Orientador: Mary Marcondes / Resumo: Os objetivos do presente estudo foram verificar, em uma população de cães com leishmaniose visceral, atendida em um hospital veterinário de área endêmica para a doença no Brasil, as principais alterações clínicas observadas, os métodos utilizados para confirmar o diagnóstico, o tempo decorrido entre o início dos sintomas e o diagnóstico e a utilização de métodos de prevenção da doença. Os prontuários dos cães atendidos durante o período do estudo foram avaliados afim de selecionar àqueles que possuíam diagnóstico da doença. Na população estudada machos e cães de raças definidas apresentaram uma maior predisposição ao desenvolvimento da doença. Dentre as alterações clínicas mais frequentemente observadas destacam-se linfoadenomegalia, lesões dermatológicas, alterações gastrointestinais, anorexia ou hiporexia, perda de peso e alterações oftálmicas. Mais de 80% dos cães apresentava hiperproteinemia. Em 59,52% dos animais o diagnóstico foi confirmado apenas por meio de exame parasitológico direto, sendo em 56,34% por citologia de punção biopsia aspirativa de linfonodos. O tempo de evolução da doença no momento da primeira consulta no hospital veterinário variou de uma semana a mais de um ano, com 42,86% dos animais apresentando sintomas entre um e 12 meses. Cerca de metade dos cães já havia recebido algum tipo de tratamento para os sintomas, sem diagnóstico de leishmaniose visceral canina. Somente quatro cães faziam uso de coleiras inseticidas como método preventivo. Os achados p... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The aim of the present study was to verify, in a population of dogs with visceral leishmaniosis referred to a veterinary teaching hospital in an area endemic for the disease in Brazil, the main clinical signs observed, the time elapsed between onset of symptoms and diagnosis, the methods used to confirm the diagnosis, and the use of preventive methods. The medical records of the dogs attented during the study period were evaluated in order to select those who had a diagnosis of the disease.In the studied population, males and pure breed dogs showed a greater predisposition to the development of the disease. Among the most frequently observed clinical signs are lymphadenomegaly, anorexia or hyporexia, weight loss, dermatological, gastrointestinal and ophthalmic alterations. More than 80% of the dogs had hyperproteinemia. In 59.52% of the animals the diagnosis was confirmed only by means of direct parasitological examination, and in 56.34% by cytology of lymph nodes. Symptoms lasted from one week to more than one year at the moment of the consultation at the veterinary hospital, with 42.86% of the dogs presenting symptoms between one and 12 months. About half of the dogs had already received some sort of treatment for the symptoms, with no diagnosis of canine visceral leishmaniasis. Only four dogs used insecticidal collars as a preventive method. The findings allow to afirm that many diseased animals are not diagnosed early and nor included as suspects for the disease, aggravat... (Complete abstract click electronic access below) / Mestre

Apical periodontitis is an inflamatory process reported by literature in a prevalence that range from 39% to 83%, depending on the sample studied. The inflammatory process represents and infectious focus that may cause systemic manifestations. Many patients can t identify it, and health professionals may have difficulty in realizing an early diagnostic since this process may be silent. Therefore the objectives of this study ware to evaluate clinical signs and the prevalence of asymptomatic apical periodontitis, through a convenience sample. 146 patients with apical periodontitis were selected, and then answered to a questionnaire. After the data was collected, it was found that the prevalence of patients with asymptomatic apical periodontitis was 57.53%. The analysis of logistical regression was used to evaluate the association between the outcome and possible predictors. The variables that presented a value of p≤0, 20 in univariate analysis were selected and in the adjusted model were kept only the ones that presented a value of p≤0,05. Patients without cavities in their teeth have a odds ratio 2.45 times bigger of not mentioning any painful symptomatology (OR: 2.45 IC: 1.08 5.54); patients that related a response to the vertical percussion test have a 86% lesser odds ratio of not perceiving pain in the dental element (OR: 0.14 IC: 0.06 0.33); smoking patients have a chance 3.96 times bigger of not relating any painful symptomatology (OR: 3.96 IC: 1.09 14.38). It can be concluded that a set of evaluations may provide an early diagnostic and a better interpretation from the patient, reducing the prevalence of apical periodontitis / A periodontite apical é um processo inflamatório cuja a prevalência relatada na literatura varia de 39% a 83% dependendo da amostra estudada. O processo inflamatório representa um foco infeccioso que pode causar manifestações sistêmicas. Muitos pacientes não o identificam e profissionais da saúde podem ter dificuldade de realizar o diagnóstico precoce já que este processo poderá ser silencioso. Portanto os objetivos deste estudo foram avaliar sinais clínicos e sintomas e a prevalência de periodontite apical assintomática, através de uma amostra de conveniência. 146 pacientes com periodontite apical foram selecionados, e em seguida responderam a um questionário. Após a coleta de dados, constatou-se que a prevalência de pacientes com periodontite apical assintomática foi de 57.53%. A análise de regressão logística foi utilizada para avaliar a associação entre o desfecho e possíveis preditores. Foram selecionadas variáveis que apresentaram valor de p≤0,20 na análise univariada e foram mantidas no modelo ajustado somente as que apresentaram um valor de p≤0,05. Pacientes sem cárie no dente tem uma razão de chance 2.45 vezes maior de não ter relatado sintomatologia dolorosa (OR: 2.45 IC: 1.08 5.54); pacientes que relataram resposta ao teste de percussão vertical tem uma razão de chance 86% menor de não ter percebido dor no elemento dentário (OR: 0.14 IC: 0.06 0.33); pacientes fumantes tem uma chance 3.96 maior de não terem relato de sintomatologia dolorosa (OR: 3.96 IC: 1.09 14.38). Concluise que o conjunto dessas avaliações poderão proporcionar um diagnóstico precoce e uma melhor intepretação do paciente diminuindo a prevalência de periodontite apical.

