Signaling across the synapse: a role for Wnt and Dishevelled in presynaptic assembly and neurotransmitter release

Proper dialogue between presynaptic neurons and their targets is essential for correct synaptic assembly and function. At central synapses, Wnt proteins function as retrograde signals to regulate axon remodeling and the accumulation of presynaptic proteins. Loss of Wnt7a function leads to defects in the localization of presynaptic markers and in the morphology of the presynaptic axons. We show that loss of function of Dishevelled-1 (Dvl1) mimics and enhances the Wnt7a phenotype in the cerebellum. Although active zones appear normal, electrophysiological recordings in cerebellar slices from Wnt7a/Dvl1 double mutant mice reveal a defect in neurotransmitter release at mossy fi ber–granule cell synapses. Deficiency in Dvl1 decreases, whereas exposure to Wnt increases, synaptic vesicle recycling in mossy fi bers. Dvl increases the number of Bassoon clusters, and like other components of the Wnt pathway, it localizes to synaptic sites. These fi ndings demonstrate that Wnts signal across the synapse on Dvl-expressing presynaptic terminals to regulate synaptic assembly and suggest a potential novel function for Wnts in neurotransmitter release.

Development of advanced silicon radiation detectors for harsh radiation environment

This thesis describes the development of advanced silicon radiation detectors and their characterization by simulations, used in the work for searching elementary particles in the European Organization for Nuclear Research, CERN. Silicon particle detectors will face extremely harsh radiation in the proposed upgrade of the Large Hadron Collider, the future high-energy physics experiment Super-LHC. The increase in the maximal fluence and the beam luminosity up to 1016 neq / cm2 and 1035 cm-2s-1 will require detectors with a dramatic improvement in radiation hardness, when such a fluence will be far beyond the operational limits of the present silicon detectors. The main goals of detector development concentrate on minimizing the radiation degradation. This study contributes mainly to the device engineering technology for developing more radiation hard particle detectors with better characteristics. Also the defect engineering technology is discussed. In the nearest region of the beam in Super-LHC, the only detector choice is 3D detectors, or alternatively replacing other types of detectors every two years. The interest in the 3D silicon detectors is continuously growing because of their many advantages as compared to conventional planar detectors: the devices can be fully depleted at low bias voltages, the speed of the charge collection is high, and the collection distances are about one order of magnitude less than those of planar technology strip and pixel detectors with electrodes limited to the detector surface. Also the 3D detectors exhibit high radiation tolerance, and thus the ability of the silicon detectors to operate after irradiation is increased. Two parameters, full depletion voltage and electric field distribution, is discussed in more detail in this study. The full depletion of the detector is important because the only depleted area in the detector is active for the particle tracking. Similarly, the high electric field in the detector makes the detector volume sensitive, while low-field areas are non-sensitive to particles. This study shows the simulation results of full depletion voltage and the electric field distribution for the various types of 3D detectors. First, the 3D detector with the n-type substrate and partial-penetrating p-type electrodes are researched. A detector of this type has a low electric field on the pixel side and it suffers from type inversion. Next, the substrate is changed to p-type and the detectors having electrodes with one doping type and the dual doping type are examined. The electric field profile in a dual-column 3D Si detector is more uniform than that in the single-type column 3D detector. The dual-column detectors are the best in radiation hardness because of their low depletion voltages and short drift distances.

Ash2 acts as an Ecdysone Receptor coactivator by stabilizing the histone methyltransferase Trr.

The molting hormone ecdysone triggers chromatin changes via histone modifica- tions that are important for gene regulation. On hormone activation, the ecdysone receptor (EcR) binds to the SET domain-containing histone H3 methyltransferase trithorax-related protein (Trr). Methylation of histone H3 at lysine 4 (H3K4me), which is associated with tran- scriptional activation, requires several cofactors, including Ash2. We find that ash2 mutants have severe defects in pupariation and metamorphosis due to a lack of activation of ecdy- sone-responsive genes. This transcriptional defect is caused by the absence of the H3K4me3 marks set by Trr in these genes. We present evidence that Ash2 interacts with Trr and is re- quired for its stabilization. Thus we propose that Ash2 functions together with Trr as an ecdysone receptor coactivator.

Homonymous Ganglion Cell Layer Thinning After Isolated Occipital Lesion: Macular OCT Demonstrates Transsynaptic Retrograde Retinal Degeneration.

