Recurrent miscarriage: do professionals adhere to their guidelines.

STUDY QUESTION: Is the actual care for recurrent miscarriage in clinical practice in accordance with 23 guideline-based quality indicators? SUMMARY ANSWER: The accordance of actual care with the guidelines was poor and there is evident room for improvement. WHAT IS KNOWN ALREADY: Evidence-based guidelines are important instruments to improve quality of care, but implementation of guidelines is often problematic. STUDY DESIGN, SIZE, DURATION: A retrospective cohort study was performed within a 12-month period (2006) in nine departments of Obstetrics and Gynaecology in the Netherlands. PARTICIPANTS, SETTING, METHODS: Five hundred and thirty women with recurrent miscarriage were included. Actual care was assessed with 23 guideline-based quality indicators (covering diagnostics, therapy and counselling) by calculating per indicator the percentage of women for whom the indicator was followed. Thereafter we did multilevel analyses, to relate the adherence to the indicator to determinants of women, professionals and hospitals. MAIN RESULTS AND THE ROLE OF CHANCE: Homocysteine and antiphospholipid antibodies were determined in 39 and 47%, respectively. Thrombophilia screening (54%) and karyotyping (50%) were offered to women regardless of their underlying risk for inherited thrombophilia or chromosome abnormalities. Higher maternal age at the time of presentation and a lower number of preceding miscarriages were improperly used to decide on diagnostic tests and were both associated with lower guideline adherence by professionals. Professionals with a subspecialization in recurrent miscarriage performed better standard care, i.e. screening for antiphospholipid antibodies and homocysteine, but also showed overuse of diagnostics in women at low risk of inherited thrombophilia. LIMITATIONS, REASONS FOR CAUTION: Retrospective cohort study. WIDER IMPLICATIONS OF THE FINDINGS: Quality indicators used will enable measurement of quality of care. STUDY FUNDING: The study was funded by The Netherlands Organisation for Health Research and Development (ZonMw) (Grant no. 94517005). None of the authors has any conflict of interest to declare.

Misoprostol and termination of pregnancy: is there a need for ultrasound screening in a general population to assess the risk for adverse outcome in cases of uterine anomaly?

PURPOSE AND METHODS: We reviewed the existing literature on medical termination of pregnancy in cases of congenital uterine malformation. Is medical termination of pregnancy safe in the presence of a uterine anomaly? Can termination of pregnancy still be performed when information concerning the presence of congenital uterine malformation is not available? RESULTS: The risk of adverse outcome, i.e. uterine rupture, was high in class 2 uterine anomalies, whereas the risks in classes 3-6 were negligible. However, the very low incidence of class 2 anomalies in pregnant women results in a calculated risk of uterine rupture in medical termination of pregnancy on the basis of this anomaly of 1 in 300,000 pregnancies. Ultrasound scanning is of limited diagnostic value to diagnose congenital uterine malformations. CONCLUSIONS: The implications of uterine anomalies are not an argument in the discussion whether to use misoprostol for termination of pregnancy in developing countries with scarce diagnostics tools.

Relation between regional and global systolic function in patients with ischemic cardiomyopathy after beta-blocker therapy or revascularization.

BACKGROUND: To assess the relationship between improved regional and global myocardial function in patients with ischemic cardiomyopathy in response to beta-blocker therapy or revascularization. MATERIALS AND METHODS: Cardiovascular magnetic resonance (CMR) was performed in 32 patients with ischemic cardiomyopathy before and 8 +/- 2 months after therapy. Patients were assigned clinically to beta-blocker therapy (n = 20) or revascularization (n = 12). CMR at baseline was performed to assess regional and global LV function at rest and under low-dose dobutamine. Wall thickening was analyzed in dysfunctional, adjacent, and remote segments. Follow-up CMR included rest function evaluation. RESULTS: Augmentation of wall thickening during dobutamine at baseline was similar in dysfunctional, adjacent and remote segments in both patient groups. Therefore, baseline characteristics were similar for both patient groups. In both patient groups resting LV ejection fraction and end-systolic volume improved significantly (p < 0.05) at follow-up. Stepwise multivariate analysis revealed that improvement in global LV ejection fraction in the beta-blocker treated patients was significantly related to improved function of remote myocardium (p < 0.05), whereas in the revascularized patients improved function in dysfunctional and adjacent segments was more pronounced (p < 0.05). CONCLUSION: In patients with chronic ischemic LV dysfunction, beta-Blocker therapy or revascularization resulted in a similar improvement of global systolic LV function. However, after beta-blocker therapy, improved global systolic function was mainly related to improved contraction of remote myocardium, whereas after revascularization the dysfunctional and adjacent regions contributed predominantly to the improved global systolic function.

