of the adjacent dura mater in four of the seven meningiomas with dural enhancement were examined histopathologically. In none of these four cases was neoplastic tissue found more than 2 mm away from the main tumour. The results strongly support the suggestion that the dural tail adjacent to meningiomas represents a hypervascular, non-neoplastic dural reaction.     

Zur forensisch-medizinischen Bewertung von Fußspuren

Zusammenfassung Zur Frage der Identifizierung mit Hilfe von Abdruckspuren des unbekleideten menschlichen Fußes wurden Untersuchungen an einem Kollektiv von 100 Personen durchgeführt.Die vergleichende Auswertung von 200 Standspuren und ca. 600 Gangspuren durch Messung und Formbeschreibung diente zunächst der Erkennung der Variabilität innerhalb des Untersuchungskollektives wie zwischen Stand- und Gangspur der gleichen Person. Als typische Gangveränderungen wurden eine Verlängerung des Sohlenabdruckes, insbesondere der Zehen mit spitzer Ausziehung derselben, und eine Verbreiterung der Großzehenbasis beobachtet. Ballen, Brücke und Ferse waren in der Gangspur häufiger verbreitert als verschmälert. Sehr variabel erwies sich die Form des Brückenanteils, relativ konstant hingegen die Anordnung der Zehenbeeren.In den Formmerkmalen völlig übereinstimmende Fußabdrücke zweier Personen wurden nicht gefunden. Die Formunterschiede zwischen Stand- und Gangspur der gleichen Person waren jedoch vereinzelt nicht geringer als die Unterschiede zur Standspur einer anderen Person.Aus diesen Beobachtungen ergaben sich Empfehlungen für die Praxis der Identifizierung von Abdruckspuren des unbekleideten Fußes ohne erkennbare Papillarleistenmuster.

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Summary 100 persons were examined for the footprints using unclad human feet. The comparison of 200 standing footprints and about 600 gait footprints were evaluated w. r. t. the form and served first the purpose of identification of the variability between whole material and between the standing and gait footprints of the same person.The typical changes during the movement were seen to be the elongation of the sole prints, especially of toes and broadening of the proximal part of the first toe. Ball, Bridge and Heel-patterns were in most cases broadened rather than narrowed down. The form of bridge showed the most variation and least variation was found in the position of toes. Completely identical footprints of 2 persons were not found. The variation between the standing and gait-footprints of the same person were sometimes equal to the variation from the standing footprints of another person.According to these observations it would be advisible to identify the prints of unclad human feet without visible dermatoglyphic patterns.

Herrn Prof. Dr. B. Mueller zum 75. Geburtstag.     

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.     

Fogging on T2-weighted MR after acute ischaemic stroke: how often might this occur and what are the implications?

Fogging is the temporary loss of visibility of an infarct on CT which occurs in the subacute phase at about 2 weeks after stroke. It occurs in up to 40% of medium to large infarcts on CT. It is unclear whether or how often fogging occurs on T2-weighted MR, but if it does occur, it can cause underestimation of true infarct size. This study examined the possible frequency and time scale of fogging on T2-weighted MR. We conducted a blinded, independent review of prospectively collected MR scans from patients with symptoms of cortical ischaemic stroke, scanned sequentially up to 7 weeks after stroke. On each scan maximum infarct area was measured, and the infarct extent and swelling were coded on a validated scale. Fogging was suggested by reduced infarct extent between initial and subsequent scans. In 30 patients (with 74 scans) there was some apparent fogging in 50% of patients between 6 and 36 days (median 10 days) after stroke. Reduction in infarct extent on T2-weighted MR which may be attributed to fogging occurs in a significant proportion of patients with cortical infarcts. This may lead to an underestimation of true final infarct extent. This suggests that true infarct extent on T2-weighted MR can probably only be assessed on scans obtained beyond 7 weeks after stroke.     

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.

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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.

