Biomedical subjects
Publications and source records attributed to R Radin.
We report the case of a 36-year-old woman with erythrocytosis due to ectopic erythropoietin production by a very large uterine leiomyoma. Awareness of this uncommon condition is important so that the correct diagnosis can be suggested prior to surgery and radical resection can be avoided.
Financial constraints due to increasing operating cost and decreased reimbursement do not allow many hospitals to maintain coverage by attending radiologists around the clock (CARAC). Preliminary film readings by radiology trainees may be inaccurate. In trauma, decisions are made fast and are often based on these preliminary readings. To examine whether there are significant discrepancies between preliminary readings (PRs) and final readings (FRs) of CT scans of trauma patients we prospectively recorded PRs (done immediately by radiology residents) and FRs (done the following working day by radiology attendings) over a period of 6 months for trauma CT scans done between 5 PM and 7 AM on weekdays or weekends. A discrepancy was classified as significant if a change in management was instituted after FR. In 42 of 383 (11%) trauma patients there was a discrepancy between PR and FR. Patients with discrepancies had a higher Injury Severity Score, higher incidence of penetrating trauma, longer hospital stay, higher hospital charges, and higher mortality than patients without any discrepancy. Most of the discrepancies were found on abdominal CT scans. The lower the level of radiology resident doing the PR the higher the likelihood of a discrepancy. In 20 patients (5%) a significant discrepancy was found. We conclude that the absence of CARAC results in inaccurate FRs risking optimal trauma patient care. The institutional savings realized by avoiding CARAC may be offset by the cost of additional care provided to patients who have delayed diagnosis and treatment due to the lack of it.
OBJECTIVE: To assess the treatment of peripancreatic fluid collections or abscess with percutaneous catheter drainage (PCD). SUMMARY BACKGROUND DATA: Surgical intervention has been the mainstay of treatment for infected peripancreatic fluid collections and abscesses. Increasingly, PCD has been used, with mixed results reported in the literature. METHODS: A retrospective chart review of 1993 to 1997 was performed on 82 patients at a tertiary care public teaching hospital who had computed tomography-guided aspiration for suspected infected pancreatic fluid collection or abscess. Culture results, need for subsequent surgical intervention, length of stay, and death rate were assessed. RESULTS: One hundred thirty-five aspirations were performed in 82 patients (57 male patients, 25 female patients) with a mean age of 40 years (range 17-68). The etiologies were alcohol (41), gallstones (32), and other (9). The mean number of Ranson's criteria was four (range 0-9). All patients received antibiotics. Forty-eight patients had evidence of pancreatic necrosis on computed tomography scan. Cultures were negative in 40 patients and positive in 42. Twenty-five of the 42 culture-positive patients had PCD as primary therapy, and 6 required subsequent surgery. Eleven patients had primary surgical therapy, and five required subsequent surgery. Six patients were treated with only antibiotics. The death rates were 12% for culture-positive patients and 8% for the entire 82 patients. CONCLUSIONS: Historically, patients with positive peripancreatic aspirate culture have required operation. This series reports an evolving strategy of reliance on catheter drainage. PCD should be considered as the initial therapy for culture-positive patients, with surgical intervention reserved for patients in whom treatment fails.
OBJECTIVE: The objective of this study was to evaluate prospectively the use of CT cystography, using retrograde filling of the bladder with diluted iodinated contrast material, versus conventional cystography to identify bladder injury in patients with hematuria after blunt abdominal trauma. SUBJECTS AND METHODS: Inclusion criteria consisted of the adult hemodynamically stable abdominal trauma patient with hematuria referred for abdominopelvic CT and also being considered for cystography. An initial abdominopelvic CT scan using IV iodinated contrast material was obtained, as would have been done routinely in the trauma victim. A second CT scan through the pelvis was obtained after retrograde distention of the bladder with dilute iodinated contrast material. CT cystography revealing bladder injury was followed with appropriate therapy. CT cystograms not revealing injury were followed by conventional cystography. Results of patient outcome were evaluated. RESULTS: Over a 21-month period from January 1995 through September 1996, CT cystography was performed on 55 patients who presented with hematuria after blunt abdominal trauma. Five of the 55 patients had bladder injury on CT cystography. The injury in each of these five patients was confirmed intraoperatively. In the remaining 50 patients, both CT and conventional cystography did not reveal bladder injury. CONCLUSION: CT cystography is an accurate method for evaluating bladder injury in the blunt abdominal trauma victim with hematuria. CT cystography, performed in conjunction with routine CT of the abdomen and pelvis for evaluating traumatic hematuria, would therefore preclude conventional cystograms in these patients.