Temporal endosonographic evaluation of anal sphincter integrity after primary repair for obstetric ruptures: a case for specific training of obstetricians.

OBJECTIVE: To evaluate primary repaired obstetric lesions of the anal sphincter complex on anal endo-ultrasound within a few days and 8 weeks after primary repair and to investigate in this way the influence of suboptimal woundhealing on the final anatomical result. Furthermore to investigate the relation between faecal incontinence and sphincter defects. DESIGN: A prospective cohort study. Setting The obstetric clinic and coloproctology outpatient clinic of the Zaans Medical Centre in Zaandam, the Netherlands. Subjects A cohort of 32 consecutive women with primary surgically repaired 3B, 3C or 4th degree anal sphincter defect after vaginal delivery. MAIN OUTCOME MEASURES: Appearance of the anal sphincter complex on anal endo-ultrasound within a few days week and 8 weeks after primary surgical repair, i.e. first and second ultrasound, respectively. Evaluation of anal continence, using the Vaizey incontinence score, at second ultrasound. RESULTS: No major wound breakdown was seen and four women had superficial, skin related wound problems. Twenty-eight women (87.5%) had a repaired external anal sphincter on the first and the second ultrasound. Of four external anal sphincter defects on first ultrasound one defect was not present on second ultrasound. The internal sphincter showed a defect on first ultrasound in 11 women and this was still present in 10 on second ultrasound. A total of 11 women had a persisting anal sphincter defect (external, internal or in combination). Mean Vaizey scores were significantly higher in women with a persisting sphincter defect (EAS, IAS or in combination) than in women with no sphincter defects, 2.3 and 0.4 respectively (95% CI 0.1-3.6, P = 0.04). CONCLUSION: Anal endo-ultrasound may be used for early evaluation of surgical repair of anal sphincter lesions after vaginal delivery. Persisting defects in the anal sphincters, in this series not because of major wound breakdown, can be explained by inadequate surgical repair.

Diastolic dysfunction in hypertensive heart disease is associated with altered myocardial metabolism.

BACKGROUND: Hypertension is an important clinical problem and is often accompanied by left ventricular (LV) hypertrophy and dysfunction. Whether the myocardial high-energy phosphate (HEP) metabolism is altered in human hypertensive heart disease and whether this is associated with LV dysfunction is not known. METHODS AND RESULTS: Eleven patients with hypertension and 13 age-matched healthy subjects were studied with magnetic resonance imaging at rest and with phosphorus-31 magnetic resonance spectroscopy at rest and during high-dose atropine-dobutamine stress. Hypertensive patients showed higher LV mass (98+/-28 g/m2) than healthy control subjects (73+/-13 g/m2, P<0.01). LV filling was impaired in patients, reflected by a decreased peak rate of wall thinning (PRWThn), E/A ratio, early peak filling rate, and early deceleration peak (all P<0. 05), whereas systolic function was still normal. The myocardial phosphocreatine (PCr)/ATP ratio determined in patients at rest (1. 20+/-0.18) and during stress (0.95+/-0.25) was lower than corresponding values obtained from healthy control subjects at rest (1.39+/-0.17, P<0.05) and during stress (1.16+/-0.18, P<0.05). The PCr/ATP ratio correlated significantly with PRWThn (r=-0.55, P<0.01), early deceleration peak (r=-0.56, P<0.01), and with the rate-pressure product (r=-0.53, P<0.001). CONCLUSIONS: Myocardial HEP metabolism is altered in patients with hypertensive heart disease. In addition, there is an association between impaired LV diastolic function and altered myocardial HEP metabolism in humans. The level of myocardial PCr/ATP is most likely determined by the level of cardiac work load.

