Skin and bones: dermatologic conditions with skeletal abnormalities.

OBJECTIVE: Radiologists should be aware of the fact that many dermatologic conditions have associated skeletal abnormalities. This pictorial essay seeks to acquaint radiologists with these associations. DESIGN: Twenty-four skin and bone conditions are portrayed and discussed under the headings of: disorders of the epidermis, disorders of the dermis, disorders of the sebaceous glands, disorders of pigmentation, disorders of the nails, tumors, the phakomatoses, immunologic-allergic disorders, and infections. In addition, a table is provided as an expanded listing of conditions with such associations. CONCLUSION: This pictorial essay will help radiologists and other practitioners become familiar with dermatologic conditions that have associated skeletal abnormalities.

Lumbosacral agenesis: clinical characteristics, imaging, and embryogenesis.

We report 5 cases of complete, or nearly complete, agenesis of the lumbar and sacral spine. In 1 case pregnancy was terminated at 23 weeks of gestation, and the others were livebirths. The surviving 4 patients were all infants of diabetic mothers. Imperforate anus was present in 2 of 4 liveborn patients and was suspected in the abortus. All liveborn cases were paraplegic, and all exhibited the 'Buddha' deformity of the lower extremities. One patient had congenital obstructive hydrocephalus, probably representing a variant of holoprosencephaly, requiring a ventriculoperitoneal shunt. No other nervous system anomaly was identified in any patient, and the other patients are showing normal cognitive development. We propose that these patients have defects which occurred during germ cell formation (i.e., during gastrulation), with interruption of the primitive streak resulting in combined failure of primary and secondary neurulation.

Sonographic detection of hematomas and fluid after imaging guided core breast biopsy.

We investigated sonographic changes to the breast after imaging guided core breast biopsy. We studied 31 breast lesions in 29 patients before, immediately after, and 2 to 9 days after core biopsy looking for hematomas. We found sonographic changes to the breast consistent with fluid collections after core biopsy in seven of 31 breast lesions (23%). Of the biopsy sites with sonographic changes, evidence suggested that six of 31 (19%) likely had hematomas. Sonographic changes after core breast biopsy are common and the formation rate of suspected hematomas is greater than previously believed although generally not clinically significant.

Use of ultrasound to guide radiation boost planning following lumpectomy for carcinoma of the breast.

PURPOSE: To determine if sonographic localization of the breast lumpectomy site is feasible and useful in boost planning. METHODS AND MATERIALS: The operative beds following lumpectomy were localized by ultrasound in 22 patients (15-infiltrating ductal, 7-ductal carcinoma in situ; size: .4-2.0 cm). Twelve patients had two ultrasound examinations on different days for a total of 34 examinations. Twenty-one patients had their course of boost electron therapy planned using ultrasound to guide field placement. While the patient was in the treatment position, the surgical scar was placed at the machine's isocenter. With the electron cone in place, the ultrasound transducer was placed within the cone on top of the surgical scar. The biopsy site was localized and the light field maneuvered so that it's central axis would follow the axis of the transducer, transecting both the scar and biopsy site. RESULTS: The operative bed was highly visible in 26 ultrasound examinations, visible in 7, and subtly visible in 1. Every biopsy site showed some hypoechoic area but most appeared as the mixed hypoechoic pattern. Ultrasound appearances were mixed or mostly hypoechoic (28), anechoic with irregular walls (4), and echoic (hypoechoic compared to parenchyma) (2). In two cases the surgeon placed surgical clips in the operative bed, and in both cases several of these clips could be identified at the margins of the operative bed as hyperechoic foci with shadowing. The mean depth of the operative bed was 21 mm (range 17-36 mm). In 12 patients, two ultrasound examinations were performed on different days, and the mean depth difference between these scans was 2 mm with a range of 0-5 mm. Among patients with two scans we found that both the location and appearance of the operative bed was highly reproducible. CONCLUSION: Ultrasound can successfully be used to localize the biopsy site and facilitate boost field placement in patients treated with lumpectomy and radiation.