Huit cent trente et un troupeaux de vaches laitières répartis dans 5 états américains ont été enrôlés dans une étude de cohorte prospective. Un modèle d’équations d'estimation généralisées a été utilisé pour étudier l'association entre les signes cliniques et la détection de salmonelles dans les fèces des animaux soupçonnés de salmonellose clinique. La sensibilité et la spécificité de la culture bactériologique ont été estimées à l’aide d’un modèle de classes latentes. Dix-huit pour cent des 874 échantillons provenant de veaux et 29% des 1479 échantillons de vaches adultes étaient positifs pour Salmonella spp. Il n’a pas été possible d’établir une association claire entre les différents signes cliniques observés et la détection de salmonelles. Les 2 sérotypes les plus fréquemment isolés étaient Typhimurium et Newport. La probabilité de détecter des salmonelles était plus élevée chez les veaux où un autre agent entéropathogène était également détecté. La proportion d’échantillons positifs était plus élevée parmi les vaches ayant reçu des antibiotiques dans les jours précédant l’échantillonnage. La sensibilité de la culture a été estimée à 0,48 (intervalle de crédibilité à 95% [ICr95%]: 0,22-0,95) pour les veaux et 0,78 (ICr95%: 0,55-0,99) pour les vaches. La spécificité de la culture était de 0,94 (ICr95%: 0,87-1,00) pour les veaux et de 0,96 (ICr95%: 0,90-1,00) pour les vaches. Malgré une sensibilité imparfaite, la culture bactériologique demeure utile pour obtenir une meilleure estimation de la probabilité post-test de salmonellose clinique chez un bovin laitier, par rapport à la probabilité estimée suite au seul examen clinique. / Eight hundred and thirty-one dairy herds in 5 states in the northeast USA were enrolled in a prospective cohort study. A generalized estimating equations model including herd as a random effect was built to study the association between clinical signs and detection of Salmonella spp. in the faeces of animals suspected of clinical salmonellosis. The sensitivity and specificity of the bacteriological culture were estimated using a latent class model. Eighteen percent of the 874 samples from calves and 29% of the 1479 samples from adult cows were positive for Salmonella spp. It was not possible to establish a clear association between the various clinical signs and detection of Salmonella spp. in the faeces. The two most frequently isolated serotypes were Typhimurium and Newport. The probability of detecting salmonellas was higher for calves when another enteric pathogen was also detected. The proportion of positive samples was higher among cows that received antibiotics in the days preceding the sampling. The sensitivity of the bacteriological culture was estimated at 0.48 (95% credibility interval [95%CrI]: 0.22 to 0.95) for calves and 0.78 (95%CrI 0.55 to 0.99) for cows. The specificity of the culture was 0.94 (95%CrI: 0.87 to 1.00) for calves and 0.96 (95%CrI: 0.90 to 1.00) for cows. Despite imperfect sensitivity, bacterial culture remains useful to obtain a better estimate of the post-test probability of clinical salmonellosis in dairy cattle, compared to the estimated probability following the clinical examination alone.

Huit cent trente et un troupeaux de vaches laitières répartis dans 5 états américains ont été enrôlés dans une étude de cohorte prospective. Un modèle d’équations d'estimation généralisées a été utilisé pour étudier l'association entre les signes cliniques et la détection de salmonelles dans les fèces des animaux soupçonnés de salmonellose clinique. La sensibilité et la spécificité de la culture bactériologique ont été estimées à l’aide d’un modèle de classes latentes. Dix-huit pour cent des 874 échantillons provenant de veaux et 29% des 1479 échantillons de vaches adultes étaient positifs pour Salmonella spp. Il n’a pas été possible d’établir une association claire entre les différents signes cliniques observés et la détection de salmonelles. Les 2 sérotypes les plus fréquemment isolés étaient Typhimurium et Newport. La probabilité de détecter des salmonelles était plus élevée chez les veaux où un autre agent entéropathogène était également détecté. La proportion d’échantillons positifs était plus élevée parmi les vaches ayant reçu des antibiotiques dans les jours précédant l’échantillonnage. La sensibilité de la culture a été estimée à 0,48 (intervalle de crédibilité à 95% [ICr95%]: 0,22-0,95) pour les veaux et 0,78 (ICr95%: 0,55-0,99) pour les vaches. La spécificité de la culture était de 0,94 (ICr95%: 0,87-1,00) pour les veaux et de 0,96 (ICr95%: 0,90-1,00) pour les vaches. Malgré une sensibilité imparfaite, la culture bactériologique demeure utile pour obtenir une meilleure estimation de la probabilité post-test de salmonellose clinique chez un bovin laitier, par rapport à la probabilité estimée suite au seul examen clinique. / Eight hundred and thirty-one dairy herds in 5 states in the northeast USA were enrolled in a prospective cohort study. A generalized estimating equations model including herd as a random effect was built to study the association between clinical signs and detection of Salmonella spp. in the faeces of animals suspected of clinical salmonellosis. The sensitivity and specificity of the bacteriological culture were estimated using a latent class model. Eighteen percent of the 874 samples from calves and 29% of the 1479 samples from adult cows were positive for Salmonella spp. It was not possible to establish a clear association between the various clinical signs and detection of Salmonella spp. in the faeces. The two most frequently isolated serotypes were Typhimurium and Newport. The probability of detecting salmonellas was higher for calves when another enteric pathogen was also detected. The proportion of positive samples was higher among cows that received antibiotics in the days preceding the sampling. The sensitivity of the bacteriological culture was estimated at 0.48 (95% credibility interval [95%CrI]: 0.22 to 0.95) for calves and 0.78 (95%CrI 0.55 to 0.99) for cows. The specificity of the culture was 0.94 (95%CrI: 0.87 to 1.00) for calves and 0.96 (95%CrI: 0.90 to 1.00) for cows. Despite imperfect sensitivity, bacterial culture remains useful to obtain a better estimate of the post-test probability of clinical salmonellosis in dairy cattle, compared to the estimated probability following the clinical examination alone.