Postoperative pulmonary flow dynamics after Fontan surgery: assessment with nuclear magnetic resonance velocity mapping.

OBJECTIVES: This study was performed to assess the value of nuclear magnetic resonance (NMR) velocity mapping for the measurement of pulmonary blood flow after Fontan surgery. BACKGROUND: Echocardiographic studies of pulmonary flow after Fontan surgery are not always satisfactory. The newly developed technique of NMR velocity mapping may contribute to the elucidation of the Fontan circulation. METHODS: At frequent intervals during the cardiac cycle, forward and backward flow volumes in the pulmonary arteries of nine volunteers were measured, summed and compared with right ventricular stroke volume to validate the velocity mapping technique. In 14 patients after Fontan surgery, assessment of pulmonary flow volumes enabled the evaluation of atriopulmonary and atrioventricular (AV) Fontan connections. The findings were correlated with precordial echocardiography. RESULTS: Validation of the NMR technique, obtained from volunteer experiments, showed a high correlation (r = 0.97) between right ventricular stroke volume and volumetric pulmonary stroke flow. In all patients with an atriopulmonary Fontan connection (n = 8), forward flow in the pulmonary artery was biphasic, similar to normal venous flow. Monophasic systolic pulmonary flow curves indicating right ventricle-dependent pulmonary blood flow were found in three of six patients with an AV Fontan connection. In the remaining three patients, the pulmonary flow pattern did not reflect right ventricular contraction. Measurement of flow velocity alone may give a false impression of forward flow and thus of right ventricular contribution. Pulmonary regurgitation was demonstrated in six of eight patients with an atriopulmonary connection. CONCLUSIONS: Nuclear magnetic resonance velocity mapping provides accurate and valuable information on pulmonary flow volume and velocity after Fontan surgery. The success of AV Fontan surgery can be deduced from the presence of a monophasic systolic pulmonary flow pattern as demonstrated by NMR velocity mapping. With NMR flow volume analysis, substantial pulmonary regurgitation occurring after atriopulmonary Fontan surgery can be measured.

Changes in muscle volume, strength, and bioenergetics during recombinant human growth hormone (GH) therapy in adults with GH deficiency.

Adults with GH deficiency (GHD) suffer from muscle weakness, which can be caused by the frequently reported decrease in muscle mass. However, measurements of both muscle strength and mass of muscle tested are scarce in adults with GHD. The aim of the present study was, therefore, to investigate intrinsic muscle strength (strength expressed per muscle volume unit) in adults with GHD at baseline and after 52 weeks of recombinant human GH (rhGH) therapy given in low, more physiological doses. A second objective was to investigate the influence of GH on muscle bioenergetics in the resting muscle. Isometric and isokinetic quadriceps strengths were measured in 28 males with GHD and in healthy controls matched for age and height. Quadriceps mass, determined by magnetic resonance imaging, and muscle bioenergetics, determined by phosphorus nuclear magnetic resonance spectroscopy, were measured in 20 of 28 patients with GHD and in controls matched for age and height. All patients were treated with doses of rhGH ranging from 0.6-1.8 IU/day, given for 52 weeks. Measurements of muscle mass, strength, and bioenergetics were repeated after 52 weeks of treatment with rhGH. The mean GH dose at 52 weeks of rhGH treatment was 1.3 +/- 0.8 IU/day. The mean serum insulin-like growth factor I level at baseline was 9.4 +/- 0.7 nmol/L and significantly increased to 26.4 +/- 1.2 nmol/L after 52 weeks of rhGH treatment. Adults with GHD had significantly reduced quadriceps muscle mass (P = 0.034) and reduced isometric muscle strength (P = 0.002) and tended to have low isokinetic muscle strength (P = 0.06), which all improved after rhGH therapy. Intrinsic muscle strength was not significantly different in adults with GHD compared with that in healthy controls and did not change during rhGH therapy. No bioenergetic abnormalities at baseline or after rhGH therapy were found in males with GHD. In conclusion, quadriceps muscle mass is decreased in adults with GHD and increased with rhGH therapy. These changes in muscle mass account for the changes in muscle strength found in these patients, as no changes in intrinsic muscle strength were found.

