The biography of Mary E. O'Sullivan: an early American headache specialist.

The aim of this study was to review the life of Mary E. O'Sullivan and to summarize her important contributions to the study of migraine. Mary E. O'Sullivan underwent extensive training to become a neurologist at a time when only 5% of women in America were physicians. She published five papers on migraine. In a 1936 Journal of the American Medical Association article, she described a patient with ergotamine overuse headache and recommended that daily doses of oral ergotamine should be avoided. Three years later she described migraine as a 'complex' syndrome with multiple causes and multiple cures. Mary E. O'Sullivan, an ambitious female headache specialist of the 1930s, was an early advocate of the use of ergotamine to treat migraine, yet she was one of the first to report ergotamine overuse headache. Although her life was short, her research, knowledge and ambition at a time when women had limited opportunities in medicine have left a mark.

Use of subcutaneous venous access ports to treat refractory ascites.

To assess the feasibility of peritoneal ports for management of patients with cirrhotic refractory ascites, 10 ports were placed in nine patients for frequent outpatient paracentesis. Retrospective review and telephone interviews were used to assess port performance. Kaplan-Meier analysis revealed a median duration of port patency of 255 days. In 1,557 port days, four access problems prompted further interventional evaluation. Three cases of bacterial peritonitis and one catheter obstruction developed. The use of subcutaneous venous access ports to allow control of ascites by nursing personnel is a promising alternative for management of patients with refractory ascites. Additional studies are needed to determine long-term effectiveness and safety.

Evaluation of bone contusions with fat-saturated fast spin-echo proton-density magnetic resonance imaging.

OBJECTIVE: To evaluate the efficacy of fast spin-echo proton-density magnetic resonance imaging (MRI) with fat saturation sequences in the evaluation of bone contusions at the knee. METHODS: Analysis of 46 consecutive knee MRI examinations performed on patients referred from a sports medicine clinic after knee trauma. All examinations included coronal fast spin-echo proton-density fat saturation, fast spin-echo proton-density and fast spin-echo T2-weighted sequences. All 3 coronal sequences were blindly reviewed independently of each other by 3 experienced musculoskeletal radiologists to identify and grade bone contusions. RESULTS: Thirty-five bone contusions were identified in 24 patients. All bone contusions were identified on fast spin-echo proton-density fat saturation sequences, which was significantly greater than the percentage identified on either fast spin-echo T2-weighted sequences (21/35, 60%, p < 0.001) or fast spin-echo proton-density sequences (10/35, 29%, p < 0.001). Fourteen (40%) of the contusions were identified only on the fast spin-echo proton-density fat saturation sequences. The average grade of contusion for all 35 examinations was also significantly higher on the fast spin-echo proton-density fat saturation sequences than on the fast spin-echo proton-density and fast spin-echo T2-weighted sequences (p < 0.05). CONCLUSION: Fast spin-echo proton-density fat saturation sequences are more sensitive in the detection of bone contusions than fast spin-echo proton-density and fast spin-echo T2-weighted sequences. Assessment of other structures in the knee with fast spin-echo proton-density fat saturation MRI provides good spatial resolution and adequate T2-weighted information. It may have advantages over the more heavily T2-weighted fast spin-echo T2 fat saturation and inversion recovery sequences.

Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging.

Congenital tarsal coalition is a diagnosis that is often overlooked in young patients who first present with foot and ankle pain. Calcaneonavicular and talocalcaneal coalitions are encountered most frequently; fusion at other sites is much less common. Tarsal coalitions may be osseous, cartilaginous, or fibrous. Calcaneonavicular coalitions are readily detected on oblique radiographs. Radiographic confirmation of talocalcaneal coalition is more difficult than for fusion at other locations, although several secondary radiographic signs may indirectly suggest the diagnosis. Computed tomography (CT) and magnetic resonance (MR) imaging are invaluable for assessment of tarsal coalitions because they allow differentiation of osseous from nonosseous coalitions and because they depict the extent of joint involvement as well as secondary degenerative changes, features of vital importance in surgical planning. Short-inversion-time inversion recovery MR images may reveal bone marrow edema along the margins of the abnormal articulation, an important clue to the diagnosis. Moreover, CT or MR imaging may be required to confirm the diagnosis of talocalcaneal coalition when radiographic findings are equivocal. Because the diagnosis of tarsal coalition is often not entertained by the clinician ordering a CT or MR imaging examination, multiplanar imaging of the ankle and hindfoot is required.

Improvement of radiologists' characterization of mammographic masses by using computer-aided diagnosis: an ROC study.