     

Morphological detection of X- and Y-chromosomes in smears and paraffin-embedded tissues using a non-isotopic in situ hybridization technique (NISH)

Pharyngeal smears and paraffin-embedded tissue specimens (skeletal muscle, kidney) obtained from 10 male and 10 female individuals were evaluated using non-isotopic in situ hybridization (NISH) with commercial X- and Y-specific biotinylated probes which recognize the pericentromeric regions DXZ1 and DYZ1/DYZ3 of the X- and Y-chromosome, respectively. The results provide evidence that the morphological sex determination of a single cell can be performed by critical application of this staining method leading to one nuclear signal in male cells using the Y-specific probe whereas female cells are negative. In situ hybridization of female tissues with an X-specific probe results regularly in 2 signals whereas male cells show only one spot in the nucleus.     

Three-dimensional display of myocardial perfusion detection of ischemic lesions using a new image subtraction method

A recent, commercially available computer program for the three-dimensional (3D) display of single-photon emission tomography (SPET) data was used to study myocardial perfusion in patients with coronary artery disease (CAD). To enable the detection of small ischemic lesions, the authors proposed a new distance-subtraction method: after suitable centering of the axial slices, 3D distance-shaded images of the stress study were subtracted from the corresponding views of the rest study. With this technique, small changes in surface-to-observer distance were highlighted, thus enabling us to detect nontransmural ischemic areas of the myocardium. General characteristics and possibilities of the subtraction technique were tested on a simple myocardial phantom. Some clinical results of the application of this method on CAD patients are presented and discussed. In CAD patients in whom only nontransmural ischemic lesions are present, the subtraction of distance-shaded images is decisive for a correct diagnosis.     

Problems with the “dural tail” sign

Prominent enhancement of the dura mater, the dural tail adjacent to a peripherally located mass on gadolinium-enhanced MRI has been described as being characteristic of meningiomas. We present a cerebral glioma showing the classical dural tail.     

“Menigeal sign”: a characteristic finding of meningiomas on contrast-enhanced MR images

Summary In meningiomas, a flat, contrast-enhancing, probably dural structure adjacent to the tumor can occasionally be observed on Gadolinium-DTPA enhanced MR images. This so called meningeal sign was evaluated with respect to the differential diagnosis of meningiomas in MR imaging. The study included 29 patients with intracranial meningiomas and 24 patients with non-meningeal brain tumors. In all meningiomas, MR studies included T2-weighted as well as unenhanced and Gadolinium-DTPA-enhanced T1-weighted images. In all nonmeningeal tumors, Gd-DTPA-enhanced MR images were available. All images were evaluated with respect to the presence of the meningeal sign. In meningiomas, a meningeal sign was seen in 15/29 cases on Gadolinium-DTPA-enhanced images. No abnormalities corresponding to the areas of contrast enhancement were found on unenhanced T2- and T1-weighted MR images. In nonmeningeal tumors only 2/24 cases showed a meningeal sign. In conclusion, with a sensitivity of 52% and a specificity of 92%, the demonstration of the meningeal sign improved the differential diagnosis of intracranial meningiomas in contrast-enhanced MR imaging.     

Short-stop-munition

Zusammenfassung Immer wieder wird Munition zur Verteidigung unter Hinweis auf ihre weniger-tödliche bis nicht-tödliche Wirkung angeboten. Die Praxis zeigt jedoch, daß von diesen Munitionstypen entgegen den oft verharmlosenden Angaben der Hersteller sehr wohl eine konkrete Gefahr ausgeht. Einerseits können daraus schwerwiegende Folgen resultieren, andererseits kann als Einlassung vor Gericht die Vorhersehbarkeit solcher Folgen begrundet in Frage gestellt werden. Unter diesem Aspekt werden eine spezielle Schrotmunition für Revolver des Typs Speer 38/357 Shot Shells des Herstellers CCI, die Patrone Short-Stop der Fa. MB Associates in San Ramon (Kalifornien) and mit eigenem Fallbeispiel eine Munition vom Schock-Defense-Typ der Fa. Rauchalles in Offenburg vergleichend hinsichtlich Aufbau und Wirkung besprochen. Sonderdruckanfragen an: W.Eisenmenger     

Ossification and pseudoepiphysis formation in the “nonepiphyseal” end of bones of the hands and feet