PURPOSE: To determine the radiologic appearance of ganglioneuromas of the adrenal gland and extra-adrenal retroperitoneum. MATERIALS AND METHODS: A retrospective review was performed of imaging findings in nine patients with ganglioneuroma, two with ganglioneuroma-pheochromocytoma, and two with malignant peripheral nerve sheath tumor (PNST) that arose in a ganglioneuroma. Patients underwent computed tomography (CT) (n = 13), magnetic resonance (MR) imaging (n = 5), and ultrasonography (US) (n = 5). RESULTS: In nine patients with ganglioneuroma, the mass ranged in size from 2 x 4 x 4 cm to 21 x 21 x 22 cm. Imaging findings included attenuation entirely or predominantly less than that of muscle on contrast material-enhanced CT images (n = 9); heterogeneous, predominantly high signal intensity on T2-weighted MR images (n = 5); partial or complete surrounding of one or more major blood vessels with little or no luminal narrowing (n = 4) and calcifications (n = 4) on CT scans; and homogeneous, moderate echogenicity (n = 3) on US scans. CT findings in two patients with ganglioneuroma-pheochromocytoma included central necrosis (n = 1) and calcifications (n = 1). In the two patients with malignant PNST that arose in a ganglioneuroma, contrast-enhanced CT showed a large, markedly heterogeneous mass. CONCLUSION: Diagnosis of ganglioneuroma should be considered when typical CT or MR imaging findings are present. Findings in cases of ganglioneuroma-pheochromocytoma and malignant PNST arising in a ganglioneuroma appear to be nonspecific.
Over the past several years, we have developed a technique to assess the resectability of periampullary and pancreatic tumors using color flow sonography. This is a feasibility study to determine if sonography with color flow imaging can play a role in evaluating patients with periampullary and pancreatic tumors. This study comprises a retrospective analysis of 51 patients referred for color flow sonographic evaluation of resectability of periampullary and pancreatic neoplasm. Scanning was performed with state-of-the-art color flow sonographic systems. Vessels that were touched or occluded by tumor were categorized according to a Pancreatic Color Doppler Score. Other factors affecting resectability (metastasis, enlarged nodes) were recorded. Sonographic findings were correlated with surgical resectability and pathologic findings regarding tumor margins. The color flow study was complete technically (all index vessels visualized) in 49 of 51 patients (96%). In all, 643 of 647 vessels (99.4%) were imaged. Forty-five patients had sufficient surgical, pathologic, or clinical proof to be included in the resectability analysis. All 18 patients with circumferential tumor or vascular occlusion (Pancreatic Color Doppler Score 4 and 5) were found to have unresectable disease. All 10 patients in whom tumor did not touch (Pancreatic Color Doppler Score 0) had negative margins. All 30 patients considered to have unresectable tumors sonographically could not be resected. Patients in this category had one or more of the following: positive pathologic margins, positive nodes, liver metastasis, or not clinically resectable. Six of 15 considered resectable sonographically (40%) were unresectable for cure. Surgeons believed that color flow sonography influenced management in 10 of 45 patients (22% overall). Color flow sonography, a painless, noninvasive, and relatively inexpensive examination, may be an effective screening tool to evaluate periampullary and pancreatic neoplasms for resectability. Our data show that color flow sonography can correctly predict unresectability of periampullary and pancreatic neoplasms. Any future evaluation of imaging and management of periampullary and pancreatic tumors should include color flow sonography.
BACKGROUND: Pylephlebitis may complicate any intra-abdominal infection and carries a high mortality rate. Acute cases are usually anticoagulated to prevent thrombus extension and enteric ischemia; however, the role of anticoagulation has not been clearly defined. METHODS: Over a 3-year period, pylephlebitis was diagnosed in 44 patients with portal vein thrombosis on computed tomography scan with fever, leukocytosis, and/or positive blood cultures. The charts were reviewed for etiology, extent of venous thrombosis, and method and results of treatment. RESULTS: Eighteen patients were hypercoagulable, due to clotting factor deficiencies (6), malignancy (8), or AIDS (4). Fifteen patients had mesenteric vein involvement. Thirty-two patients were not anticoagulated, and 5 died (3 with hypercoagulable states and 2 with normal clotting function). Twelve patients were anticoagulated, and none developed subsequent bowel infarction or died. CONCLUSION: Patients with pylephlebitis and a hypercoagulable state due to neoplasms or clotting factor deficiencies should be anticoagulated. Patients with normal clotting function and mesenteric vein involvement may also benefit. We believe anticoagulation in patients with thrombus isolated to the portal vein and normal clotting function may be unnecessary.
