Biomedical subjects
Publications and source records attributed to J N Diaconis.
Skin grafting following extensive soft-tissue loss is often delayed until adequate granulation tissue can be generated. Surgical drill holes into the marrow cavity promote development of granulation tissue. This article illustrates the radiology appearance of these drill holes in four patients.
The American College of Surgery currently recommends routine performance of lateral cervical radiography of C-1 to C-7 for all patients admitted with a history of major blunt trauma. A survey of 125 North American hospitals with experience in acute trauma care revealed that 96% obtain cervical radiographs as a routine or protocol study on all patients who have suffered major blunt trauma. To ascertain the cost-benefit effect of this practice, a prospective study was conducted during a 19-month period to compare the results of admission bedside clinical assessment of the cervical spine and the outcome of cervical radiography and computed tomography (CT) performed on 408 patients admitted with a history of major blunt trauma. Among these patients, there were 138 (34%) who were judged to be mentally alert and without symptoms referable to cervical spine injury. CT was performed after cervical radiography to adequately visualize the lower cervical spine (132 patients) or to clarify uncertain radiographic findings (six patients). One nondisplaced transverse process fracture of C-7 was detected (a prevalence of less than 1% of asymptomatic patients). The combined cost of cervical radiography and CT for the 138 asymptomatic patients was $59,202. These results call into question both the cost and clinical efficacy of routine or protocol-driven cervical spine imaging for all patients who have sustained major blunt trauma and support the value of careful bedside clinical assessment of the cervical spine in mentally alert blunt-trauma victims.
The usual causes of hemomediastinum and hemothorax include chest trauma, rupture of an aortic aneurysm or aortic dissection. We report two patients who presented with a clinical picture of aortic dissection. In both patients, the chest radiograph revealed anterior mediastinal masses. Aortic dissection could not be excluded on the basis of the chest radiograph, and additional investigation by thoracic aortography was performed. The tumors had undergone spontaneous bleeding into the mediastinum and the pleural space, presumably causing the patients pain. The interesting and unusual causes of spontaneous hemomediastinum and hemothorax are reviewed.
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Rupture of the cervical esophagus and trachea secondary to cervical spine fracture-dislocation occurs rarely. Herein we describe a case and propose a mechanism to account for these associated injuries. Awareness of this complication of cervical spine fracture is crucial for prompt recognition and management.
A retrospective review of chest radiographs from 205 patients with blunt chest trauma who also underwent aortography was performed. Forty-one of the 205 had aortographically proved aortic rupture. Discriminant analysis of 16 radiographic signs indicated that the most discriminating signs were loss of the aorticopulmonary window, abnormality of the aortic arch, rightward tracheal shift, and widening of the left paraspinal line without associated fracture. No single or combination of radiographic signs demonstrated sufficient sensitivity to indicate all cases of traumatic aortic rupture on plain chest radiographs without the performance of a large number of aortographically negative studies. The bedside anteroposterior "erect" view of the chest proved far more valuable than the supine view in detecting true-negative studies. Despite significant reader variability in the interpretation of the various radiographic signs, in general the analysis confirmed the role of chest radiography in this clinical situation, but suggests that its most beneficial use is in excluding the diagnosis and eliminating unwarranted aortography rather than in predicting aortic rupture.
A patient is described in whom dense calcifications developed in the presternal soft tissues of the chest four years after mediastinal radiotherapy. This is believed to represent dystrophic calcification in previously normal but incidentally radiated tissues following standard dose radiotherapy to the mediastinum for stage IIA Hodgkin's disease.
Radiographic measurements of the cardiothoracic ratio in four adult victims of blunt thoracic trauma with pneumopericardium demonstrated a sudden, substantial decrease in the size of the cardiac silhouette, which was accompanied by pathophysiologic effects of cardiac tamponade. The sudden decrease in cardiac size could not be attributed to a decrease in intravascular volume or to changes in positive airway pressure. Following surgical relief of tension pneumopericardium, the cardiac size was restored to baseline dimensions and the hemodynamic effects of tamponade resolved. In the presence of pneumopericardium, the "small heart" sign may alert one to the presence of tension pneumopericardium and impending cardiac tamponade.
Transient hilar and mediastinal lymphadenopathy accompanying right-sided bacterial endocarditis without concurrent roentgenographically-demonstrable pulmonary parenchymal abnormalities has not, to our knowledge, been previously reported. The roentgenographic finding of hilar or mediastinal lymphadenopathy should not be considered incompatible with the diagnosis of bacterial endocarditis in the appropriate clinical setting. Possible mechanisms for the development of lymphadenopathy secondary to bacterial endocarditis are discussed.
Atresia and hypoplasia of the bile ducts are the most common congenital biliary anomalies of clinical importance. Surgical correction can help about 10% of these infants. However, surgery should be performed within the first month of life to avoid irreversible liver parenchymal changes. It is difficult to separate the surgical condition, biliary atresia, from conditions in which the trauma of laparotomy should be avoided, such as neonatal hepatitis and other clinically indistinguishable causes of obstructive jaundice. Radionuclide imaging with the 99mTc-labeled N-substituted iminodiacetic acids (HIDA, PIDIDA, DISIDA, etc) have been helpful in the differential diagnosis of biliary atresia.
Perforation of a sigmoid diverticulum occurred in two patients in the immediate postoperative period after coronary artery surgery. Etiological factors leading to diverticular perforation after coronary artery bypass grafting are discussed. The significance of pneumoperitoneum on the postoperative chest radiograph, which prompted diagnosis in these cases, is also discussed.
The Angelchik antireflux prosthesis is a ringlike device used in the surgical treatment of sliding hiatal hernia and gastroesophageal reflux. This article describes an unusual postoperative complication whereby the prosthesis had migrated into the lumen of the stomach.
Fatal generalized barium sulfate (BaSO4) embolization followed erroneous vaginal insertion of the enema tip intended for colon examination. Light microscopy revealed the presence of swollen, granular reticuloendothelial cells in most visceral organs such as lung, liver, spleen, bone marrow, kidney, and brain. Transmission electron microscopy showed the reticuloendothelial cells loaded with uniformly electron-dense granules of various sizes. Scanning electron microscopy equipped with an energy-dispersive x-ray analyzer confirmed the BaSO4 composition of these granules when unstained paraffin sections of different organs mounted on glass slides without coverslips were examined. The use of the technique of x-ray microanalysis is recommended when absolute identification of inorganic material in human organs is needed. The technique can be used directly on routine paraffin-embedded material mounted on glass slides as well as with material expressly prepared.
Pulmonary nodules may develop following bleomycin therapy, a previously undescribed entity that may simulate metastatic disease. Two asymptomatic patients are reported with nodules that developed following low dose bleomycin treatment for testicular tumors. One patient had previously documented pulmonary metastases that had resolved after chemotherapy. The other patient had nodular-appearing densities on routine chest examination without a history of previous metastatic lung involvement.
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Stercoraceous perforation of the colon is most often unsuspected and is usually diagnosed at operation or autopsy. Abdominal radiographs show large fecal masses in the rectum and sigmoid colon, and occasionally lying free in the peritoneal cavity. Free intraperitoneal air is present. We have reported a single case, with a discussion of the pathophysiology.
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