Metacarpals, metatarsals, and phalanges were studied to assess the developmental morphology of secondary ossification in the nonepiphyseal ends of these bones as well as the formation of the pseudoepiphysis as an epiphyseal ossification variant. Both direct ossification extension from the metaphysis into the epiphysis and pseudoepiphysis formation preceded, and continued to be more mature than, formation and expansion of the classic epiphyseal (secondary) ossification center at the opposite end of each specific bone. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously. In contrast, when remnants of physis were retained, while juxtaposed epiphyseal cartilage was replaced, a pseudoepiphysis formed. There were three basic patterns of pseudoepiphysis formation. First, a central osseous bridge extended from the metaphysis across the physis into the epiphysis and subsequently expanded to create a mushroom-like osseous structure. In the second pattern a peripheral osseous bridge formed, creating either an osseous ring or an eccentric bridge between the metaphysis and the epiphysis. In the third pattern, multiple bridging occurred. In each situation the associated remnant physis lacked typical cell columns and was incapable of significantly contributing to the postnatal longitudinal growth of the involved bone. Pseudoepiphyses were well formed by 4–5 years and coalesced with the rest of the bone months of years before skeletal maturation was attained at the opposite epiphyseal end, which ossified in the typical pattern (i.e., formation of a secondary center de novo completely within the cartilaginous epiphysis). This process may also affect the development and appearance of ossification within the longitudinal epiphyseal bracket (delta phalanx).     

Unspecific white matter lesions: prevalence,number and distribution in cranial MRI

To establish data about prevalence, number and topography of unspecific white matter lesions as seen on MRI, the T2-weighted MRI scans of 83 patients with hyperintense focal white matter changes were reviewed. Patients with known inflammatory central nervous system disease were excluded. There was an approximately linear increase in prevalence and number of lesions with age. Prevalence ranged from 18% in the third decade to over 90% in those over 70 years. We found a close correlation with concomitant periventricular hyperintensity. However, rating of Virchow-Robin spaces did not correlate with the number of white matter lesions. Both hemispheres were involved nearly equally with a minimal non-significant right side preponderance. Lesions showed a strong predilection for the frontal and parietal paraventricular watershed areas. Offprint requests to: Erich Hofmann     

Sodium bicarbonate-augmented stress thallium myocardial scintigraphy

It is well known that sodium bicarbonate in pharmacological doses induces transient alkalosis, causing intracellular transport of serum potassium. The aims of this study were (a) to investigate whether, in humans, myocardial thallium-201 uptake can be augmented by pretreatment with a single bolus of sodium bicarbonate at a pharmacological dose, (b) to verify general safety aspects of the intervention and (c) to evaluate the clinical implications of augmentation of ²⁰¹Tl uptake, if any. Routine exercise myocardial scintigraphy was performed twice in eight adult volunteers (five normal and three abnormal), once without intervention and the second time (within a week) following intravenous administration of sodium bicarbonate (88 mEq in 50 ml) as a slow bolus 1 h prior to the injection of ²⁰¹Tl. Conventional myocardial thallium study was compared with sodium bicarbonate interventional myocardial scintigraphy with respect to myocardial uptake (counts per minute per mCi injected dose), washout patterns in normal and abnormal myocardial segments, and overall clinical interpretation based on planar and single-photon emission tomographic (SPET) images. All patients remained asymptomatic after the intervention. A mean increase of 53% in myocardial uptake of thallium was noted in post-exercise acquisitions after the intervention, confirming uptake of the tracer via the potassium-hydrogen pump and its augmentation by transient alkalosis. The washout pattern remained unchanged. The visual quality of planar and SPET images improved significantly after the intervention. Out of the five abnormal myocardial segments identified in three cases, four showed significant filling-in after the intervention, causing the diagnosis to be upgraded from partial scar to ischaemia, or from ischaemia to normal. The overall scan impression changed in two out of three such cases. Sodium bicarbonate augmentation may have significant implications for stress-thallium scintigraphy and may be a new parameter for defining myocardial viability.     

Positron CT imaging of an impending stroke

Summary We present PET findings of a case of a transient ischemic attack which later progressed to cerebral infarction. Cerebral blood flow at the stroke focus in the right parietal cortex measured after a TIA attack and before stroke was as low as 24 ml/100 g/min with some increase in oxygen extraction fraction and blood volume. The condition was compatible with misery perfusion. This case may be an example suggestive that the misery perfusion sign is a warning of impending stroke and its poor prognosis if left without appropriate treatments.     