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The authors report three patients with features of the Carney complex: cardiac myxomas (n = 2), multicentric (n = 1) or recurrent (n = 1); pigmented skin lesions (n = 2); cutaneous myxomas (n = 2); melanotic schwannoma (n = 2); and sonographic evidence of multicentric, large cell, calcifying Sertoli cell tumors of the testes (n = 1). The initial component of the complex was cutaneous myxoma (n = 1), cardiac myxoma (n = 1), or psammomatous melanotic schwannoma (n = 1). Two patients died of metastatic schwannoma.
PURPOSE: To evaluate abdominal computed tomographic (CT) findings in patients with human immunodeficiency virus (HIV) infection. MATERIALS AND METHODS: CT scans with abnormal findings in 259 patients (247 men, 12 women; age range, 21-60 years) with HIV infection were analyzed. Diagnoses were mycobacterial infection (n = 87), lymphoproliferative disease (n = 63), Kaposi sarcoma (n = 17), fungal infection (n = 17), hepatocellular disease (n = 13), Pneumocystis carinii infection (n = 8), other disorders (n = 39), or unknown (n = 30). RESULTS: Abnormal findings included lymph-node enlargement (n = 159), hepatomegaly (n = 100), splenomegaly (n = 62), gastrointestinal mass or wall thickening (n = 61), and low-attenuation lesions in the liver (n = 50) or spleen (n = 55). Diagnoses thought to account for CT findings were made (n = 229) or suspected (n = 18) in 247 (95%) of the 259 patients. CONCLUSION: In most patients with HIV infection, abnormal abdominal CT findings are due to a second disease. Even relatively nonspecific findings should not be ascribed to HIV infection and should prompt a search for an opportunistic infection or neoplasm.
PURPOSE: A clinical trial for patients with gastric cancer amenable to curative resection was undertaken to determine feasibility and response to preoperative systemic chemotherapy followed by postoperative intraperitoneal (IP) chemotherapy. METHODS AND MATERIALS: Thirty-eight patients with resectable gastric tumor received two cycles of protracted intravenous (IV)-infusion fluorouracil (5FU), 200 mg/m2/d, for 3 weeks with weekly IV leucovorin 20 mg/m2 and IV cisplatin 100 mg/m2 days 1 and 29. Resection of the gastric tumor followed within 3 weeks of completion of systemic chemotherapy. Those who had all visible tumor removed with clear margins received two cycles of IP floxuridine 3,000 mg (total dose) per day for 3 days and IP cisplatin 200 mg/m2 with IV sodium thiosulfate on the fourth day of IP therapy. RESULTS: Thirty-seven of 38 patients (97%) received two cycles of systemic chemotherapy. Thirty-five of 38 patients (92%) underwent laparotomy for gastric tumor resection. Thirty-three patients (87%) had gastric resections performed; 29 (76%) had all visible tumor removed with microscopically negative margins. No operative mortality was encountered. Twenty-six patients (68%) received IP treatment. IV neoadjuvant treatment was well tolerated and resulted in 68% of the patients reporting improvement in abdominal pain, 45% objective remissions by computed tomography (CT), 38% objective remissions by gastroscopy and biopsy, and 8% had complete surgical pathologic response. Neutropenic sepsis during the IP treatment phase contributed to the only treatment-related death. Four of 29 completely resected patients (14%) have had tumor recurrence. The median follow-up time of patients remaining alive is now 19 months. The median survival for 38 patients entered onto this protocol has not been reached at 17+ months. CONCLUSION: This novel approach to the treatment of adenocarcinoma of the stomach is feasible. The neoadjuvant systemic therapy results in significant primary tumor regression. The determination of whether systemic or IP components of the program contribute to decreased recurrence or increased survival awaits a prospectively randomized clinical trial.