Circadian rhythm of plasma leptin levels in upper and lower body obese women: influence of body fat distribution and weight loss.

Plasma leptin concentrations were measured every 20 min for 24 h in eight normal weight women and in eight upper body and eight lower body obese women matched for body mass index. The circadian rhythm of leptin, which could mathematically be described by a cosine, was characterized by an acrophase just after midnight in all subjects. The amplitude of a cosine fit as well as the average 24-h leptin concentration were increased by 280% and 420%, respectively, in obese compared to normal weight women. All characteristics of leptin concentration profiles were similar in upper body and lower body obese women, except for a significantly higher amplitude in the lower body obese group. Visceral and sc body fat depots were measured using magnetic resonance imaging in all three groups. Average 24-h leptin concentrations were strongly correlated with sc fat (r = 0.84), whereas visceral fat was not an independent predictor of the plasma leptin level. A loss of 50% of the overweight was associated with a 55% decrease in the average 24-h leptin concentrations in obese women (95% confidence interval, 12.3, 26.6), whereas the characteristics of the circadian rhythm of leptin remained unchanged. Finally, it was observed that a fasting plasma leptin concentration is not an acceptable indicator of the average leptin concentration over 24 h.

Chemodectoma of the temporal bone: a comparison of surgical and radiotherapeutic results.

Between January 1950 and December 1981, 32 patients with chemodectomas of the temporal bone were treated at the University of Iowa Hospitals and Clinics. Thirteen patients were treated with surgery alone, 15 with radiation therapy alone, one with preoperative radiation therapy and surgery, and three with surgery and postoperative radiation therapy. In general, the patients treated with radiotherapy alone or combined therapy (radiotherapy group) had more advanced tumors than those treated with surgery alone (surgery group). For the surgery group, the initial local control rate was 46% and the ultimate local control rate 84% following salvage with additional surgery, 31% developed complications, and 78% survived 10 years. For the radiotherapy group, 84% had local tumor control, 11% developed complications, and 77% survived 10 years. These results demonstrate that radiation therapy is an effective treatment modality for chemodectomas of the temporal bone.

Analysis of movement of intrathoracic neoplasms using ultrafast computerized tomography.

Twenty patients with intrathoracic neoplasms were evaluated with ultrafast (cine) computerized tomography to determine the contribution of tumor motion to geographic errors. The treatment portals were setup with conventional simulation techniques and then scanned with cine computerized tomography. Eight tomographic levels were studied, 10 images per level over 7 seconds time. Major geographic misses were detected in three patients (15%), and minor geographic misses in an additional three (15%). The greatest tumor movement was noted in lesions located adjacent to the heart or aorta or near the diaphragm. Five of six hilar lesions showed significant lateral motion (average = 9.2 mm) with cardiac contraction, and three of four lower lobe lesions showed significant craniocaudal movement with respiration. Mediastinal lesions moved an average of 8.7 mm laterally. Lesions in the upper lobes showed minimal movement (average = 2.2 mm), and tumors attached to the chest wall showed no measurable movement.

The role of kilovoltage irradiation in the treatment of keloids.