In my thesis I deal with canine hip dysplasia. The paper consist of two parts. The first part summarizes all the information available about this disease. These include factors influencing the emergence of the disease, clinical signs, evaluation systems, diagnosis, conservative ang surgical treatment, prognosis and prevalence. The second part is methodological. There are summarized data about particular breeds of dogs that were obtained Mastiff, Auvergne Pointing Dog, Beauceron, Fila Brasileiro, Brittany, Cavalier King Charles Spaniel, Czechoslovakian Wolfdog, French Pointing Dog, Italian Pointing Dog, Italian Wirehaired Pointing Dog, Small Blue Gascony Hound, Blue Picardy Spaniel, Newfoundland, Portuguese Pointing Dog, St. Germain Pointing Dog, Tibetan Terrier and Golden Retriever. In the end I gave breeding recommendations regarding to reducing the incidence of high grade of canine hip dysplasia.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The genus Pestivirus is composed by four important pathogens of livestock: bovine viral diarrhea virus 1 and 2 (BVDV-1 and BVDV-2), classical swine fever virus (CSFV) and border disease virus (BDV) of sheep. An emerging group of pestivirus temptatively called as HoBi-like, BVDV-3, or atypical pestiviruses was first detected and characterized in Europe from a fetal bovine serum (FBS) lot originated in Brazil. HoBi-like viruses share genetic and antigenic similarities with BVDV species. The present thesis is composed by studies that address the emergence of this virus group and its potential impact on BVDV diagnostic and control. Monoclonal antibody binding demonstrated the existence of conserved regions within epitopes in the glycoprotein Erns and the non-structural protein NS2/3 among the pestiviruses species (BVDV-1; BVDV-2; e HoBi-like), whereas high degree of divergence was detected in glycoprotein E2. These findings suggest that panpestiviruses diagnostic tests may rely on the Erns and NS2/3 proteins, and pestiviruses specific species diagnostic tests should target the E2 glycoprotein. The threshold for detection of HoBi-like virus using commercial BVDV antigen capture ELISA was statistically similar to BVDV detection. On the other hand, two BVDV antibody detection ELISA kits failed to detect at least 20% of animals harboring antibodies against HoBi_D32/00. Thus, it is obvious the need for the development of specific diagnostic tests to HoBi-like viruses. Likewise, it was verified that vaccines containing strains of BVDV-1 and BVDV-2 inactivated or modified live (MLV) virus generate suboptimal protection against HoBi-like viruses. Higher levels of protective antibodies against HoBi-like virus were verified using MLV. Nevertheless the geometric mean titer for HoBi-like was 12.9, while 51.1 and 23.5 for BVDV-1 and BVDV-2, respectively. In addition to low levels of protective antibodies, seroconversion was verified in 68% of animals to HoBi-like virus, although reached 100% and 94% against BVDV-1 and BVDV-2, respectively. Regarding to the diagnostic and control of pestiviruses, the trade of FBS may poses as an important route for dissemination of agents contaminating this product. Composed by a homogenate of serum from hundreds to thousands of fetuses, pestiviruses screening in FBS lots are potentially an important source of information regarding the presence and/or dissemination of these viruses in the region where samples were originated from. Therefore, FBS lots originated in North American countries and processed in the United States of America (USA) or Europe were tested. While several lots were detected as positive for BVDV, none of the lots manufactured in the USA were detected as positive for HoBi-like viruses or antibodies against it. However, two FBS lots processed in Europe were positive for HoBi-like viruses, suggesting that the contamination did occur during the pooling or package of these samples in Europe. These results strongly indicate the need for international rules regarding certification of FBS origin, employment of certified diagnostic tests and measures to avoid contamination of FBS during the manufacturing process. Was also verified the need to include specific tests to detect HoBi-like viruses in the FBS quality control routine. Briefly, the studies here presented demonstrated that the available BVDV diagnostic tests frequently fail in detecting HoBi-like viruses and/or differentiate between HoBi-like virus and BVDV species. In addition, the detection of animal harboring antibodies against HoBi-like using commercial diagnostic tests is unreliable. Likewise, in-vitro studies demonstrated that the cross protection against HoBi-like viruses in serum of animals immunized against BVDV-1 and BVDV-2 is limited. Therefore, the detection and control of this emergent group of viruses require the development of specific diagnostic tests and vaccines. / O gênero Pestivirus é composto por quatro espécies virais: vírus da diarréia viral bovina tipos 1 e 2 (BVDV-1 e BVDV-2), vírus da peste suína clássica (CSFV) e vírus da doença da fronteira (BDV). Um novo grupo de pestivírus, provisoriamente denominado de HoBi-like, BVDV-3, ou pestivirus atípicos foi inicialmente identificado na Europa em uma amostra de soro fetal bovino (SFB) importada do Brasil. O vírus (ou grupo de vírus) HoBi-like possui similaridades ao nível genético e antigênico com o BVDV. A presente tese apresenta trabalhos de avaliação do impacto da emergência deste novo grupo de vírus no diagnóstico e controle do BVDV. Utilizando anticorpos monoclonais, verificou-se maior reatividade cruzada entre as espécies de pestivírus (BVDV-1; BVDV-2; e HoBi-like) em epitopos da glicoproteína Erns e proteína não-estrutural NS2/3, comparando com epitopos da glicoproteína E2. Assim, sugere-se que testes panpestivírus devem ser direcionados às proteínas Erns e NS2/3, enquanto testes específicos podem explorar diferenças existentes na glicoproteína E2. Por meio de um teste comercial de ELISA de captura de antígeno, verificou-se que o limiar de detecção do vírus HoBi_D32/00 é estatisticamente similar ao do BVDV. Entretanto, dois kits de ELISA para a detecção de anticorpos contra o BVDV falharam em detectar ao menos 20% dos animais soropositivos para HoBi_D32/00. Sugere-se a necessidade de reformular os testes diagnósticos para BVDV ou desenvolvimento de testes específicos. Da mesma forma, verificou-se que vacinas para BVDV-1 e BVDV-2 contendo antígenos inativados ou atenuados produzem uma proteção cruzada fraca contra o vírus HoBi-like. Os melhores resultados de proteção foram verificados com o uso de vacina viva atenuada, entretanto, o título médio geométrico (GMT) contra vírus HoBi-like foi de 12,9, enquanto para o BVDV-1 e BVDV-2 foram respectivamente, 51,1 e 23,5. Somado aos baixos títulos de anticorpos, a soroconversão verificada para o vírus HoBi-like foi de 68% dos animais, enquanto 100% e 94% para BVDV-1 e BVDV-2, respectivamente. Relacionado ao diagnóstico e controle dos pestivírus, o comércio de SFB possui papel relevante na disseminação de agentes infecciosos. Composto por um homogeneizado do soro de centenas a milhares de fetos bovinos, lotes de SFB possuem alto potencial para a identificação de pestivírus circulantes na região de origem dos animais abatidos. Assim, foram testados lotes de SFB originados na América do Norte e manufaturados nos EUA ou na Europa. Apesar de vários lotes estarem contaminados com BVDV, não foi evidenciada a presença do vírus HoBi-like ou de anticorpos específicos em lotes produzidos nos EUA. Entretanto, foi detectada a presença do agente em dois lotes manufaturados na Europa, indicando a possibilidade de contaminação dessas amostras durante o processo de pooling e embalagem na Europa. Demonstra-se imprescindível a criação de regras internacionais relacionadas à certificação de origem do SFB, a implementação de testes padrão para a detecção de agentes, e adoção de medidas que impeçam a contaminação do produto durante o processamento. Verificou-se também a necessidade de incluir testes específicos para os vírus HoBi-like na rotina de testes utilizada para certificação de qualidade do SFB. Em resumo, os resultados demonstraram que os testes diagnósticos para BVDV frequentemente falham em detectar o vírus HoBi-like ou em diferenciar BVDV de HoBi-like vírus. Testes comerciais para detecção de anticorpos contra BVDV não detectam eficientemente animais expostos ao vírus HoBi-like. Da mesma forma, estudos in-vitro demonstram que a proteção cruzada contra o vírus HoBi-like conferida a animais vacinados para BVDV é limitada. Assim, medidas de detecção e controle para pestivírus devem incluir testes diagnósticos e vacinas específica para o vírus HoBi-like.