A 48-year-old man was examined 24 months after medial and surgical treatment of an isolated well-circumscribed right occipital lobe abscess. An asymptomatic residual left homonymous inferior scotoma was present. Fundus examination revealed temporal pallor of both optic discs, and optical coherence tomography (OCT) revealed mild temporal loss of retinal nerve fiber layer in both eyes. No relative afferent pupillary defect was present. Assessment of the retinal ganglion cell layer demonstrated homonymous thinning in a pattern corresponding to the homonymous visual field loss. There were no abnormalities of the lateral geniculate nuclei or optic tracts on review of the initial brain computed tomography and follow-up magnetic resonance imaging. We believe our patient showed evidence of transsynaptic retrograde degeneration after an isolated right occipital lobe lesion, and the homonymous neuronal loss was detected on OCT by assessing the retinal ganglion cell layer.

Molecular insight into heart development and congenital heart disease: An update review from the Arab countries.

Congenital heart defect (CHD) has a major influence on affected individuals as well as on the supportive and associated environment such as the immediate family. Unfortunately, CHD is common worldwide with an incidence of approximately 1% and consequently is a major health concern. The Arab population has a high rate of consanguinity, fertility, birth, and annual population growth, in addition to a high incidence of diabetes mellitus and obesity. All these factors may lead to a higher incidence and prevalence of CHD within the Arab population than in the rest of the world, making CHD of even greater concern. Sadly, most Arab countries lack appropriate public health measures directed toward the control and prevention of congenital malformations and so the importance of CHD within the population remains unknown but is thought to be high. In approximately 85% of CHD patients, the multifactorial theory is considered as the pathologic basis. The genetic risk factors for CHD can be attributed to large chromosomal aberrations, copy number variations (CNV) of particular regions in the chromosome, and gene mutations in specific nuclear transcription pathways and in the genes that are involved in cardiac structure and development. The application of modern molecular biology techniques such as high-throughput nucleotide sequencing and chromosomal array and methylation array all have the potential to reveal more genetic defects linked to CHD. Exploring the genetic defects in CHD pathology will improve our knowledge and understanding about the diverse pathways involved and also about the progression of this disease. Ultimately, this will link to more efficient genetic diagnosis and development of novel preventive therapeutic strategies, as well as gene-targeted clinical management. This review summarizes our current understanding of the molecular basis of normal heart development and the pathophysiology of a wide range of CHD. The risk factors that might account for the high prevalence of CHD within the Arab population and the measures required to be undertaken for conducting research into CHD in Arab countries will also be discussed.

Natural history of growth hormone deficiency in a pediatric cohort.

BACKGROUND/AIMS: Controversies still exist regarding the evaluation of growth hormone deficiency (GHD) in childhood at the end of growth. The aim of this study was to describe the natural history of GHD in a pediatric cohort. METHODS: This is a retrospective study of a cohort of pediatric patients with GHD. Cases of acquired GHD were excluded. Univariate logistic regression was used to identify predictors of GHD persisting into adulthood. RESULTS: Among 63 identified patients, 47 (75%) had partial GHD at diagnosis, while 16 (25%) had complete GHD, including 5 with multiple pituitary hormone deficiencies. At final height, 50 patients underwent repeat stimulation testing; 28 (56%) recovered and 22 (44%) remained growth hormone (GH) deficient. Predictors of persisting GHD were: complete GHD at diagnosis (OR 10.1, 95% CI 2.4-42.1), pituitary stalk defect or ectopic pituitary gland on magnetic resonance imaging (OR 6.5, 95% CI 1.1-37.1), greater height gain during GH treatment (OR 1.8, 95% CI 1.0-3.3), and IGF-1 level <-2 standard deviation scores (SDS) following treatment cessation (OR 19.3, 95% CI 3.6-103.1). In the multivariate analysis, only IGF-1 level <-2 SDS (OR 13.3, 95% CI 2.3-77.3) and complete GHD (OR 6.3, 95% CI 1.2-32.8) were associated with the outcome. CONCLUSION: At final height, 56% of adolescents with GHD had recovered. Complete GHD at diagnosis, low IGF-1 levels following retesting, and pituitary malformation were strong predictors of persistence of GHD. © 2015 S. Karger AG, Basel.

