Systemic sarcoidosis presenting as complete heart block in a patient with normal chest radiography.

A previously healthy 44-year-old Caucasian man presented with recurrent syncope and was found to have a complete heart block with a ventricular rate of 24 bpm. No biochemical abnormalities were identified. Tick borne illnesses were ruled out. Paced echocardiogram revealed left ventricular systolic dysfunction with septal hypokinesis. Chest radiography and subsequent CT scan did not reveal adenopathy. However, a positron emission tomography scan demonstrated increased fluorodeoxyglucose uptake in the spleen, a right retro-clavicular lymph node, right ventricle and the interventricular septum of the heart. Excision biopsy of the retro-clavicular lymph node revealed non-caseating granulomas consistent with sarcoidosis. Complete heart block persisted despite steroid treatment. A pacemaker/biventricular implantable cardioverter defibrillator was placed for complete heart block and primary prevention of ventricular tachycardia and sudden cardiac death.

Portable CT imaging of acute stroke patients in the emergency department.

A study was performed to determine whether the use of a portable CT scanner dedicated for ED patients would reduce the time elapsed from the physician's request for CT imaging until the start time of the study. The portable scanner allowsfor more rapid assessment of stroke patients and does not require additional facilities or personnel. In addition, when not in use in the ED, the scanner couldbe transported elsewhere in the hospital, for example the ICU, and be available for alternative clinical applications. For most hospitals, it is not neccessary to invest in an additional CT scanner dedicated for stroke imaging in the ED unless demand for the scanner exceeds 60 patients per day or, alternatively, the prevalence of stroke in the community served by the hospital is approximately 4-5 times the national average.

Atherosclerosis and matrix metalloproteinases: experimental molecular MR imaging in vivo.

PURPOSE: To evaluate the capability of P947, a magnetic resonance (MR) imaging contrast agent that molecularly targets matrix metalloproteinases (MMPs), to aid detection and imaging of MMPs in atherosclerotic lesions in vivo; its specificity compared with that of P1135; expression and distribution of MMPs in atherosclerotic vessels; and in vivo distribution and molecular localization of fluorescent europium (Eu) P947. MATERIALS AND METHODS: The Animal Care and Use Committee approved all experiments. P947 was synthesized by attaching a gadolinium chelate (1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid) to a peptide that specifically binds MMPs. Scrambled form of P947 (P1135) was synthesized by replacing the targeting moiety of P947 with a scrambled peptide lacking the ability to bind MMPs. P947, P1135, and gadoterate meglumine were injected into atherosclerotic apolipoprotein E-deficient and wild-type mice. The aortic MR imaging enhancement produced by the contrast agents was measured at different times and was compared by using one-way analysis of variance. MMP expression was investigated in the aortas by using MMP immunostaining and in situ MMP zymography. A fluorescent form of P947 (Eu-P947) was synthesized to compare the in vivo distribution of the contrast agent (Eu-P947) with specific MMP immunofluorescent staining. RESULTS: MMP-targeted P947 facilitated a 93% increase (P < .001) in MR image signal intensity (contrast-to-noise ratio [CNR], 17.7 compared with 7.7; P < .001) of atherosclerotic lesions in vivo. Nontargeted P1135 (scrambled P947) provided 33% MR image enhancement (CNR, 10.8), whereas gadoterate meglumine provided 5% (CNR, 6.9). Confocal laser scanning microscopy demonstrated colocalization between fluorescent Eu-P947 and MMPs in atherosclerotic plaques. Eu-P947 was particularly present in the fibrous cap region of plaques. CONCLUSION: P947 improved MR imaging for atherosclerosis through MMP-specific targeting. The results were validated and provide support for further assessment of P947 as a potential tool for the identification of unstable atherosclerosis.

The economic and clinical benefits of portable head/neck CT imaging in the intensive care unit.

* There is a 13% morbidity associated with transporting critically-ill patients outside of the ICU. The incidence of adverse events during transport specifically for CT imaging is as high as 71%. The objective of this study was to assess the feasibility and cost-effectiveness of a portable CT scanner designated to perform bedside imaging in the ICU. * A fully mobile 8-slice head/neck CT scanner was evaluated for efficiency and personnel allocation. The return-on-investment for the purchase of the portable scanner was calculated. * Data demonstrates that the introduction of a portable CT scanner in the ICU is feasible and cost-effective. At the Cleveland Clinic in Mayfield Heights, Ohio, the portable scanner provided a full return-on-investment within the first 6.9 months of its operation, an internal rate of return of 169%, and a 5 year expected economic benefit of $2,619,290.

Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair.

PURPOSE: To evaluate the utility of time-resolved MR angiography (TR-MRA), compared with digital subtraction angiography (DSA), in the classification of endoleaks in patients who have undergone endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Thirty-one patients who had undergone EVAR to repair an abdominal aortic aneurysm were evaluated with both TR-MRA and DSA to determine endoleak etiology. The patient population consisted of 26 men and 5 women with a mean age of 78.5 years (range, 55-93 years). The mean time interval between TR-MRA and DSA was 1.5 weeks (range, 1-8 weeks). Endoleaks were classified as type II when enhancement of the external iliac vessels was observed before the appearance of the endoleak; otherwise the endoleak was classified as type I or III. The results of TR-MRA classification were compared with the reference gold standard, DSA. RESULTS: Agreement between TR-MRA and DSA regarding endoleak classification occurred in 30 of 31 cases (97%). Discordant classification occurred in a case in which a Type II endoleak was misclassified as a Type III due to failure to visualize a lumbar vessel. CONCLUSION: TR-MRA is highly effective in classifying endoleaks following EVAR when compared with DSA.