Einleitung: Die Diagnosestellung und Differenzierung der klinischen Symptome einer Vergiftung von anderen Erkrankungsbildern ist oft herausfordernd. Die Häufigkeit des tatsächlichen Auftretens von Vergiftungen ist schwierig zu bestimmen, da sie nur selten sicher nachgewiesen werden; hierzu wäre eine verlässliche toxikologische Untersuchung unabdingbar. Daher werden eine gründliche Anamneseerhebung sowie das Zusammenführen der Befunde aus der klinischen Untersuchung und dem Auffinden von Fremdmaterial durch Dekontaminationsmaßnahmen sowie ein kritisches Überdenken des möglichen Zusammenhanges mit durch andere Erkrankungen hervorgerufenen Symptomen von dem Kliniker gefordert. Die Anwendung einer intravenösen Lipidemulsion (ILE) als alternative Eliminationstherapie ist ebenso diskutabel, jedoch möglichst ausschließlich nach vorangegangener erfolgreicher Dekontamination durchzuführen. Die symptomatische Therapie steht je nach klinischem Befund weiterhin im Vordergrund der Vergiftungstherapie bei Hunden und Katzen. Ziele der Untersuchungen: Das Ziel dieser Arbeit war die Darstellung der häufigsten Vergiftungsursachen und -symptome sowie ein Ausblick auf die klinische Entwicklung unter symptomatischer Therapie und optionaler Anwendung einer ILE. Die in dieser Studie untersuchte Hypothese bestand darin, dass eine speziesspezifische Häufung zugrundeliegender Giftstoffe, wie Speisereste und Kumarinderivate bei Hunden bzw. Lilien und Permethrine bei Katzen, besteht. Es wurde dabei von einer vorwiegend neurologischen Vergiftungssymptomatik ausgegangen. Weiterhin wurde die Hypothese aufgestellt, dass die ILE in den aktuell empfohlenen (vorbehaltlichen) Dosierungen eine nebenwirkungsarme optionale Eliminationstherapie für eine Vielfalt toxischer Substanzen darstellt. Material and Methoden: Die ersten beiden Teile der Studie waren retrospektive Auswertungen von Fallserien bei 634 Hunden bzw. 166 Katzen über einen Zeitraum von fünf Jahren hinsichtlich der Kausalitätsbewertung der Vergiftungswahrscheinlichkeit, des Auftretens verantwortlicher Giftstoffe und Giftstoffgruppen, des zeitlichen Auftretens der Giftstoffaufnahme, der Laborwertveränderungen, der Symptomatik und des klinischen Verlaufes, der therapeutischen Maßnahmen, einschließlich der ILE-Gabe, aufgetretener giftstoff- bzw. behandlungsassoziierter Komplikationen und der Überlebens- bzw. Mortalitätsraten. Der dritte Teil der Studie befasste sich eingehender mit 313 Hunden und 100 Katzen, bei denen eine ILE angewandt wurde. Dabei wurden die verantwortlichen Giftstoffe, die Dosierungen und Dosisintervalle für die ILE sowie der klinische Verlauf bzw. der Therapieerfolg und das Auftreten von Nebenwirkungen untersucht. Ergebnisse: Neben zumeist nicht zu eruierenden toxischen Substanzen treten Vergiftungserscheinungen bei Hunden vor allem nach der Aufnahme von Speiseresten, Rodentiziden, aber auch tremorgenen Mykotoxinen, Cannabinoiden und Nikotin sowie Chemikalien, Metaldehyd und Antiparasitika auf. Bei Katzen dominieren Vergiftungen mit Rodentiziden, Pflanzen, Antiparasitika, insbesondere Permethrin-haltiger Spot-On-Präparate, und Chemikalien. Ein überwiegendes Auftreten neurologischer Symptome ist bei beiden Tierarten (Hunde: 56 %, Katzen: 69 %) zu konstatieren. Weiterhin traten vorrangig Beeinträchtigungen des Allgemeinbefindens sowie kardiovaskuläre Komplikationen oder eine Dehydratation, gefolgt von Problemen der Thermoregulation, gastrointestinalen oder respiratorischen Beschwerden und spontanen Hämorrhagien auf. Klinisch unauffällig wurden im präklinischen Stadium eher Hunde (19 %) als Katzen (5 %) vorgestellt oder bei Ersteren selten allergische Reaktionen festgestellt. Die Überlebensrate war bei Hunden (97 %) insgesamt höher als bei Katzen (89 %). Nebenwirkungen der ILE-Gabe traten selten (<6 %) auf und äußerten sich hauptsächlich mit neurologischen Ausfällen hinsichtlich einer Bewusstseinstrübung oder auch Ataxie, gastrointestinalen, thermoregulatorischen, kardiovaskulären oder respiratorischen Beschwerden oder Auswirkungen auf den Allgemeinzustand, seltener als allergische Reaktion oder Zeichen einer lokalen Kontamination. Schlussfolgerungen: Die Datenlage einer für die Veterinärmedizin großen Patientenzahl unterstreicht den hohen Stellenwert von Vergiftungen in der Kleintiermedizin mit einer Variabilität der auslösenden Noxen, notwendigen therapeutischen Maßnahmen und klinischen Präsentationen mit milden bis schwerwiegenden Verläufen. Die Ergebnisse deuten darauf hin, dass bei frühzeitigem Behandlungsbeginn eine generelle hohe Überlebenschance mit und auch ohne ILE-Anwendung besteht. Die ILE stellt eine insgesamt nebenwirkungsarme Therapieoption im Rahmen der Eliminationstherapie von Vergiftungen dar. Unter Berücksichtigung potenziell schwerwiegender, dennoch transienter Nebenwirkungen, ist der Einsatz nur unter strenger Indikationsstellung solchen Vergiftungen vorbehalten, deren auslösende Substanz einen log P >1,0 aufweist oder bei denen der Patient schwerwiegende lebensbedrohliche Symptome bei strikter Indikation zeigt. Es bedarf prospektiver randomisierter Wirksamkeitsstudien, um Dosierungsvorschläge und -intervalle einheitlich zu spezifizieren und klare Behandlungsempfehlungen für die ILE unter bestimmen Umständen für Hunde und Katzen auszusprechen.:1 Einleitung 2 Literaturübersicht 2.1. Begriffsdefinitionen 2.2. Giftstoffe und deren Häufung, Toxizität und toxisches Prinzip 2.2.1. Nahrungsmittel 2.2.2. Medikamente 2.2.3. Partydrogen 2.2.4. Schwermetalle 2.2.5. Insektizide 2.2.6. Rodentizide 2.2.7. Molluskizide 2.2.8. Organische Substanzen und pflanzliche Toxine 2.2.9. Tierische Toxine 2.2.10. Umwelttoxine 2.2.11. Chemisch-technische Substanzen 2.3. Diagnostische Aufarbeitung von Vergiftungen 2.3.1. Anamnese 2.3.2. Klinische Untersuchung 2.3.3. Laboruntersuchungen 2.3.4. Toxikologische Untersuchung 2.3.5. Bildgebende Diagnostik 2.4. Behandlungsmöglichkeiten von Vergiftungen 2.4.1. Symptomatische Therapie 2.4.2. Dekontaminationsmöglichkeiten und deren Indikationen 2.4.2.1. Emesisinduktion 2.4.2.2. Gastrale und enterale Lavage 2.4.2.3. Haut- und Schleimhautdekontamination 2.4.2.4. Adsorbens- und Laxanzgabe 2.4.3. Eliminationsmöglichkeiten und deren Indikationen 2.4.3.1. Diurese 2.4.3.2. Intravenöse Lipidtherapie 2.4.3.3. Extrakorporale Elimination toxischer Substanzen 2.4.3.4. Antidottherapie 2.5. Die Intravenöse Lipidtherapie als Therapieoption von Vergiftungen 2.5.1. Historische Übersicht der Lipidtherapie 2.5.2. Wirkmechanismen von intravenöser Lipidtherapie 2.5.3. Lipidformulierungen 