SAP R/3 -toimimianohjausjärjestelmän käytettävyyden parantaminen metsäteollisuusyrityksessä

Työn tavoitteena on parantaa SAP R/3-järjestelmän käytettävyyttä muutoksenhallintaprosessia mallintamalla. Työn alussa selkeytetään järjestelmän käytön nykytilaa yrityksessä sekä käyttäjien vaatimia parannuskohteita. Työn teoriaosassa käsitellään asiakasnäkökulmasta prosessien kehittämisen sekä niiden mallintamisen teoriaa. Teoriaosassa haetaan vastauksia järjestelmiin liittyviin kysymyksiin: - Kuinka selkeytetään käyttöönottoa sekä hyödynnetään toiminnan prosessilähtöistä kehittämistä? - Kuinka asiakastarpeita kartoittamalla huomioidaan käyttäjien tulevat taipeet? - Miten prosessimallintaminen lisää käyttäjien luottamusta ja yrityksen kilpailukykyä? Soveltavassa osassa tutkitaan vika- ja pienkehityspyyntöjen hallintaa ARIS-mallinnuksen avulla. Toimintoketjun avulla luodaan M-real-konsemissa käyttäjien ja palveluntarjoajan yhteinen toimintamalli. Prosessin omistajuus, käyttäjien liittymäpinta sekä toiminnan organisointi huomioidaan kaikkien osapuolten kesken

Visual signs and symptoms in patients with the visual variant of Alzheimer disease.

BACKGROUND: Prominent visual symptoms can present in the visual variant of Alzheimer's disease (VVAD). Ophthalmologists have a significant role to play in the early diagnosis of VVAD. METHODS: We retrospectively reviewed the files of ten consecutive patients diagnosed with VVAD. All patients had a full neuro-ophthalmologic examination, a formal neurological and neuro-psychological testing, and cerebral MRI to confirm diagnosis. In addition, functional neuroimaging was obtained in seven patients. RESULTS: The common primary symptom at presentation with all patients was difficulty with near vision (reading difficulty n = 8, "visual blur" in near vision n = 2), and difficulty writing (n = 3). Following assessment, impaired reading and writing skills were evident in 9/10 and 8/10 patients respectively. Median distance visual acuity was 20/25 and at near the median visual acuity was J6. Partial homonymous visual field defect was detected in 80 % (8/10) of the patients. Color vision was impaired in all patients when tested with Ishihara pseudoisochromatic plates, but simple color naming was normal in 8/9 tested patients. Simultanagnosia was present in 8/10 patients. Vision dysfunction corresponded with cerebral MRI findings where parieto-occipital cortical atrophy was observed in all patients. PET scan (5 patients) or SPECT (2 patients) revealed parieto-occipital dysfunction (hypometabolism or hypoperfusion) in all 7 tested patients CONCLUSIONS: Visual difficulties are prominent in VVAD. Dyslexia, incomplete homonymous hemianopia, preserved color identification with abnormal color vision on Ishihara, and simultanagnosia were all symptoms observed frequently in this patient series. Ophthalmologists should be aware of the possibility of neurodegenerative disorders such as VVAD in patients with unexplained visual complaints, in particular reading difficulties.