Cerebral ultrasound images in prenatal cytomegalovirus infection

Summary A male newborn with prenatal cytomegalovirus infection was referred for cranial ultrasound. The cranial ultrasound demonstrated areas of increased echogenicity in the thalamic and gray nuclei resembling a branched candlestick. Doppler technique located the branched candlestick along the thalamostriate arteries. This image is particularly interesting because to our knowledge it has never before been described in congenital cytomegalovirus infection, but only in congenital rubella.     

DNA extraction from mixtures of body fluid using mild preferential lysis

Summary A modification to the DNA extraction method preferential lysis (Gill et al. 1985) is proposed which can be applied to DNA mixtures of vaginal cells and spermatozoa. In mixtures with a low sperm content the further loss of sperm DNA caused by the extraction can be avoided by using mild preferential lysis. Amplification by PCR (polymerase chain reaction) then yields sufficient DNA to be able to identify both components in the mixture.     

A comparison of the structure and function of the terminal lleum in crohn's disease using radiology,the “dicopac” schilling test and [14C] G.C.A. Breath test

Twenty patients with Crohn's disease were studied. Thirteen had radiological evidence of involvement of the terminal ileum. None had significant bacterial overgrowth of the small bowel contents and none had had resection of the terminal ileum. In all patients a [¹⁴C] glycocholic acid ([¹⁴C] G.C.A.) breath test and a Dicopac Schilling test were performed to assess terminal ileal function. The data showed poor correlation between the radiological appearance of the terminal ileum and the results of the functional tests. There was also poor correlation between the results of the [¹⁴C] G.C.A. breath test and the Dicopac Schilling test. Without terminal ileal histology, any assessment of the extent of Crohn's disease of the terminal ileum and of its effect on terminal ileal function, must include the [¹⁴C] G.C.A. breath test as well as radiology and the Dicopac Schilling test. The limitations of the [¹⁴C] G.C.A. breath test as a test of terminal ileal function in Crohn's disease are discussed.     

Dose reduction in subsecond multislice spiral CT examination of children by online tube current modulation

The potential of online tube current modulation in subsecond multislice spiral CT (MSCT) examinations of children to reduce the dose without a loss in image quality is investigated in a controlled patient study. The dose can be reduced for oval patient sectional view without an increase in noise if the tube current is reduced where the patient diameter and, consequently, attenuation are small. We investigated a product version of an online control for tube current in a SOMATOM Sensation 4 (Siemens, Forchheim). We evaluated image quality, noise and dose reduction for examinations with online tube current modulation in 30 MSCT of thorax/abdomen and abdomen and compared mA s for tube current modulation to the mA s in standard weight-adapted children protocols. Image quality was rated as very good, good, diagnostic and poor in a consensus by three radiologists. Noise was assessed in comparison to 24 MSCT examinations without tube current modulation measured as SD in ROIs. The dose was reduced from 26 to 43% (mean 36%), depending on the patients geometry and weight. In general, no loss of image quality was observed. Measured noise showed a decrease up to 26% and an increase up to 36%, although there was no decrease of image quality. Online tube current modulation is now used as a standard in MSCT at our institution. Dose in MSCT examinations of children can be reduced substantially in routine examinations by online tube current modulation without a loss of image quality.     

Patterns of radioiodine uptake by the lactating breast

Breast uptake of radioiodine, if not suspected, may be misinterpreted as thyroid cancer metastasis to the lung. To characterize the patterns of radioiodine breast uptake, we retrospectively studied 20 radioiodine scans that were performed within 1 week of cessation of breast feeding. Four patterns of uptake were identified: full, focal, crescent and irregular. The uptake was asymmetric in 60% (left>right in 45%, right>left in 15%), symmetric in 25% and unilateral in 15% of cases. A characteristic full bilateral uptake was present in 40% of cases. In three cases with the irregular pattern, caused in part by external contamination with radioactive milk, the uptake closely mimicked lung metastases. Delayed images, obtained in one case, showed an apparent radioiodine shift from the breast to the thyroid, suggesting that the presence of breast uptake can modulate radioiodine uptake by thyroid tissue. In a case of unilateral breast uptake, a history of mastitis was obtained, which to our knowledge has not been previously reported. Breast uptake of radioiodine may take several scintigraphic patterns that are not always characteristic of the lactating breast and may affect the apparent extent of thyroid remnant/metastasis.