This is a retrospective analysis of the results of kilovoltage irradiation given to prevent the regrowth of 203 keloids excised at the University of Iowa Hospitals and Clinics, Iowa City, Iowa, Lutheran Hospital in Moline, Illinois, and Mercy Hospital in Cedar Rapids, Iowa. We found that a minimum follow-up of 1 year is needed to evaluate the results of post-excisional kilovoltage x-ray therapy. A dose versus response effect was also observed. Although it is desirable to use the lowest possible dose of radiation that is likely to be effective, the likelihood of failure is too great to justify the routine use of doses of less than 900 cGy regardless of how they are fractionated or when they are given. It appears that the total dose of irradiation that is given to prevent the regrowth of an excised keloid is more important than when irradiation is started, the size of the largest fraction given, whether the irradiation is completed in 1 week or 3, or where the keloid has grown. When a small number of keloids were irradiated less than 1 year after they first appeared greater than or equal to 1500 cGy were sufficient to control 90% of them without re-excision.

Preliminary results of a pilot study of pentoxifylline in the treatment of late radiation soft tissue necrosis.

Between September 1988 and August 1989, 12 patients with 15 sites of late radiation necrosis of the soft tissues were treated with pentoxifylline, a hemorrheologic agent that has been used to treat a variety of vasculo-occlusive disorders. Four of these necroses were located in the oromucosa, four in the mucosa of the female genitalia, and seven in the skin. At the time of analysis, 87% (13/15) of the necroses had healed completely, and one was partially healed. Furthermore, the time-course of healing with pentoxifylline was significantly less than the duration of nonhealing prior to pentoxifylline (average: 9 weeks vs 30 1/2 weeks). All patients had pain relief. These results indicate that pentoxifylline can contribute to the healing of soft tissue radiation necrosis. They also support the concept that late radiation injury in skin and mucosa is at least partly due to vascular injury.

Extended field irradiation for carcinoma of the uterine cervix with positive periaortic nodes.

Forty-three patients were treated with extended field irradiation for periaortic metastasis from carcinoma of the uterine cervix (FIGO stages IB-IV). Twelve patients (28%) remained continuously free of disease to the time of analysis or death from intercurrent disease, 20 (46%) had persistent cancer within the pelvis, 11 (26%) had persistent periaortic disease, and 23 (53%) developed distant metastasis. The actuarial 5-year survival rate was 32%. The results correlated well with the periaortic tumor burden at the time of irradiation. None of 19 patients (0%) with microscopic or small (less than 2 cm) periaortic disease had periaortic failures, compared to 29% (4/14) of those with moderate-sized (2-5 cm) disease and 70% (7/10) of those with massive (greater than 5 cm) periaortic metastasis. Similarly, the 5-year survival rates were 50% (6/12) with microscopic disease, 33% (2/6) with small gross disease, 23% (3/13) with moderate-sized disease, and 0% (0/10) with massive periaortic metastases. Only 10% (1/10) of patients whose tumor extended to the L1-2 level survived 5 years, compared with 31% (9/29) of those whose disease extended no higher than the L3-4 level. The periaortic failure rates correlated to some extent with the dose delivered through extended fields, although the difference was not statistically significant. Only 8% (1/13) of those who had undergone extraperitoneal lymphadenectomies developed small bowel complications, compared with 25% (7/29) of those who had had transperitoneal lymphadenectomies. The incidence of small bowel obstruction was 8% (1/13) following periaortic doses of 4000-4500 cGy, 10% (1/10) after 5000 cGy, and 32% (6/19) after approximately 5500 cGy. From this, we concluded that the subset of patients who would benefit most from extended field irradiation are those in whom the residual disease in the periaortic area measures less than 2 cm in size at the time of treatment, whose disease extends no higher than L3, and whose cancer within the pelvis has a reasonable chance of control with standard radiation therapy techniques.

A comparison of the roles of surgery and radiation therapy in the management of craniopharyngiomas.