Ewing sarcoma cancer stem cells : from mechanisms to therapeutic targeting

Le sarcome d'Ewing (SE) est la 2ème tumeur des os la plus fréquente chez les enfants, et le pronostic est sombre au stade métastatique. La pathogenèse du SE repose sur une translocation, provocant la fusion du domaine activateur du facteur de transcription EWS, avec la partie liant l'ADN de la protéine FLI-1. Les cellules souches cancéreuses (CSC) sont supposées être les moteurs de la croissance tumorale, et représente de ce fait des cibles thérapeutiques préférentielles. Dans ce travail nous nous sommes efforcés de comprendre, ainsi que de cibler les mécanismes liés à l'émergence des CSC dans le sarcome d'Ewing. La formation des CSC du ES est liée à un défaut de maturation des miRNAs provoqué par une sous-expression d'un gène, TARBP2, dans les CSC. Ce défaut de maturation peut être corrigé par un traitement des cellules avec de l'enoxacine, une fluoroquinolone utilisée pour traiter les infections urinaires. L'enoxacine seule n'étant pas suffisante pour éradiquer les tumeurs in vivo, nous avons testé la combinaison d'une thérapie ciblée sur les CSC avec une chimiothérapie classique, la doxorubicine, ciblant les cellules différentiées. In vitro l'enoxacine induit l'apoptose dans les CCS sans affecter les cellules différentiées, alors que à l'inverse, la doxorubicine n'affecte que les cellules de la « masse » tumorale. In vivo la combinaison de ces deux drogues inhibe la croissance de tumeurs provenant de cellules primaires xenotranplantées et éradique les CSCs. Nos résultats mettent en lumière une nouvelle approche thérapeutique directement applicable pour le sarcome d'Ewing, et pourraient ainsi rapidement déboucher sur des essais cliniques. Dans la deuxième partie de ce travail nous avons essayé de comprendre comment EWS-FLI1, la protéine de fusion issue de la translocation chromosomique du sarcome d'Ewing conduit à la génération des CSC. Pour cela nous avons effectué des ChIPseq (immunoprecipitation de la chromatine suivi de séquençage) pour EWS-FLI1 ainsi que pour certaines modifications histoniques. -- Ewing sarcoma family tumors (ESFT) are the second most frequent bone tumors in children and have a high rate of recurrence when metastatic at presentation. The pathogenesis of Ewing sarcoma is underlayed by a translocation, leading to the fusion of the trans-activating domain of EWS with the FLU DNA binding domain. Cancer stem cells (CSCs) are thought to be the driving force of tumor growth. In this work we focused on understanding the mechanisms underlying ESFT CSC emergence as well as defining targeted therapeutic strategies. Emergence of CSCs in ESFT has been shown to arise from a defect in TARBP2-dependent microRNA maturation, which can be corrected by exposure to the fluoroquinolone enoxacin. As enoxacin alone is not sufficient to reverse tumor growth in vivo, we assessed the effect of combining a drug that abrogates CSC properties with doxorubicin, a standard-of-care therapy in ESFT. Primary ESFT CSCs and bulk tumor cells were treated with different concentration of drugs and displayed divergent responses to doxorubicin and enoxacin. Doxorubicin, which targets the tumor bulk, displayed toxicity toward primary adherent ESFT cells in culture but not to CSC-enriched ESFT spheres. Conversely, enoxacin induced apoptosis but only in ESFT spheres and specifically on the CD133+ population. In combination, the two drugs markedly depleted CSC and strongly reduced primary growth in xenograft assays of two primary ESFT. Our results identify a potentially attractive therapeutic strategy for ESFT that combines mechanism-based targeting of CSC using a low toxicity antibiotic with a standard-of-care cytotoxic drug, offering immediate applications for clinical evaluation. In the second part of this work we performed chromatin immunopercipitation on CSCs and bulk cells for EWS-FLI1 binding as well as some chromatin modifications, and concluded that EWS-FLI1 shows cell context dependent binding.

Immersioultraäänitutkimuksen kehittäminen

Teräksenvalmistajilta edellytetään jatkuvasti panostusta laadun ja laadunvarmistuksen kehittämiseen. Teräksen laatu ja puhtaus korostuvat varsinkin silloin, kun terästä käytetään vaativiin käyttökohteisiin, kuten autoteollisuuden tarpeisiin. Ultraäänitarkastusmenetelmää käytetään laadun-varmistuksessa teräksen sisävikojen etsimiseen. Ultraäänitarkastuksessa lähetetään suuritaajuuksista ääntä kappaleeseen. Ääni etenee materiaalissa ja heijastuu erilaisista epäjatkuvuuskohdista. Luotaimeen palaavaa ääntä analysoimalla saadaan tietoa teräksestä ja sen sisävioista. Ultraäänitarkastuksen ongelmana on vian tyypin määrittäminen hankaluus sekä herkkyys tutkittavan materiaalin aineominaisuuksille. Työn tavoitteena oli immersioultraäänitarkastuksen kehittäminen sovellettuna teräksenvalmistajan tarpeisiin. Materiaalin aineominaisuuksista tutkittiin seostuksen vaikutusta. Teräslajit tarkastettiin valssitilaisena, karkaistuna ja normalisoituna. Lisäksi tutkittiin kappaleen pinnankarheuden ja -muodon vaikutusta tarkastukseen. Vikatyyppien tunnistamisen mahdollisuuksia ultra-äänitarkastuksessa selvitettiin käyttäen FFT- taajuusanalyysiä. Erilailla lämpökäsitellyillä teräslajeilla näytti eniten tuloksiin vaikuttavan terästen raekoko. Valssitilaisilla teräksillä raekoko on suuri, jolloin ultraääni vaimenee voimakkaasti teräksessä. Huomattavaa kuitenkin oli, että mikäli lämpö-käsittelyillä ei teräksen raekokoa saada juuri pienennettyä, ei myöskään vaimeneminen vähene. Tämän vuoksi lämpökäsittely ei välttämättä ole aina tarpeellinen valmisteltaessa ultraääninäytteitä. Fourier’n taajuusanalyysissä huomattiin olevan eroavaisuuksia verrattaessa huokosista ja sulkeumista palaavien kaikujen taajuusspektrejä. Näiden tulosten perusteella näyttäisi olevan mahdollista käyttää FFT- menetelmää ultraääni-tarkastuksessa vikojen luokitteluun.

