[Needle in the haystack - potentially dangerous syncope in childhood]

Syncope is a frequently observed symptom in pediatrics with teenagers being the age group most often affected. In contrast to older age, organic cardiac causes of syncope in child-hood are observed in a minority of only 2-5% of cases, in their majority pediatric syncopes thus are neurocardiogenic in origin. The rare organic cardiac causes that may manifest with syncope are all potentially dangerous entities such as cardiomyopathies, genetic primary electrical disease and some forms of structural heart disease, as well as some other rare diseases such as e.g. primary pulmonary hypertension. These diseases have to be actively looked for or excluded. Guidelines recommend patient evaluation including history, physical examination and ECG, which is sufficient to sort out suspect cases after a syncopal episode.

Post mortem computed tomography and core needle biopsy in comparison to autopsy in eleven bernese mountain Dogs with histiocytic sarcoma

Background: Bernese mountain dogs are reported to have a shorter life expectancy than other breeds. A Major reason for this has been assigned to a high tumour prevalence, especially of histiocytic sarcoma. The efforts made by the breeding clubs to improve the longevity with the help of genetic tests and breeding value estimations are impeded by insufficiently reliable diagnoses regarding the cause of death. The current standard for post mortem examination in animals is performance of an autopsy. In human forensic medicine, imaging modalities, such as computed tomography and magnetic resonance imaging, are used with increasing frequency as a complement to autopsy. The present study investigates, whether post mortem computed tomography in combination with core needle biopsy is able to provide a definitive diagnosis of histiocytic sarcoma. For this purpose we have analysed the results of post mortem computed tomography and core needle biopsy in eleven Bernese mountain dogs. In the subsequent autopsy, every dog had a definitive diagnosis of histiocytic sarcoma, based on immunohistochemistry. Results: Computed tomography revealed space-occupying lesions in all dogs. Lesion detection by post mortem computed tomography was similar to lesion detection in autopsy for lung tissue (9 cases in computed tomography / 8 cases in autopsy), thoracic lymph nodes (9/8), spleen (6/7), kidney (2/2) and bone (3/3). Hepatic nodules, however, were difficult to detect with our scanning protocol (2/7). Histology of the core needle biopsies provided definitive diagnoses of histiocytic sarcoma in ten dogs, including confirmation by immunohistochemistry in six dogs. The biopsy samples of the remaining dog did not contain any identifiable neoplastic cells. Autolysis was the main reason for uncertain histological diagnoses. Conclusions: Post mortem computed tomography is a fast and effective method for the detection of lesions suspicious for histiocytic sarcoma in pulmonary, thoracic lymphatic, splenic, osseous and renal tissue. Optimization of the procedure regarding the scanning protocol and tissue sample size and number will improve the accuracy of the method. Keywords: Post mortem computed tomography, Core needle biopsy, Bernese mountain dog, Histiocytic sarcoma, Autopsy

Real-Time In Vivo Characterization of Primary Liver Tumors With Diffuse Optical Spectroscopy During Percutaneous Needle Interventions: Feasibility Study in Woodchucks

OBJECTIVE This study presents the first in vivo real-time optical tissue characterization during image-guided percutaneous intervention using near-infrared diffuse optical spectroscopy sensing at the tip of a needle. The goal of this study was to indicate transition boundaries from healthy tissue to tumors, namely, hepatic carcinoma, based on the real-time feedback derived from the optical measurements. MATERIALS AND METHODS Five woodchucks with hepatic carcinoma were used for this study. The woodchucks were imaged with contrast-enhanced cone beam computed tomography with a flat panel detector C-arm system to visualize the carcinoma in the liver. In each animal, 3 insertions were performed, starting from the skin surface toward the hepatic carcinoma under image guidance. In 2 woodchucks, each end point of the insertion was confirmed with pathologic examination of a biopsy sample. While advancing the needle in the animals under image guidance such as fluoroscopy overlaid with cone beam computed tomography slice and ultrasound, optical spectra were acquired at the distal end of the needles. Optical tissue characterization was determined by translating the acquired optical spectra into clinical parameters such as blood, water, lipid, and bile fractions; tissue oxygenation levels; and scattering amplitude related to tissue density. The Kruskal-Wallis test was used to study the difference in the derived clinical parameters from the measurements performed within the healthy tissue and the hepatic carcinoma. Kurtoses were calculated to assess the dispersion of these parameters within the healthy and carcinoma tissues. RESULTS Blood and lipid volume fractions as well as tissue oxygenation and reduced scattering amplitude showed to be significantly different between the healthy part of the liver and the hepatic carcinoma (P < 0.05) being higher in normal liver tissue. A decrease in blood and lipid volume fractions and tissue oxygenation as well as an increase in scattering amplitude were observed when the tip of the needle crossed the margin from the healthy liver tissue to the carcinoma. The kurtosis for each derived clinical parameter was high in the hepatic tumor as compared with that in the healthy liver indicating intracarcinoma variability. CONCLUSIONS Tissue blood content, oxygenation level, lipid content, and tissue density all showed significant differences when the needle tip was guided from the healthy tissue to the carcinoma and can therefore be used to identify tissue boundaries during percutaneous image-guided interventions.