PURPOSE: To evaluate the effects of computer-aided diagnosis (CAD) on radiologists' classification of malignant and benign masses seen on mammograms. MATERIALS AND METHODS: The authors previously developed an automated computer program for estimation of the relative malignancy rating of masses. In the present study, the authors conducted observer performance experiments with receiver operating characteristic (ROC) methodology to evaluate the effects of computer estimates on radiologists' confidence ratings. Six radiologists assessed biopsy-proved masses with and without CAD. Two experiments, one with a single view and the other with two views, were conducted. The classification accuracy was quantified by using the area under the ROC curve, Az. RESULTS: For the reading of 238 images, the Az value for the computer classifier was 0.92. The radiologists' Az values ranged from 0.79 to 0.92 without CAD and improved to 0.87-0.96 with CAD. For the reading of a subset of 76 paired views, the radiologists' Az values ranged from 0.88 to 0.95 without CAD and improved to 0.93-0.97 with CAD. Improvements in the reading of the two sets of images were statistically significant (P = .022 and .007, respectively). An improved positive predictive value as a function of the false-negative fraction was predicted from the improved ROC curves. CONCLUSION: CAD may be useful for assisting radiologists in classification of masses and thereby potentially help reduce unnecessary biopsies.

Complications in Paget disease at MR imaging.

PURPOSE: To determine the MR imaging findings in patients with complications of Paget disease of bone. MATERIALS AND METHODS: Of 45 patients with Paget disease who underwent MR imaging, 33 (26 men, seven women; age range, 64-91 years) with known complications of the disease were examined. Imaging in this subgroup included radiography (n = 26), computed tomography (n = 12), bone scintigraphy (n = 15), and magnetic resonance (MR) imaging (n = 33). Patients were examined specifically for musculoskeletal and neurologic complications of Paget disease, including fracture, basilar impression, spinal stenosis, bone tumor, and osteoarthrosis. RESULTS: The 56 complications documented in the 33 patients were fracture (n = 17), neurologic entrapment (n = 19), neoplasm (n = 9), and arthropathy (n = 11). MR imaging was beneficial in the diagnostic evaluation of basilar impression (n = 7), spinal stenosis (n = 12), and the tumor stage (n = 9). It also helped to successfully evaluate pagetic bone narrowing of the coracoacromial arch, which was associated with impingement syndrome and rotator cuff rupture (n = 2). The signal intensities in pagetic bone were most commonly similar to those in fat; this finding had a 100% negative predictive value in excluding neoplasm. CONCLUSION: Although Paget disease is diagnosed economically with conventional radiography, MR imaging is well suited for demonstrating the presence and extent of several characteristic disease complications, including basilar impression, spinal stenosis, and secondary neoplasm.

Identification of SV40 in brain, kidney and urine of healthy and SIV-infected rhesus monkeys.

Recent reports of simian virus 40 (SV40) sequences in human tumors have prompted investigations into the poorly understood association of this polyomavirus with its primate host, the rhesus monkey (Macaca mulatta). In the present study we have used PCR to analyze tissues from 20 monkeys for the presence of SV40. Five of the animals, which were infected with simian immunodeficiency virus (SIV), were found to exhibit SV40-induced lesions and to have SV40 sequences present in their kidney and brain. Lesions associated with SV40 were not observed in 15 SIV monkeys, and SV40 DNA was detected in kidney and urine of only one of these animals. Three regions of SV40 DNA were examined in each tissue: the non-coding transcriptional control region (TCR), the sequences encoding the host range domain (HRD) within the carboxy-terminus of T antigen (TAg), and a portion of the VP1 gene. Each region contained nucleotide alterations compared to the SV40 reference strain 776. In all six animals, the TCR had an archetype structure containing a single 72 bp enhancer element. In addition, the TCR amplified from two animals lacked one of three copies of a GC-rich 21 bp repeat which is part of the promoter in strain 776. Multiple clones of unique HRD sequences were derived from different animals, and in some instances from the same animal. No correlation was found between a particular HRD sequence and its presence in a specific tissue type. Nucleotide changes identified within the VP1 gene indicate that this region, as with the closely-related human polyomavirus JCV, may permit the typing of the virus into individual strains. This study is the first to characterize SV40 sequences present in both healthy and SIV-infected animals and supports the suggestion that strain 776 is not the predominant type of SV40 circulating in its natural host.

Power Doppler sonography in tenosynovitis: significance of the peritendinous hypoechoic rim.