Prosessilähtöinen laadunarviointi ohutlevymekaniikkasopimusvalmistajan näkökulmasta

Diplomityö on tehty Lappeenrannan teknillisessä korkeakoulussa Konepajatekniikan laitoksella. Työ on osa Konepajatekniikan laitoksen toteuttamaa ”LELA” levytuotteiden laadunvalvontaprojektia. Projektiosapuolet olivat: Abloy Oy (Joensuu), Flextronics Enclosures (Oulu), Hihra Oy (Turku), Lillbacka Oy (Alahärmä), Nokia Networks (Oulu), Segerström & Svensson (Uusikaupunki) ja Scanfil Oy (Sievi). Lisäksi projektin pääasiallisena rahoittavana osapuolena toimi Teknologian kehittämiskeskus, Tekes. Työ perustui ohutlevykomponentteja valmistavissa kohdeyrityksissä suoritettuun laadunarviointitutkimukseen, joka sisälsi tuotantoon kohdistetun virhekartoituksen sekä laadunarviointikyselyn. Tutkimuksessa suoritetun tuotannon virhekartoituksen mukaan tyypillisessä ohutlevykomponentteja valmistavassa yrityksessä virheidenesiintymistodennäköisyys on n. 5 – 12 % / tuote. Eniten virheitä syntyi epäkeskopuristintöissä. Tutkimus osoittaa, että virhekartoituksen avulla yrityksen on mahdollista kartoittaa tuotannossa syntyvät virheet ja edelleen kohdistaa laadun kehitystoimenpiteet oikeisiin tuotannon osa-alueisiin.

Päällystettyä hienopaperia valmistavan tuotantolinjan tuotannon tehokkuuden kehittäminen

Diplomityön tavoitteena on selvittää paperivioista aiheutuvien katkojen syyt paperikoneella ja pyrkiä löytämään ratkaisu ongelmiin erilaisia vianilmaisujärjestelmiä apuna käyttäen. Työssä analysoidaan laatuhylyn synty tuotantolinjan eri kohteissa. Lisäksi tilastoidaan häiriöseisokkisyyt ja sitä kautta pyritään painottamaan kunnossa-pidon tärkeyttä tuotantolinjan tehokkuudessa. Kirjallisuusosassa tutustutaan hyötysuhteen määritelmään ja käsitellään tuotantolinjan hyötysuhteeseen vaikuttavia tekijöitä. Kirjallisuusosassa selvitetään päällystetyn hienopaperin tuoteanalyysin avulla ominaisuudet, joilla on vaikutusta ajettavuuteen ja katkoherkkyyteen on-line päällystävällä hienopaperikoneella. Kokeellisessa osassa selvitetään tuotantoaikaa vähentävien tekijöiden syyt ja mahdolli-set aiheuttajat erilaisten vikaprofiilien avulla. Kokeellisessa osassa analysoidaan myös tuotantolinjan hylyn syntyyn vaikuttavat tekijät ja pyritään minimoimaan hylyn määrä. Pohjapaperin täplät aiheuttivat reikäkatkoja ja hylyn syntymistä kalanterin aukaisujen takia. Reunaviat ja kireysheitot aiheuttivat myös runsaasti katkoja. Lukuisat häiriöseisokit aiheuttivat aikahävikkiä. Häiriöseisokkeja aiheuttivat viat mekaanisissa laitteissa, narujen vaihdot ja rullausruuhkat. Telasuojelun aiheuttamat kalanterin aukaisut olivat työn alussa suurin paperin hylkäyssyy. Telasuojelun optimoinnin ja pohjapaperin täplien määrän vähenemisen myötä telasuojeluaukaisut vähenivät. Lajinvaihdot ja katkot olivat suurimmat hylyn aiheuttajat työn loppuaikana.