Diagnostic endoscopy of the navicular bursa using a needle endoscope by direct or transthecal approach: A comparative cadaver study

OBJECTIVES: To compare the practicability, visualization of structures, and iatrogenic damage of direct and transthecal approaches to the navicular bursa for diagnostic needle endoscopy. STUDY DESIGN: Descriptive study. SAMPLE POPULATION: Equine cadaver forelimbs (n = 30). METHODS: Direct and transthecal approaches for insertion of a needle endoscope into the navicular bursa were performed. Video recordings of endoscopic procedures were assessed to determine all structures visualized within the navicular bursa. Number of attempts to gain access to the navicular bursa and total time for insertion and examination were recorded. Distribution and severity of iatrogenic lesions were assessed and scored after dissection. RESULTS: There were no statistical differences for number of attempts or time needed for insertion and examination between direct and transthecal approaches. The direct approach offered significantly increased visibility of the ipsilateral abaxial and proximal margins of the navicular bone, and ipsilateral collateral sesamoidean ligament. Iatrogenic lesions were superficial and focal, regardless of approach taken, or whether a blunt or sharp trocar tip was used. CONCLUSIONS: The direct approach provided significantly better visualization of the ipsilateral structures within the navicular bursa compared to the transthecal approach. Needle endoscopy offers a reliable technique to evaluate the navicular bursa and may complement or replace other diagnostic modalities in horses with lameness localized to the navicular region.

An examination chair to measure internal rotation of the hip in routine settings: a validation study

OBJECTIVE: To determine the performance of a newly developed examination chair as compared with the clinical standard of assessing internal rotation (IR) of the flexed hip with a goniometer. METHODS: The examination chair allowed measurement of IR in a sitting position simultaneously in both hips, with hips and knees flexed 90 degrees, lower legs hanging unsupported and a standardized load of 5 kg applied to both ankles using a bilateral pulley system. Clinical assessment of IR was performed in supine position with hips and knees flexed 90 degrees using a goniometer. Within the framework of a population-based inception cohort study, we calculated inter-observer agreement in two samples of 84 and 64 consecutive, unselected young asymptomatic males using intra-class correlation coefficients (ICC) and determined the correlation between IR assessed with examination chair and clinical assessment. RESULTS: Inter-observer agreement was excellent for the examination chair (ICC right hip, 0.92, 95% confidence interval [CI] 0.89-0.95; ICC left hip, 0.90, 95% CI 0.86-0.94), and considerably higher than that seen with clinical assessment (ICC right hip, 0.65, 95% CI 0.49-0.77; ICC left hip, 0.69, 95% CI 0.54-0.80, P for difference in ICC between examination chair and clinical assessment examination chair and clinical assessment were similar (difference 1.1 degrees, 95% CI - 0.7-2.8 degrees, P=0.23), and the correlation was strong (Pearson's coefficient, 0.75, 95% CI 0.62-0.84). CONCLUSIONS: The use of the examination chair resulted in a precise assessment of hip IR in our population-based inception cohort study of young asymptomatic males. It was strongly correlated with standard clinical assessment of IR but was considerably more reliable.