Nine patients who had undergone end-to-side portocaval shunts were assessed using a sector real-time color Doppler sonography system. Shunt patency was demonstrated in 8 of 9 patients by detection of color-coded flow within the portal vein, in the anastomotic region, and in the inferior vena cava adjacent to the shunt. Color flow could not be detected in 1 patient. This patient had no evidence of shunt compromise. Spectral Doppler studies were also performed in these patients and flow was demonstrated in all 8. In these instances, information available with color Doppler imaging allowed visualization of the shunt even when it had not been apparent on preliminary real-time grey-scale imaging. This study, which does not assess accuracy, nevertheless suggests that color flow Doppler sonography may prove useful in assessing patients with portocaval shunts.
Generalized juvenile polyposis usually is not associated with an increased risk for gastrointestinal carcinoma. A subgroup of patients, however, have juvenile polyps with adenomatous features. A case report of juvenile polyposis, together with adenocarcinoma of the colon and review of the literature, are presented to emphasize the potential for malignancy in this subgroup of patients and to guide appropriate evaluation.
An unusual patient with blue rubber bleb nevus syndrome is presented. At birth a single abdominal wall hemangioma was noted, and over a 21-year follow-up the full syndrome developed, including many cutaneous and intestinal lesions and anemia. Our long-term follow-up of this patient allows an understanding of the natural history of this condition, especially regarding recurrence of lesions after excision.
The authors report a case of malignant peripheral nerve sheath tumor arising in an adrenal ganglioneuroma in an adult. This is the first such case occurring in the absence of a history of childhood neuroblastoma treated with radiation, and provides evidence that such a transformation can occur spontaneously. The neoplasm demonstrated a highly malignant biologic behavior with rapid growth, local recurrence, and metastasis.
An unusual case of colitis cystica profunda is described. The patient presented with intestinal obstruction due to a polypoid mass in the descending colon, which was diagnosed as colitis cystica profunda after the patient underwent colectomy. Three other separate lesions were present in the ascending, transverse, and sigmoid colon. There was no antecedent or associated colonic disease. The disease recurred 1 yr later in the remaining colon and rectum.
We studied the diagnostic utility of an enzyme-linked immunosorbent assay (ELISA) in hospitalized patients with suspected pulmonary tuberculosis (TB). A positive culture for M. tuberculosis identified active disease, and 3 negative cultures and smears defined the negative group. IgG antibody activity was determined by adding a 1:1,000 dilution of serum to plates coated with PPD antigen. Alkaline phosphatase labeled anti-IgG was added, color developed, and an optical density index (ODI) was determined. Twenty-one patients with M. tuberculosis TB had a mean ODI of 0.27, which was higher than 99 patients without TB, ODI 0.10 (p less than 0.001). An ODI of 0.15 or greater was established as a positive ELISA test. For patients with M. tuberculosis TB, the ELISA had a sensitivity of 67 and a specificity of 79%. The first smear had a sensitivity of 57 and a specificity of 99%. With the first smear and the ELISA test results, a combined sensitivity of 86% was achieved. When both ELISA and the first smear were negative (101 cases), active TB caused by M. tuberculosis was found in only three patients (3.0%).
We evaluated two children with allergy to egg-white protein (ovalbumin) who had generalized urticaria, angioedema, and respiratory difficulty after immunization with live rubeola vaccine. In both patients, serum IgE reactive with ovalbumin-related antigens in the vaccine was demonstrated. Subsequent evaluation of 24 children with ovalbumin allergy revealed that those who had positive ovalbumin skin tests, but no clinical reaction to egg white, were skin test negative on prick and intradermal testing with measles vaccine and were safely immunized. They had no detectable IgE directed against the rubeola vaccine, although IgE directed at ovalbumin was present. Six patients who had severe allergic hypersensitivity reactions on exposure to ovalbumin had IgE antimeasles vaccine antibody and had positive reactions after intracutaneous or intradermal testing with the vaccine. These patients were safely immunized with increasing volumes (0.05 ml increments every 20 minutes) of measles vaccine to receive the full dose. These studies suggest that children with severe allergic hypersensitivity to egg white should be screened with an intracutaneous test prior to immunization with measles vaccine; however, children who have positive skin tests but no clinical reaction to ovalbumin exposure are at minimal risk for hypersensitivity reactions to measles immunization, as previously reported.