Evolutionary dynamics of collective action in spatially structured populations.

Many models proposed to study the evolution of collective action rely on a formalism that represents social interactions as n-player games between individuals adopting discrete actions such as cooperate and defect. Despite the importance of spatial structure in biological collective action, the analysis of n-player games games in spatially structured populations has so far proved elusive. We address this problem by considering mixed strategies and by integrating discrete-action n-player games into the direct fitness approach of social evolution theory. This allows to conveniently identify convergence stable strategies and to capture the effect of population structure by a single structure coefficient, namely, the pairwise (scaled) relatedness among interacting individuals. As an application, we use our mathematical framework to investigate collective action problems associated with the provision of three different kinds of collective goods, paradigmatic of a vast array of helping traits in nature: "public goods" (both providers and shirkers can use the good, e.g., alarm calls), "club goods" (only providers can use the good, e.g., participation in collective hunting), and "charity goods" (only shirkers can use the good, e.g., altruistic sacrifice). We show that relatedness promotes the evolution of collective action in different ways depending on the kind of collective good and its economies of scale. Our findings highlight the importance of explicitly accounting for relatedness, the kind of collective good, and the economies of scale in theoretical and empirical studies of the evolution of collective action.

The Aldosterone/Renin Ratio as a Diagnostic Tool for the Diagnosis of Primary Hypoaldosteronism in Newborns and Infants.

BACKGROUND/AIMS: Primary hypoaldosteronism is a rare inborn disorder with life-threatening symptoms in newborns and infants due to an aldosterone synthase defect. Diagnosis is often difficult as the plasma aldosterone concentration (PAC) can remain within the normal range and thus lead to misinterpretation and delayed initiation of life-saving therapy. We aimed to test the eligibility of the PAC/plasma renin concentration (PRC) ratio as a tool for the diagnosis of primary hypoaldosteronism in newborns and infants. Meth ods: Data of 9 patients aged 15 days to 12 months at the time of diagnosis were collected. The diagnosis of primary hypoaldosteronism was based on clinical and laboratory findings over a period of 12 years in 3 different centers in Switzerland. To enable a valid comparison, the values of PAC and PRC were correlated to reference methods. RESULTS: In 6 patients, the PAC/PRC ratio could be determined and showed constantly decreased values <1 (pmol/l)/(mU/l). In 2 patients, renin was noted as plasma renin activity (PRA). PAC/PRA ratios were also clearly decreased. The diagnosis was subsequently genetically confirmed in 8 patients. CONCLUSION: A PAC/PRC ratio <1 pmol/mU and a PAC/PRA ratio <28 (pmol/l)/(ng/ml × h) are reliable tools to identify primary hypoaldosteronism in newborns and infants and help to diagnose this life-threatening disease faster. © 2015 S. Karger AG, Basel.

Stafne bone cavity: a retrospective study of 11 cases

Objective: to describe the clinical and radiological characteristics of patients with Stafne bone cavity. Study design: a retrospective, observational study of 11 cases of Stafne bone cavity. After finding an imagine compatible with Stafne bone cavity in the Orthopantomograph® of 11 patients, a sialography of the mandibular gland was made in 3 cases, computerized tomography (CT) in 6 cases, and in 4 cases surgical intervention to confirm the diagnosis. Results: the average age was 51.5 years, predominantly males. The entity was diagnosed incidentally during a routine radiology in all cases. The sialography revealed glandular tissue within the defect, and the CT demonstrated the conservation of the lingual cortical and the peripheral origin of the lesion. Glandular tissue was found within the lesions of two of the patients who underwent surgery, and in the other two the cavity was empty. No progressive changes were found in any of the 11 cases. Conclusions: Stafne bone cavity was an incidental finding, presenting no evolutionary changes, and as such conservatory therapy based on periodic controls was indicated. Currently, complementary techniques such as CT are sufficient to establish a certain diagnosis.