The aim of this study was to evaluate the ability of power Doppler sonography to distinguish between hypoechoic fluid and synovium in patients with suspected tenosynovitis. Gray scale sonography and power Doppler sonography were performed on 26 tendons in 24 patients with tenosynovitis and 30 tendons in five asymptomatic volunteers. Peritendinous blood flow was graded on a scale of 0 to 3 and the percentage of the hypoechoic rim that contained blood flow was also noted. In the symptomatic group, flow was demonstrated in more than 50% of the peritendinous hypoechoic rim in 17 of 26 tendons. A positive correlation was found between the power Doppler sonographic grade and the percentage of the rim that had flow. These results suggest that a significant proportion of the hypoechoic rim probably represents vascularized synovium rather than complex fluid.

Extraskeletal mesenchymal chondrosarcoma of the rectus sheath.

Mesenchymal chondrosarcomas (MSCs) are a rare form of chondrosarcoma which usually arise in bone. Extraskeletal chondrosarcomas constitute a minority (14-25%) of MSCs. We describe the imaging features of an extraskeletal mesenchymal chondrosarcoma that arose from the rectus abdominus muscle.

Power Doppler sonography: use in measuring alterations in muscle blood volume after exercise.

OBJECTIVE: The purpose of this study was to show the ability of power Doppler sonography (PDS) to evaluate exercise-induced changes in muscle blood volume. SUBJECTS AND METHODS: We evaluated 20 biceps muscles with PDS in 10 healthy volunteers before and after they underwent a standardized exercise protocol. Intramuscular blood volume was qualitatively analyzed using a subjective scoring system to evaluate vascular conspicuity, comparing sonograms obtained before and after exercise. We also collected preliminary data on the quantification of estimated fractional moving blood volume (EFMBV) measured on sonograms obtained in eight biceps muscles of five volunteers. Assessment of significance was calculated using a Wilcoxon signed-rank correlation of significance. The stability of relative changes in EFMBV was also assessed with measurements performed at three different times in five healthy volunteers. RESULTS: With exercise, all 20 biceps muscles showed a significant subjective increase in apparent vascularity (p < .0005). Likewise, preliminary data on EFMBV showed significant increases (p < .01) between baseline and peak exercise values (mean, 470%; range, 180-900%). CONCLUSION: PDS revealed marked increases in intramuscular vascular conspicuity after exercise. EFMBV provided a potentially useful parameter to document such increases quantitatively.

Power Doppler sonography in the assessment of musculoskeletal fluid collections.

OBJECTIVE: Power Doppler sonography is a relatively new technique that has been shown to depict hyperemia associated with musculoskeletal inflammatory disease. We performed this study to evaluate the ability of power Doppler sonography to differentiate musculoskeletal fluid collections of varying etiologies. SUBJECTS AND METHODS: Gray-scale and power Doppler sonography were performed on 39 patients with joint effusions or appendicular fluid collections. Blood flow (hyperemia) in the soft tissues adjacent to the fluid collections was subjectively analyzed and graded on a scale of 1 to 4 (1, normal flow; 2-4, increasing degrees of hyperemia). All fluid collections were aspirated within 24 hr of the sonographic examination. We found 31 joint effusions and 12 periarticular collections with appropriate imaging and pathologic correlation. RESULTS: Adjacent to 36 effusions and fluid collections, we saw moderate or marked hyperemia. Thirty-five of the 36 had an inflammatory or neoplastic cause, including 15 infected collections. One fluid collection had a degenerative etiology (subdeltoid bursitis secondary to supraspinatus tendon tear). Adjacent to the seven remaining effusions and fluid collections, we saw normal or mildly increased hyperemia; none of these collections had an inflammatory etiology. CONCLUSION: Power Doppler sonography helps distinguish inflammatory and infectious musculoskeletal fluid collections from those that are noninflammatory, and it may help guide the decision to perform diagnostic aspiration. Power Doppler sonography does not reliably differentiate between inflammatory collections of infectious and noninfectious origin because collections of either origin may significantly increase adjacent soft-tissue perfusion.

Power Doppler sonography of synovitis: assessment of therapeutic response--preliminary observations.

Power Doppler sonography was used in eight symptomatic knees in seven patients with arthritis before and after joint aspiration and intraarticular administration of steroids. A qualitative decrease in synovial perfusion was observed in all eight knees, and symptoms improved in seven of the eight cases. These preliminary data suggest a role for power Doppler sonography in assessment of serial changes in synovial inflammation.

Prostate cancer: diagnosis with color Doppler sonography with histologic correlation of each biopsy site.