Fifty-two patients with craniopharyngioma were seen between January 1961 and July 1986. Of these, 40 were treated with surgery alone, 8 with surgery and postoperative radiotherapy, and 3 with radiotherapy alone. One patient received no treatment. For the group treated with surgery alone, 33% (13/40) had local tumor control, 42.5% (17/40) developed major complications, and 71% (25/35) survived 5 years. With surgery and postoperative radiotherapy, 100% (8/8) had local tumor control, 25% (2/8) developed major complications, and 100% (7/7) survived 5 years. Two of the three patients treated with radiotherapy alone had local tumor control and the third was salvaged with surgery. The "complete resection" rate for 32 patients treated with radical surgery was 63% (20/32). Tumor control was achieved in 50% (10/20) of the patients treated with "complete resection" without radiotherapy, in 15% (3/20) of the patients treated with "incomplete resection" without radiotherapy, and in 100% (8/8) of the patients treated with "incomplete resection" and postoperative radiotherapy. In this series, doses of 5000-5500 cGy were as effective in achieving control as 5500-6000 or 6000-7000 cGy.

A comparison of the roles of surgery and radiation therapy in the management of carcinoma of the female urethra.

Between 1939 and 1986, 42 patients with carcinoma of the female urethra were treated with surgery and/or radiation therapy at the University of Iowa. Ten patients were treated with surgery alone, 28 with radiation therapy alone, and 4 with combined surgery and radiation therapy. Seventeen patients (40%) developed persistent or recurrent disease at the primary site and 15 (36%) had failures in the inguinal nodes. The actuarial 5-year survival rate was 33.5%. Only 36% (10/28) of patients treated with radiation therapy had local failures, compared to 60% (6/10) of those treated with surgery alone. The best results were achieved with combined interstitial and external beam irradiation. Whereas 57% (8/14) of patients who were treated with combined interstitial and external beam irradiation were alive NED at 3 years, none of 7 patients (0%) treated with interstitial implants only and 2 of 7 patients (29%) treated with external beam irradiation alone were alive NED at 3 years. There was a significantly lower inguinal failure rate in patients who received treatment to the inguinal nodes (10%) than in those who did not receive inguinal area treatment (52%), and this translated into a superior 5-year survival for those patients (60% vs 18%). Survival rates did not correlate with histopathologic type in this series, although there were differences in the patterns of failure. Survival rates did correlate well with clinical stage.

The role of radiation therapy in the management of ependymomas of the spinal cord.

Twenty patients with biopsy-proven ependymomas of the spinal cord were treated between 1960 and 1984-7 with surgery only, 3 with radiation therapy only, and 10 with surgery and postoperative radiation therapy. Of these, 2 patients developed recurrent tumor at the primary site, 3 developed a recurrent tumor in the thecal sac, and 1 developed distant metastasis. The absolute 5- and 10-year survival rates were 95% (19/20) and 86% (12/14), respectively. None of 13 patients who were treated with radiation therapy only or combined surgery and postoperative radiation therapy developed recurrent tumor at the primary site, and none of 7 patients who received thecal sac irradiation developed thecal sac recurrences. In contrast, 2 of 7 patients (29%) treated with surgery alone developed recurrent tumor at the primary site, and 3 of 13 patients (23%) who received no thecal sac irradiation developed a recurrent tumor in the thecal sac. The failure rates following surgery were greatest in patients who had tumor removed in a piecemeal fashion (43%, 6/14). The results show that radiation therapy is probably not necessary if the tumor has been removed completely in an en bloc fashion. However, radiation therapy is needed if the tumor has been incompletely removed or removed in a piecemeal fashion. If the tumor has been removed in a piecemeal fashion, the radiation portals should be extended to include the thecal sac. Histologic subtypes influenced the pattern of recurrence. Myxopapillary ependymomas and high grade cellular ependymomas appear to be more likely to recur in the thecal sac. However, no big difference could be detected in local recurrence.

Usefulness of tumor volumetry by magnetic resonance imaging in assessing response to radiation therapy in carcinoma of the uterine cervix.