Examination of FGFRL1 as a candidate gene for diaphragmatic defects at chromosome 4p16.3 shows that Fgfrl1 null mice have reduced expression of Tpm3, sarcomere genes and Lrtm1 in the diaphragm

Fgfrl1 (also known as Fgfr5; OMIM 605830) homozygous null mice have thin, amuscular diaphragms and die at birth because of diaphragm hypoplasia. FGFRL1 is located at 4p16.3, and this chromosome region can be deleted in patients with congenital diaphragmatic hernia (CDH). We examined FGFRL1 as a candidate gene for the diaphragmatic defects associated with 4p16.3 deletions and re-sequenced this gene in 54 patients with CDH. We confirmed six known coding single nucleotide polymorphisms (SNPs): c.209G > A (p.Pro20Pro), c.977G > A (p.Pro276Pro), c.1040T > C (p.Asp297Asp), c.1234C > A (p.Pro362Gln), c.1420G > T (p.Arg424Leu), and c.1540C > T (p.Pro464Leu), but we did not identify any gene mutations. We genotyped additional CDH patients for four of these six SNPs, including the three non-synonymous SNPs, to make a total of 200 chromosomes, and found that the allele frequency for the four SNPs, did not differ significantly between patients and normal controls (p > or = 0.05). We then used Affymetrix Genechip Mouse Gene 1.0 ST arrays and found eight genes with significantly reduced expression levels in the diaphragms of Fgfrl1 homozygous null mice when compared with wildtype mice-Tpm3, Fgfrl1 (p = 0.004), Myl2, Lrtm1, Myh4, Myl3, Myh7 and Hephl1. Lrtm1 is closely related to Slit3, a protein associated with herniation of the central tendon of the diaphragm in mice. The Slit proteins are known to regulate axon branching and cell migration, and inhibition of Slit3 reduces cell motility and decreases the expression of Rac and Cdc42, two genes that are essential for myoblast fusion. Further studies to determine if Lrtm1 has a similar function to Slit3 and if reduced Fgfrl1 expression can cause diaphragm hypoplasia through a mechanism involving decreased myoblast motility and/or myoblast fusion, seem indicated.

Mild cognitive impairment in medical inpatients: the mini-mental state examination is a promising screening tool

AIM: To assess the prevalence of mild cognitive impairment (MCI) in medical inpatients aged 55-85 years without known cognitive deficits, and how often ward physicians mentioned MCI in their discharge notes. Moreover, we aimed to identify variables associated with MCI and to assess the sensitivity and specificity of the Mini-Mental State Examination (MMSE) for MCI. METHODS: Two neuropsychologists administered a 60-min battery of validated tests to evaluate different cognitive domains. The diagnosis of MCI was based on a prespecified algorithm. The sensitivity and specificity of the MMSE for MCI were calculated. RESULTS: Fifteen patients showed a normal cognitive profile (21.4%), while 55 patients (78.6%) showed MCI. Ward physicians, blinded to the results of the neuropsychological evaluation, did not mention MCI in their discharge notes of any of the evaluated patients. The only variable independently associated with MCI was the MMSE. A MMSE score of < or =28 showed a sensitivity of 85.5% and a specificity of 66.7% for MCI. CONCLUSION: MCI is frequent albeit overlooked in elderly medical inpatients without previously known cognitive deficits. In view of therapies preventing the progression of MCI to dementia, MCI screening will be crucial. The MMSE represents a promising screening tool for MCI in medical inpatients.

[Thyroid nodules: which further investigations should be done]

Thyroid nodules are a very common clinical finding with an age-related increase in prevalence. The clinical detection of thyroid nodules is outnumbered by the ultrasonographic assessment of thyroid nodules. The clinical challenge is to exclude thyroid cancer and clinical or subclinical hyperthyroidism. Ultrasonography is the first imaging study in all patients with palpable nodules; their size and TSH determine further diagnostic evaluations. Fine-needle aspiration (cytology) is recommended in euthyroid patients of nodules measuring more than 1-1.5 cm in diameter. Nodules more than 4 cm in diameter have to be removed surgically without preceding cytological examination. Without risk factors thyroid nodules are followed by clinical examination and ultrasonography every 6-12 months, in case of symptoms or rapid growth a follow-up assessment should be done earlier.