2.5.4. Dosierung der Lipidtherapie 2.5.5. Beschriebene Komplikationen von Lipidtherapien 2.5.5.1. Fettüberladungssyndrom/Hyperlipidämie 2.5.5.2. Allergische Reaktion/Anaphylaxie 2.5.5.3. Hämatologische und blutchemische Abweichungen 2.5.5.4. Metabolische Komplikationen 2.5.5.5. Kardiovaskuläre Komplikationen 2.5.5.6. Respiratorische Komplikationen 2.6. Ziele und Hypothesen 3 Eigene Publikationen 4 Diskussion 4.1. Zielsetzung der Studie 4.2. Diskussion der Ergebnisse 4.3. Limitationen der Studie 4.4. Schlussfolgerungen 5 Zusammenfassung 6 Summary 7 Literaturverzeichnis 8 Appendix 9 Danksagung / Background: Diagnosing and differentiating the clinical signs of poisoning from other diseases is often challenging. The frequency of the actual occurrence of poisoning is difficult to determine, as it is rarely reliably detected; this would require an accurate toxicological examination. Therefore, the clinician is obligated to focus on taking a thorough patient history and integrate it with the findings from the physical examination, possibly also the detection of foreign material obtained via decontamination measures, and carefully consider the potential relationship to clinical signs caused by other diseases. The use of intravenous lipid emulsion (ILE) might present an alternative elimination therapy but should only be carried out after successful prior decontamination. Depending on the clinical findings, symptomatic treatment remains the main pillar of treating poisonings in dogs and cats. Objectives: This study aimed to describe the most common causes and clinical signs of poisonings in dogs and cats, and to provide an overview of the clinical course with symptomatic therapy and optional use of ILE. The hypothesis investigated in this study was that there is a species-specific overrepresentation of certain underlying toxicants, such as food residues and coumarin derivatives in dogs or lilies and permethrins in cats. A predominance of neurological signs of poisoning was assumed for both dogs and cats. Furthermore, it was hypothesized that ILE, administered at currently – but conditionally – recommended doses, represents an option for additional elimination therapy for a variety of toxic substances and carries a low risk of adverse effects. Material and methods: The first two parts of the study included the retrospective evaluations of a case series including 634 dogs and 166 cats over five years presenting to a large tertiary veterinary care facility. These cases were reviewed with regard to the probability of poisoning (assessment of causality), the frequency of the corresponding toxicants and toxicant groups, the temporal relationship with the toxicant ingestion, clinicopathological abnormalities, clinical signs and the clinical course of the condition, therapeutic measures, including ILE administration, complications associated with the toxicants and/or treatment, and outcomes (survival and mortality rates). The third part of the study included those patients who had undergone ILE (313 dogs and 100 cats). The responsible toxicants, doses and dose intervals of ILE treatment, clinical course, treatment success, and the occurrence of adverse treatment effects were investigated. Results: Beyond the most frequent scenario that the exact toxic substances remain to be determined, clinical signs of poisoning in dogs are predominantly seen after the ingestion of food residues, rodenticides, but also tremorgenic mycotoxins, cannabinoids and nicotine as well as chemicals, metaldehyde, and antiparasitics. In cats, poisoning with rodenticides, plants, antiparasitics, especially permethrin-containing spot-on formulations, and chemicals predominate. Neurological signs were most frequently detected in both species (dogs: 56%, cats: 69%). Furthermore, a reduced demeanor, cardiovascular complications or dehydration, followed by thermoregulatory, gastrointestinal or respiratory issues and spontaneous hemorrhage were the main clinical signs. As for the clinical stage, rather dogs (19 %) were presented in a clinically unremarkable (preclinical) condition than cats (5 %) and allergic reactions were rarely observed in the former. The survival rate was generally higher in dogs (97%) than in cats (89%). Adverse effects of ILE administration were infrequently noted (<6%) and mainly comprised of neurological (reduced consciousness or ataxia), gastrointestinal, thermoregulatory, cardiovascular, or respiratory signs or affecting the overall patient condition, less frequently signs of an allergic reaction or localized contamination. Conclusions: This data, derived from a large number of small animal patients, underscores the clinical significance of acute poisoning cases in small animal veterinary practice, not limited to specialty care medicine. This study documents the variability of possible causative noxious agents, necessary therapeutic measures, and clinical presentations with mild to severe courses and corresponding outcomes. The results prove that the chance of survival with and without ILE is generally high if treatment is initiated early in the course of the condition. ILE is a therapeutic option with few adverse effects and might be considered in the context of elimination efforts for dogs and cats with poisoning. Considering its potential for serious, albeit transient adverse effects, ILE administration should be reserved for poisonings with toxicants that have a log p > 1.0 or where the patient is determined to be in a serious, life-threatening condition with a strict indication for ILE administration. Prospective, randomized efficacy studies are needed to reevaluate the current (preliminary) dosage recommendations for ILE and be able to offer specific recommendations for (or against) ILE treatment under certain circumstances.:1 Einleitung 2 Literaturübersicht 2.1. Begriffsdefinitionen 2.2. Giftstoffe und deren Häufung, Toxizität und toxisches Prinzip 2.2.1. Nahrungsmittel 2.2.2. Medikamente 2.2.3. Partydrogen 2.2.4. Schwermetalle 2.2.5. Insektizide 2.2.6. Rodentizide 2.2.7. Molluskizide 2.2.8. Organische Substanzen und pflanzliche Toxine 2.2.9. Tierische Toxine 2.2.10. Umwelttoxine 2.2.11. Chemisch-technische Substanzen 2.3. Diagnostische Aufarbeitung von Vergiftungen 2.3.1. Anamnese 2.3.2. Klinische Untersuchung 2.3.3. Laboruntersuchungen 2.3.4. Toxikologische Untersuchung 2.3.5. Bildgebende Diagnostik 2.4. Behandlungsmöglichkeiten von Vergiftungen 2.4.1. Symptomatische Therapie 2.4.2. Dekontaminationsmöglichkeiten und deren Indikationen 