PURPOSE: To correlate the findings at prostate color Doppler sonography (CDS) with those of site-specific transrectal core biopsy. MATERIALS AND METHODS: Forty-three patients underwent prostate transrectal ultrasonography (US) and biopsy. CDS was performed at all biopsy sites before US-guided core biopsy. Vascularity at CDS was prospectively graded on a scale of 0-2 (0 = no visible peripheral zone [PZ] flow, 2 = markedly increased PZ vascularity). CDS results were correlated with histologic findings from 220 separate biopsy sites that included 27 focal lesions. RESULTS: Of 34 grade 2 biopsy sites, 21 revealed carcinoma, eight revealed prostatitis, and five were negative. CDS depicted at least one focus of carcinoma in seven patients with no gray-scale abnormality. CDS had a sensitivity of 49%, specificity of 93%, and positive predictive value of 62%. CONCLUSION: Focal PZ hypervascularity at CDS is associated with an increased likelihood of prostate cancer or inflammation at biopsy, often without a focal gray-scale abnormality. CDS may help identify an appropriate site for biopsy. A negative CDS scan, however, should not preclude biopsy, as CDS has a limited sensitivity in the detection of all sites of cancer.

The surgical management of intra-abdominal inflammatory conditions during pregnancy.

The timely diagnosis and treatment of intra-abdominal conditions during pregnancy can challenge the surgical consultant. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk by trimester. The general surgeon will be called upon to diagnose and treat appendicitis, biliary tract disease (including pancreatitis), and liver disease. Knowledge of how these conditions become manifest is essential. The surgical consultant should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process.

The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy.

OBJECTIVE: Our purpose was to evaluate the location of the major blood vessels of the abdominal wall relative to landmarks apparent at laparoscopy. STUDY DESIGN: Abdominal computed tomographic images of 21 reproductive-aged women at an academic center were retrospectively reviewed to determine the location of the inferior epigastric, superficial epigastric, and superficial circumflex iliac arteries and the lateral rectus muscle margins in relation to the symphysis pubis, the umbilicus, and the abdominal midline. These locations were correlated with each other and with body mass index using Pearson's correlation coefficient. RESULTS: Above the symphysis the inferior and superficial epigastric arteries were 5.6 +/- 1.0 cm (mean +/- SD) and 5.5 +/- 2.0 cm from the midline, respectively. Although the location of these two vessels correlated (r = 0.6, p = 0.02), the mean difference in their location was 1.4 +/- 1.1 cm. Near the level of the umbilicus the superficial epigastric and circumflex iliac arteries and the lateral rectus muscle margin were 4.6 +/- 1.4 cm, 10.7 +/- 1.7 cm, and 7.6 +/- 1.5 from the midline, respectively. Only the lateral rectus muscle margin correlated with body mass index (r = 0.65, p = 0.004). CONCLUSION: When laparoscopic landmarks are not visible to guide placement, lateral trocars should be placed approximately 8 cm from the midline and at least 5 cm above the symphysis to minimize the risk of vessel injury.

Detection of soft-tissue hyperemia: value of power Doppler sonography.

OBJECTIVE: Power Doppler sonography is a new technique that offers extended dynamic range over that provided by conventional color Doppler imaging, thereby facilitating measurement of tissue perfusion. We evaluated the efficacy of power Doppler sonography in depicting soft-tissue hyperemia in musculoskeletal inflammatory conditions. SUBJECTS AND METHODS: Twenty-three patients with predominantly unifocal musculoskeletal symptoms were evaluated with conventional gray-scale imaging and power Doppler sonography. The shoulder was evaluated in 14 patients, the elbow in three, and various other sites in six. For comparison purposes, the contralateral asymptomatic joint or site was examined in 17 cases. Fluid collections were aspirated in seven patients. RESULTS: Soft-tissue hyperemia was seen on power Doppler sonograms at the symptomatic site(s) in 22 of 23 cases studied, with an appearance ranging from frank tissue blush to large, isolated peritendinous/peribursal vessels. Findings associated with hyperemia included rotator cuff tendinitis and/or tear, bursitis, and symptomatic wrist ganglia. Findings on power Doppler sonograms were normal in one patient who had a small, sterile hip joint effusion, and findings on subsequent scintigrams, pelvic radiographs, and CT scans were normal. CONCLUSION: Power Doppler sonography consistently shows hyperperfusion associated with musculoskeletal inflammatory disease. As such, it represents a useful adjunct to gray-scale sonography in these settings, particularly as findings on conventional sonograms in inflammatory conditions can be nonspecific.