Diagnosis of fatal pulmonary fat embolism with minimally invasive virtual autopsy and post-mortem biopsy

We report a case of a 78-year-old female with a proximal femur fracture caused by an accidental fall who died suddenly 1h after orthopaedic prosthesis insertion. Post-mortem computed tomography (CT) scan and histological examination of samples obtained with post-mortem percutaneous needle biopsies of both lungs were performed. Analysis of the medical history and the clinical scenario immediately before death, imaging data, and biopsy histology established the cause of death without proceeding to traditional autopsy. It was determined to be acute right ventricular failure caused by massive pulmonary fat embolism. Although further research in post-mortem imaging and post-mortem tissue sampling by needle biopsies is necessary, we conclude that the use of CT techniques and percutaneous biopsy, as additional tools, can offer a viable alternative to traditional autopsy in selected cases and may increase the number of minimally invasive forensic examinations performed in the future.

Performance of laser fluorescence devices, visual and radiographic examination for the detection of occlusal caries in primary molars

The aim of this in vitro study was to compare the performance of two laser fluorescence devices (LF, LFpen), conventional visual criteria (VE), ICDAS and radiographic examination on occlusal surfaces of primary teeth. Thirty-seven primary human molars were selected from a pool of extracted teeth, which were stored frozen at -20°C until use. Teeth were assessed twice by two experienced examiners using laser fluorescence devices (LF and LFpen), conventional visual criteria, ICDAS and bitewing radiographs, with a 2-week interval between measurements. After measurement, the teeth were histologically prepared and assessed for caries extension. The highest sensitivity was observed for ICDAS at D(1) and D(3) thresholds, with no statistically significant difference when compared to the LF devices, except at the D(3) threshold. Bitewing radiographs presented the lowest values of sensitivity. Specificity at D(1) was higher for LFpen (0.90) and for VE at D(3) (0.94). When VE was combined with LFpen the post-test probabilities were the highest (94.0% and 89.2% at D(1) and D(3) thresholds, respectively). High values were observed for the combination of ICDAS and LFpen (92.0% and 80.0%, respectively). LF and LFpen showed the highest values of ICC for interexaminer reproducibility. However, regarding ICDAS, BW and VE, intraexaminer reproducibility was not the same for the two examiners. After primary visual inspection using ICDAS or not, the use of LFpen may aid in the detection of occlusal caries in primary teeth. Bitewing radiographs may be indicated only for approximal caries detection.

Primary tuberculosis of the TMJ: presentation of a case and literature review

Tuberculosis (TB) is a frequent health problem. The prevalence of extrapulmonary TB has increased in the last couple of years. Head and neck tuberculosis forms nearly 10% of all extrapulmonary manifestations of the disease. TB of the temporomandibular joint (TMJ) is rare; only a few cases have been reported. The clinical appearance of TB infection of the TMJ has been described as unspecific, resembling arthritis, osteomyelitis, cancer or any kind of chronic joint diseases. This article describes a 22-year-old woman with pain and left preauricular swelling. Magnetic resonance imaging and computed tomography showed an expansive process with destruction of the left condyle and condylar fossa. A fine needle aspiration examination of the swelling showed non-specific granulomatous inflammation. In the following days, a preauricular fistula developed, of which a swab and biopsy specimens were taken. Histological and microbiological examinations revealed an infection with Mycobacterium tuberculosis. The initial antituberculosis treatment consisted of a combination of four antibiotics and could be reduced to two antibiotics in the course of treatment. The treatment was completed successfully after 9 months.

Influence of examiner's clinical experience on the reproducibility and accuracy of radiographic examination in detecting occlusal caries

The aim of this in vitro study was to assess the influence of varying examiner's clinical experience on the reproducibility and accuracy of radiographic examination for occlusal caries detection. Standardized bitewing radiographs were obtained from 166 permanent molars. Radiographic examination was performed by final-year dental students from two universities (A, n = 5; B, n = 5) and by dentists with 5 to 7 years of experience who work in two different countries (C, n = 5; D, n = 5). All examinations were repeated after 1-week interval. The teeth were histologically prepared and assessed for caries extension. For intraexaminer reproducibility, the unweighted kappa values were: A (0.11-0.40), B (0.12-0.33), C (0.47-0.58), and D (0.42-0.71). Interexaminer reproducibility statistics were computed based on means ± SD of unweighted kappa values: A (0.07 ± 0.05), B (0.12 ± 0.09), C (0.24 ± 0.08), and D (0.33 ± 0.10). Sensitivity, specificity, and accuracy were calculated at D(1) and D(3) thresholds and compared by performing McNemar test (p = 0.05). D(1) sensitivity ranged between 0.29 and 0.75 and specificity between 0.24 and 0.85. D(3) specificity was moderate to high (between 0.62 and 0.95) for all groups, with statistically significant difference between the dentists groups (C and D). Sensitivity was low to moderate (between 0.21 and 0.57) with statistically significant difference for groups B and D. Accuracy was similar for all groups (0.55). Spearman's correlations were: A (0.12), B (0.24), C (0.30), and D (0.38). In conclusion, the reproducibility of radiographic examination was influenced by the examiner's clinical experience, training, and dental education as well as the accuracy in detecting occlusal caries.