2.4.2.1. Emesisinduktion 2.4.2.2. Gastrale und enterale Lavage 2.4.2.3. Haut- und Schleimhautdekontamination 2.4.2.4. Adsorbens- und Laxanzgabe 2.4.3. Eliminationsmöglichkeiten und deren Indikationen 2.4.3.1. Diurese 2.4.3.2. Intravenöse Lipidtherapie 2.4.3.3. Extrakorporale Elimination toxischer Substanzen 2.4.3.4. Antidottherapie 2.5. Die Intravenöse Lipidtherapie als Therapieoption von Vergiftungen 2.5.1. Historische Übersicht der Lipidtherapie 2.5.2. Wirkmechanismen von intravenöser Lipidtherapie 2.5.3. Lipidformulierungen 2.5.4. Dosierung der Lipidtherapie 2.5.5. Beschriebene Komplikationen von Lipidtherapien 2.5.5.1. Fettüberladungssyndrom/Hyperlipidämie 2.5.5.2. Allergische Reaktion/Anaphylaxie 2.5.5.3. Hämatologische und blutchemische Abweichungen 2.5.5.4. Metabolische Komplikationen 2.5.5.5. Kardiovaskuläre Komplikationen 2.5.5.6. Respiratorische Komplikationen 2.6. Ziele und Hypothesen 3 Eigene Publikationen 4 Diskussion 4.1. Zielsetzung der Studie 4.2. Diskussion der Ergebnisse 4.3. Limitationen der Studie 4.4. Schlussfolgerungen 5 Zusammenfassung 6 Summary 7 Literaturverzeichnis 8 Appendix 9 Danksagung

Les médecins de famille, les pédiatres, les chiropraticiens et les physiothérapeutes sont parmi les professionnels de la santé les plus susceptibles de rencontrer des patients atteints d’une scoliose idiopathique adolescente. Les recherches démontrent que certaines lacunes existent à l’égard des connaissances acquises, par ces professionnels, dans le domaine musculosquelettique, incluant la scoliose. De plus, il ne semble pas exister d’informations sur le niveau de connaissances et la démarche clinique de ces professionnels en matière de scoliose, bien que les bonnes pratiques actuelles dictent une détection hâtive de cette condition pour en optimiser la gestion thérapeutique. Les objectifs de notre étude visaient donc à évaluer les connaissances ainsi que les aptitudes en matière de démarche clinique des professionnels les plus susceptibles à traiter des patients atteints d’une scoliose idiopathique adolescente. À l’aide d’un questionnaire semi-structuré, 51 professionnels de la santé ont été interviewés. Parmi ces professionnels recrutés par l'entremise de leur ordre professionnel respectif, on retrouvait 21 médecins de famille, 10 pédiatres, 10 chiropraticiens et 10 physiothérapeutes. Les entrevues évaluaient les connaissances en matière de signes cliniques, de facteurs de risque, de démarche clinique et de processus référentiel vers les soins spécialisés. De plus, les préférences des professionnels à l’égard des guides de bonne pratique ont été abordées. Parmi les professionnels interviewés, 59 % étaient des femmes, 43 % étaient âgés de moins de 40 ans et la moyenne d’années de pratique était de 20,3 ans. Les résultats démontrent qu’il existe des lacunes à l’égard des connaissances des signes cliniques et des facteurs de risque : moins du tiers des professionnels interviewés pouvaient mentionner au moins 2 signes cliniques et 31 % d’entre eux ne pouvaient se souvenir des facteurs de risque associés à la scoliose idiopathique adolescente; les médecins de famille étaient les moins connaissants dans ces domaines. De plus, en présence d’une mise en contexte nécessitant une référence urgente en soins spécialisés, 70 à 90 % des professionnels auraient référé le patient en dépit du fait que seulement 38 à 60 % d’entre eux considéraient cette situation comme urgente. Près de 40 % des professionnels mentionnaient qu’ils seraient inconfortables à gérer un patient atteint d’une scoliose. Néanmoins, la majorité d’entre eux reconnaissaient qu’il existe un problème en ce qui a trait à l’accessibilité aux soins spécialisés en orthopédiatrie. Presque la totalité c’est-à-dire, 98 % étaient favorables à la production de guides de bonne pratique et les accueilleraient positivement dans leur pratique quotidienne. Les conclusions de cette étude ont montré qu’il existe des vides en matière de connaissances de signes cliniques et de facteurs de risque de progression de la scoliose idiopathique adolescente; ces lacunes ont particulièrement été remarquées chez les médecins de famille. La majorité des professionnels reconnaissent l’importance de référer les conditions urgentes en soins spécialisés. Néanmoins, tous semblent souligner des difficultés dans ce processus référentiel. Une meilleure collaboration interprofessionnelle semble prometteuse en ce qui concerne la gestion de patients atteints d’une scoliose idiopathique adolescente. / Family physicians, peadiatricians, chiropractors and physical therapists are among health professionals most likely to encounter and treat patients with adolescent idiopathic scoliosis. Research shows that there are gaps in musculoskeletal knowledge among professionals but no studies assess knowledge of scoliosis among professionals most likely to treat patients with scoliosis. Best current practice dictates that early detection of adolescent idiopathic scoliosis leads to better decision-making regarding optimal course of management. The objectives of our study were to evaluate basic knowledge and the management skills of professionals most likely to encounter adolescent idiopathic scoliosis. We developed a semi-structured questionnaire and interviewed 51 health professionals. Among these professionals, who were recruited through their professional regulatory board registries, were 21 family physicians, 10 peadiatricians, 10 chiropractors and 10 physical therapists. The interview assessed knowledge of clinical signs and risk factors, management options, including referral to specialized care. We also discussed preferences and acceptability of clinical guidelines in regard to scoliosis. Among interviewed professionals, 59 % were female, 43 % were under 40 and mean years of practice was 20.3. Our results demonstrated gaps in knowledge with respect to clinical signs and risk factors. Less than a third of professionals were able to mention at least 2 clinical signs and 31 % were unaware of any risk factors associated with scoliosis progression. Family physicians appeared least knowledgeable in these areas. When presented with a situation where urgent referral was indicated, 70 – 90 % said that they would refer the patient although only 38 – 60 % rated this case as urgent. Close to 40 % of professionals indicated that they would not be comfortable doing the follow-up of a patient with a scoliosis. Nevertheless, the majority felt that accessibility to specialized care was a problem. Almost all (98 %) mentioned that the development of clinical guidelines would positively affect their daily practice. In conclusion, our study shows that knowledge gaps exist among professionals regarding clinical signs and risk factors of curve progression in adolescent idiopathic scoliosis. Most professionals recognize the importance of referring urgent cases to specialized care although there may be problems with access to peadiatric orthopedic specialists. Interprofessional collaboration may be a promising approach to improve management of patients with adolescent idiopathic scoliosis.