Diagnosis of bowel obstruction on plain abdominal radiographs: significance of air-fluid levels at different heights in the same loop of bowel.

OBJECTIVE: Differential air-fluid levels are two distinct air-fluid interfaces on horizontal-beam abdominal radiographs that are at different heights but within the same loop of bowel. Differential air-fluid levels have been considered by many to be strong evidence of mechanical bowel obstruction, but others have found this sign unreliable for differentiating mechanical from adynamic obstructions. Neither opinion is supported by evidence from large series of patients. Accordingly, we determined the efficacy of differential air-fluid levels for distinguishing mechanical from adynamic bowel obstruction. MATERIALS AND METHODS: We identified patients who had a total of 62 episodes of proved mechanical bowel obstruction and 38 episodes of adynamic obstruction through a computer search of medical records and radiographic files. On horizontal-beam abdominal radiographs of these patients, the presence and height of intestinal differential air-fluid levels were determined by the consensus of two experienced radiologists. These data were then statistically analyzed to determine the usefulness of differential air-fluid levels for distinguishing between mechanical and adynamic bowel obstructions. RESULTS: Plain films showed differential air-fluid levels in 32 (52%) of the 62 episodes of mechanical obstructions compared with 11 (29%) of the 38 adynamic obstructions, giving a sensitivity for mechanical obstruction of 0.52 and a specificity of 0.71. As the minimum significant height of differential air-fluid levels increased, specificity increased and sensitivity decreased. The positive predictive value also increased as differential air-fluid level heights increased, reaching a level of 0.86 or greater at 20 mm. CONCLUSION: The presence of differential air-fluid levels is an insensitive method of determining if a bowel obstruction is mechanical, because only a small proportion of mechanical obstructions have differential air-fluid levels. In our population of patients, however, a differential air-fluid level of 20 mm or greater was moderately suggestive that a bowel obstruction was mechanical in nature.

Imaging of the expanded polytetrafluoroethylene prosthetic diaphragm following extrapleural pneumonectomy for mesothelioma.

Extrapleural pneumonectomy, which usually requires placement of a prosthetic hemidiaphragm, can be offered to approximately 24% of patients with malignant mesothelioma. Expanded polytetrafluoroethylene (Gore-Tex) has superior physical characteristics for diaphragmatic grafting and is the material of choice at the authors' institutions. This article describes conventional radiography and computed tomography findings in three patients who underwent extrapleural pneumonectomy. A freshly placed Gore-Tex prosthetic diaphragm appears as a radiolucent crescent-shaped band at the inferior border of the hemithorax and could be confused with a pneumoperitoneum. With time, the lucent crescent becomes thinner and eventually becomes radiopaque; it may be confused with a calcified diaphragm.

Endocrine activation and altered muscle metabolism after hemorrhagic shock.

Studies were conducted to examine glucose and amino acid metabolism by skeletal muscle isolated from rhesus monkeys before and sequentially after an episode of resuscitated hemorrhagic shock. After shock and reinfusion, the tissue exhibited decreased effect of insulin on glucose utilization increased leucine oxidation, and a reduced rate of leucine incorporation into protein. These changes were observed 15 min after reinfusion and persisted in part for at least 3 days. All of the observed abnormalities were more pronounced 24 h after shock and reinfusion than 15 min after and returned to normal by 2-4 wk. The shock-induced metabolic abnormalities in skeletal muscle occurred in spite of prevention of shock-induced adrenal steroid and catecholamine secretion and of changes in blood insulin concentration using adrenalectomized-streptozotocin diabetic monkeys receiving replacement cortisol and insulin infusions. This study thus demonstrated that hemorrhagic shock in rhesus monkeys was followed by insulin resistance plus abnormalities of glucose and amino acid metabolism by skeletal muscle that were not dependent on the concurrent changes in plasma levels of adrenal steroids or catecholamines or on altered circulating insulin levels associated with shock.