[Examination results and autopsy findings in assaults on elderly people]

As the percentage of elderly people in the population grows, violence against persons of advanced age constitutes an increasing social problem. The findings of the clinical forensic examinations (CE group) and autopsies performed on elderly violence victims (> or = 60 years) between 1999 and 2008 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analysed. In all, the study material comprised 55 victims of the CE group (35 females and 20 males, median age 73.5 years) and 55 autopsies (33 females and 22 males, median age 72.7 years). In most of the autopsy cases, the suspect was a family member or partner. In contrast, the alleged perpetrator was a stranger in most cases of the CE group. Blunt force injuries were most often found in the CE group victims (63.6%). Altogether, 38.2% (CE group) and 20.0% (autopsy cases) of the violent assaults were associated with robbery. In the majority of the CE cases, the victims suffered potentially or acute life-threatening injuries. In summary, the analysis shows that elderly people frequently become victims of robbery and blunt force injury. In most homicides of old people, the perpetrator is familiar to the victim. In surviving elderly violence victims, the assault is more likely to be reported to the police if the suspect is a stranger.

[Examination reports on survived strangulation cases]

Clinical-forensic examination of strangulation victims is an increasing part of the routine of many forensic pathology institutes. The cases examined between 2004 and 2008 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analysed. In total, the study material comprised 218 victims (175 females and 43 males). In 80.7 %, the clinical-forensic examination was performed within 24 hours after the incident. In the overwhelming number of cases, the alleged perpetrator was no stranger. 128 victims (58.7 %) had strangulation marks, 32 victims (14.7 %) ligature marks and 65 victims (29.8 %) nail marks. Four victims showed injuries of the laryngeal and pharyngeal structures (reddening, hematomas, swelling and in one case a fracture of the cricoid cartilage on both sides). Extensive petechiae were predominantly seen in the conjunctivae, the buccal mucosa and the skin of the face in cases where the victims suffered a loss of consciousness. 87 cases (39.9% were classified as potentially life-threatening and 30 cases (13.8 %) as acute life-threatening events. This classification is of legal relevance for the penalty. In addition, 60 victims experienced sexual violence. These results suggest that early clinical-forensic examination is crucial for documenting forensic evidence in support of police investigations and may deliver significant details relevant in court.

[Analysis of clinical forensic examination reports on sexually abused children]

Clinical forensic examinations of children suspected of having been sexually abused are increasingly part of the routine of medicolegal institutes. The findings collected from 2005 until 2007 at the Institute of Legal Medicine of the Hanover Medical School were analysed retrospectively. Altogether, 91 children (74 females, 17 males, mean age 8.7 years) were examined. In 87.9% of the cases, the examination had been ordered by the police. In 73.6%, the victim knew the suspected perpetrator well or he was a family member. 40.7% of the children were seen within 72 hours after the alleged abuse. 12.1% of the children had extragenital lesions. In 27% of the victims, marked anogenital injuries were found, which were characteristic of sexual abuse in 9%. In 18 cases (20.2%), swabs were taken for spermatozoa detection. 3 of 17 vaginal smears showed positive test results for sperm up to 21 hours after the incident. No spermatozoa could be detected in 4 anal and 2 oral swabs as well as in one swab taken from the skin of the victim's thigh. In summary, the evaluation shows that early clinical forensic examination of children suspected of having been sexually abused is crucial to document evidence that is highly significant for the investigation and court proceedings. Often suspected sexual child abuse cannot be proved by medical findings alone. Of course, the absence of anogenital injuries does nor rule out sexual abuse.