Les médecins de famille, les pédiatres, les chiropraticiens et les physiothérapeutes sont parmi les professionnels de la santé les plus susceptibles de rencontrer des patients atteints d’une scoliose idiopathique adolescente. Les recherches démontrent que certaines lacunes existent à l’égard des connaissances acquises, par ces professionnels, dans le domaine musculosquelettique, incluant la scoliose. De plus, il ne semble pas exister d’informations sur le niveau de connaissances et la démarche clinique de ces professionnels en matière de scoliose, bien que les bonnes pratiques actuelles dictent une détection hâtive de cette condition pour en optimiser la gestion thérapeutique. Les objectifs de notre étude visaient donc à évaluer les connaissances ainsi que les aptitudes en matière de démarche clinique des professionnels les plus susceptibles à traiter des patients atteints d’une scoliose idiopathique adolescente. À l’aide d’un questionnaire semi-structuré, 51 professionnels de la santé ont été interviewés. Parmi ces professionnels recrutés par l'entremise de leur ordre professionnel respectif, on retrouvait 21 médecins de famille, 10 pédiatres, 10 chiropraticiens et 10 physiothérapeutes. Les entrevues évaluaient les connaissances en matière de signes cliniques, de facteurs de risque, de démarche clinique et de processus référentiel vers les soins spécialisés. De plus, les préférences des professionnels à l’égard des guides de bonne pratique ont été abordées. Parmi les professionnels interviewés, 59 % étaient des femmes, 43 % étaient âgés de moins de 40 ans et la moyenne d’années de pratique était de 20,3 ans. Les résultats démontrent qu’il existe des lacunes à l’égard des connaissances des signes cliniques et des facteurs de risque : moins du tiers des professionnels interviewés pouvaient mentionner au moins 2 signes cliniques et 31 % d’entre eux ne pouvaient se souvenir des facteurs de risque associés à la scoliose idiopathique adolescente; les médecins de famille étaient les moins connaissants dans ces domaines. De plus, en présence d’une mise en contexte nécessitant une référence urgente en soins spécialisés, 70 à 90 % des professionnels auraient référé le patient en dépit du fait que seulement 38 à 60 % d’entre eux considéraient cette situation comme urgente. Près de 40 % des professionnels mentionnaient qu’ils seraient inconfortables à gérer un patient atteint d’une scoliose. Néanmoins, la majorité d’entre eux reconnaissaient qu’il existe un problème en ce qui a trait à l’accessibilité aux soins spécialisés en orthopédiatrie. Presque la totalité c’est-à-dire, 98 % étaient favorables à la production de guides de bonne pratique et les accueilleraient positivement dans leur pratique quotidienne. Les conclusions de cette étude ont montré qu’il existe des vides en matière de connaissances de signes cliniques et de facteurs de risque de progression de la scoliose idiopathique adolescente; ces lacunes ont particulièrement été remarquées chez les médecins de famille. La majorité des professionnels reconnaissent l’importance de référer les conditions urgentes en soins spécialisés. Néanmoins, tous semblent souligner des difficultés dans ce processus référentiel. Une meilleure collaboration interprofessionnelle semble prometteuse en ce qui concerne la gestion de patients atteints d’une scoliose idiopathique adolescente. / Family physicians, peadiatricians, chiropractors and physical therapists are among health professionals most likely to encounter and treat patients with adolescent idiopathic scoliosis. Research shows that there are gaps in musculoskeletal knowledge among professionals but no studies assess knowledge of scoliosis among professionals most likely to treat patients with scoliosis. Best current practice dictates that early detection of adolescent idiopathic scoliosis leads to better decision-making regarding optimal course of management. The objectives of our study were to evaluate basic knowledge and the management skills of professionals most likely to encounter adolescent idiopathic scoliosis. We developed a semi-structured questionnaire and interviewed 51 health professionals. Among these professionals, who were recruited through their professional regulatory board registries, were 21 family physicians, 10 peadiatricians, 10 chiropractors and 10 physical therapists. The interview assessed knowledge of clinical signs and risk factors, management options, including referral to specialized care. We also discussed preferences and acceptability of clinical guidelines in regard to scoliosis. Among interviewed professionals, 59 % were female, 43 % were under 40 and mean years of practice was 20.3. Our results demonstrated gaps in knowledge with respect to clinical signs and risk factors. Less than a third of professionals were able to mention at least 2 clinical signs and 31 % were unaware of any risk factors associated with scoliosis progression. Family physicians appeared least knowledgeable in these areas. When presented with a situation where urgent referral was indicated, 70 – 90 % said that they would refer the patient although only 38 – 60 % rated this case as urgent. Close to 40 % of professionals indicated that they would not be comfortable doing the follow-up of a patient with a scoliosis. Nevertheless, the majority felt that accessibility to specialized care was a problem. Almost all (98 %) mentioned that the development of clinical guidelines would positively affect their daily practice. In conclusion, our study shows that knowledge gaps exist among professionals regarding clinical signs and risk factors of curve progression in adolescent idiopathic scoliosis. Most professionals recognize the importance of referring urgent cases to specialized care although there may be problems with access to peadiatric orthopedic specialists. Interprofessional collaboration may be a promising approach to improve management of patients with adolescent idiopathic scoliosis.