PURPOSE: Clinical evaluation of tumor size in cervical cancer is often difficult, and clinical signs of radiation therapy failure may not be present until well after completion of treatment. The purpose of this study is to investigate early indicators of treatment response using magnetic resonance (MR) imaging for quantitative assessment of tumor volume and tumor regression rate before, during, and after radiation therapy. METHODS AND MATERIALS: Thirty-four patients with cervical cancer Stages IB [5], IIB [8], IIIA [1], IIIB [14], IVA [3], IVB [1], and recurrent [2] were studied prospectively with four serial MR examinations obtained at the start of radiation therapy, at 2-2.5 weeks (20-24 Gy), at 4-5 weeks (40-50 Gy), and 1-2 months after treatment completion. Tumor volume was assessed by three-dimensional volumetric measurements using T2-weighted images of each MR examination. The volume regression rate was generated based on the four sequential MR studies. These findings were correlated with local control, metastasis rate, and disease-free survival. Median follow-up was 18 months (range: 9-43 months). RESULTS: The tumor regression rate after a dose of 40-50 Gy correlated significantly with treatment outcome. The actuarial 2-year disease-free survival was 88.4% in patients with tumors regressing to < 20% of the initial volume compared with 45.4% in those with > or = 20% residual (p = 0.007). The incidence of local recurrence was 9.5% (2 out of 21) and 76.9% (10 out of 13), respectively (p < 0.001). Analysis by initial tumor volume showed that this observation was valid in patients with initial volumes between 40 and 100 cm3. Analysis by FIGO stage confirmed this observation in all patients except those with Stage IB. CONCLUSION: Sequential tumor volumetry using MR imaging appears to be a sensitive measure of the responsiveness of cervical cancer to irradiation. Treatment response can be assessed as early as during the course of radiation therapy by measurement of initial tumor volume and regression rate at 40-50 Gy. In patients with large (> 40 cm3) and advanced (Stage > or = IIIA) tumors, this technique may be helpful in supplementing the clinical examination for response assessment. The identification of patients at high risk for treatment failure may ultimately lead to improved clinical outcome.

Value of fast gradient echo magnetic resonance angiography as an adjunct to coronary arteriography in detecting and confirming the course of clinically significant coronary artery anomalies.

We investigated the additional value of magnetic resonance (MR) angiography in 12 patients with clinically significant coronary anomalies. In 5 patients, the referring cardiologist requested additional evaluation because coronary arteriography was inconclusive about the course of the anomaly. For comparison, 7 patients with known anomalous coronary arteries were collected from our database. In these patients, there had been no doubt about the course of the anomalous coronary arteries. MR angiography provided the diagnosis in all 5 patients in whom the diagnosis was inconclusive beforehand. From the 7 patients in whom diagnosis had been established previously by contrast arteriography, the anomaly was confirmed in 5 by MR angiography. In 1 patient, the initial diagnosis at contrast arteriography had to be changed as a result of MR angiography. In 1 patient, the MR image was of insufficient quality to be conclusive. In conclusion, in patients with angiographically suspected coronary anomalies, fast gradient echo MR angiography is a helpful adjunct to coronary arteriography in identifying and confirming the origin and course of clinically significant coronary anomalies. The additional value of fast gradient echo MR coronary angiography is the visualization of both the artery and its surrounding structures.

The role of radiation therapy in the treatment of solitary plasmacytomas.

Between 1960 and 1985, 30 patients with solitary plasmacytomas were treated with radiotherapy at the University of Iowa: 13 patients with extramedullary plasmacytomas (EMP) and 17 with solitary plasmacytomas of bone (SPB). The local control rates were 92% for patients with EMP and 88% for those with SPB. Two of nine patients (22%) with EMP treated to the primary tumor only developed regional lymph node metastasis, indicating the need for elective irradiation of this area. The most common pattern of failure in both groups was progression to multiple myeloma. This occurred in 23% of the patients with EMP and 53% of those with SPB. The time course of progression to multiple myeloma differed for the two groups. All of those who progressed to multiple myeloma in the EMP group did so within 2 years, whereas a significant number of those in the SPB group progressed more than 5 years after initial therapy. None of five patients who received adjuvant chemotherapy in the SPB group progressed to multiple myeloma, compared to 75% (9/12) of the patients who did not receive chemotherapy.