Abstract Isolated lateral malleolar supination-external rotation (SER) -type ankle fractures without incongruity on the standard radiographs can be either stable or unstable depending on the status of the deep deltoid ligament. Neither clinical signs of injury on the medial aspect of the ankle nor the displacement of fibular fracture on mortise radiographs seem to predict stability. Therefore, stress testing has been adopted in clinical use. No “gold standard” method exists but the manual external rotation (ER) stress test is the most extensively studied. The ER stress test has some disadvantages, and other methods—such as gravity stress radiography and magnetic resonance imaging—have been suggested instead. However, the evidence to support the use of these methods is still insufficient. The aims of this dissertation were to assess the roles of (1) morphological factors from standard radiographs of 286 patients, (2) clinical findings on the medial side of the ankle and gravity stress radiography of 79 patients, and (3) MRI of 61 patients in evaluating the stability of the ankle mortise in patients with unimalleolar SER-type fractures with no talar shift on standard radiographs. The ER stress test result was considered to be the reference for stability throughout these studies. We found that a fracture line width &lt; 2 mm in lateral radiographs, only two fracture fragments, and female sex are independent factors predicting a stable ankle mortise. Neither clinical signs on the medial side of the ankle nor gravity stress radiography alone predict the stability of the ankle mortise accurately. According to our MRI findings, total tears of the deep deltoid ligaments are rare, and partial tears are common in this this patient group. The reliability of the MRI assessment is only moderate. In conclusion, patients with non-comminuted fractures and &lt; 2 mm displacement on lateral radiographs have stable ankle mortises and need no further stress testing. The gravity stress radiography is an accurate test for the evaluation of the ankle mortise stability only if the clinical signs indicate a similar result with the gravity stress radiographs. The use of MRI provides no additional benefit compared to ER stress testing for stability evaluation of an SER-type ankle fracture. / Tiivistelmä Supinaatio-ulkokiertomekanismilla syntyneet isoloidut ulkokehräsluun murtumat ilman röntgenkuvassa näkyvää telaluun siirtymää voivat olla joko vakaita tai epävakaita nilkan sisemmän nivelsiteen syvän lehden tilasta riippuen. Kliinisessä tutkimuksessa todettujen nilkan sisäreunan vamman merkkien tai röntgenkuvauksella todettavan ulkokehräsluun murtuman virheasennon ei ole osoitettu ennustavan nivelhaarukan mahdollista epävakautta, joten nilkkaa kuormittaen tehtäviä röntgenkuvauksia on otettu kliiniseen käyttöön. Mikään näistä kuvausmenetelmistä ei ole niin sanottu kultainen standardi, mutta ulkokiertovääntötestiä (ER-testi) on tutkittu laajimmin. ER-testin käyttöön liittyy kuitenkin ongelmia, joiden vuoksi niin sanottua painovoimakuvausta tai muun muassa magneettikuvausta (MRI) on ehdotettu käytettäväksi sen sijaan. Näiden menetelmien käyttöä tukeva tieteellinen näyttö on kuitenkin vielä riittämätöntä. Tämän väitöskirjatyön tarkoituksena oli tutkia (1) 286 potilaan tavallisista kuormittamattomista röntgenkuvista morfologisten tekijöiden, (2) 79 potilaan nilkan sisäreunan kliinisen tutkimuksen ja painovoimakuvauksen sekä (3) 61 potilaalla MRI:n merkitystä ja tarkkuutta arvioitaessa supinaatio-ulkokiertomekanismilla syntyneiden ulkokehräsluun murtumien vakautta. ER-testin tulosta käytettiin referenssinä nivelhaarukan vakaudelle kaikissa osatöissä. Sivukuvasta mitattuna ulkokehräsluun murtuman leveys &lt; 2 mm, vain kahden kappaleen murtuma ja naissukupuoli ovat itsenäisiä vakaata nivelhaarukkaa ennustavia tekijöitä. Kliininen tutkimus tai painovoimakuvaus eivät yksinään pysty ennustamaan nivelhaarukan vakautta riittävän tarkasti. MRI:n perusteella sisemmän nivelsiteen syvän lehden täydelliset repeämät ovat tässä vammatyypissä harvinaisia mutta osittaiset repeämät ovat hyvin tavallisia huolimatta ER-testin tuloksesta. MRI:n tulkinnan luotettavuus on ainoastaan kohtalainen. Yhteenvetona voidaan todeta, että ilman ilmeistä telaluun siirtymää röntgenkuvassa yksinkertaiset supinaatio-ulkokiertomekanismilla syntyneet ulkokehräsluun murtumat ovat vakaita eikä nivelhaarukan vakauden testaaminen ole tarpeen, jos murtumaraon leveys sivukuvassa on &lt; 2 mm. Painovoimakuvaus on luotettava, mikäli sen tulos on sama ulkoisten vamman merkkien kanssa. Magneettikuvauksesta ei ole hyötyä arvioitaessa tämän nilkkamurtumatyypin vakautta.