Non-invasive MRI of mouse models of atherosclerosis.

Early detection and characterization of atherosclerotic lesions susceptible to sudden rupture and thrombosis may decrease morbidity and mortality. Plaque development has been extensively studied using MRI in animal models of rapidly progressing atherosclerosis. These transgenic mice develop atherosclerotic plaques in the aortic root by 10 weeks of age and throughout the vasculature thereafter. Transplantation of lesion-containing segments of the thoracic aorta into wild-type mice results in nearly total reversal of atherosclerosis, making it possible to study both progression and regression of plaques in this model. MRI permits the non-invasive accurate assessment of atherosclerotic plaque burden and the differentiation between the lipid and fibrous content of individual plaques, thus providing a non-invasive approach to serially monitor the evolution of individual plaques in the mouse models. Emergence of novel contrast agents that target a diverse set of molecules within the plaque are now helping to elucidate the changes at the cellular and molecular levels during plaque progression and regression.

Detecting and assessing macrophages in vivo to evaluate atherosclerosis noninvasively using molecular MRI.

We investigated the ability of targeted immunomicelles to detect and assess macrophages in atherosclerotic plaque using MRI in vivo. There is a large clinical need for a noninvasive tool to assess atherosclerosis from a molecular and cellular standpoint. Macrophages play a central role in atherosclerosis and are associated with plaques vulnerable to rupture. Therefore, macrophage scavenger receptor (MSR) was chosen as a target for molecular MRI. MSR-targeted immunomicelles, micelles, and gadolinium-diethyltriaminepentaacetic acid (DTPA) were tested in ApoE-/- and WT mice by using in vivo MRI. Confocal laser-scanning microscopy colocalization, macrophage immunostaining and MRI correlation, competitive inhibition, and various other analyses were performed. In vivo MRI revealed that at 24 h postinjection, immunomicelles provided a 79% increase in signal intensity of atherosclerotic aortas in ApoE-/- mice compared with only 34% using untargeted micelles and no enhancement using gadolinium-DTPA. Confocal laser-scanning microscopy revealed colocalization between fluorescent immunomicelles and macrophages in plaques. There was a strong correlation between macrophage content in atherosclerotic plaques and the matched in vivo MRI results as measured by the percent normalized enhancement ratio. Monoclonal antibodies to MSR were able to significantly hinder immunomicelles from providing contrast enhancement of atherosclerotic vessels in vivo. Immunomicelles provided excellent validated in vivo enhancement of atherosclerotic plaques. The enhancement seen is related to the macrophage content of the atherosclerotic vessel areas imaged. Immunomicelles may aid in the detection of high macrophage content associated with plaques vulnerable to rupture.

Renal transplant patient with polyoma virus bladder infection and subsequent polyoma virus nephropathy.

Polyoma virus nephropathy (PVN) is a significant cause of renal allograft dysfunction in transplant patients. A 58-year-old male received a cadaveric renal transplant and 12 weeks later presented with fever, diarrhea, and dysuria. He was diagnosed with a polyoma virus infection of the bladder by a transurethral bladder biopsy. One year post-transplant, he presented with renal allograft dysfunction and was diagnosed by biopsy with PVN of the non-native kidney. The diagnosis of a polyoma virus infection was confirmed by immunoreactivity to the polyoma T-antigen. We suggest that polyoma virus infection of the bladder be included in the differential diagnosis of urinary dysfunction in post-transplant patients, as such infections might be an under-recognized comorbidity in individuals with PVN.

Expression of p53 in virally infected tubular cells in renal transplant patients with polyomavirus nephropathy.

Polyomavirus (PV) infection is associated with ureteral stenosis, hemorrhagic cystitis, and interstitial nephritis in renal transplant patients. The 3 PVs detected in human beings-BK virus, JC virus, and simian virus 40-each encode highly homologous forms of a large T antigen, a transcriptional and replicational regulatory protein. We describe immunohistochemical findings in 5 renal transplant patients who developed PV nephropathy (PVN) and a sixth patient with both PVN and PV infection of the bladder mucosa. Polyomavirus infection was confirmed by immunohistochemical detection of T antigen in kidney and bladder biopsies. We report on the expression of p53 specific to virally infected cells in all biopsies positive for T antigen. Examination of posttransplant biopsies obtained from these 6 patients before they were diagnosed with PVN revealed no expression of T antigen or p53. Accumulation of p53 in PV-infected cells may occur in response to binding of p53 by T antigen, resulting in stabilization of p53. These results provide the first evidence for intracellular actions of PV T antigen in the context of nonneoplastic diseases.

Role of Pur alpha in targeting mRNA to sites of translation in hippocampal neuronal dendrites.

Using genetic inactivation in the mouse, PURA, encoding Pur alpha, is demonstrated to be essential for developmentally-timed dendrite formation in the cerebellum and hippocampus. Comparison of RNA species bound by Pur alpha prompts the hypothesis that Pur alpha functions with non-coding RNA in transport of certain mRNA molecules to sites of translation in dendrites. Pur alpha binds to human BC200 RNA, implicated in dendritic targeting, and this has homologies to 7SL RNA, implicated in compartmentalized translation. Results using hippocampal rat neurons in situ show that Pur alpha binds to BC1 RNA, implicated in dendritic targeting as a mouse counterpart of BC200, and to mRNA molecules translated in dendrites; Pur alpha is specifically located in dendrites, where it is colocalized with Map2, but not in axons, where it fails to colocalize with Ankyrin G. Pur alpha and Staufen are colocalized at dendritic sites of mRNA translation. Microtubule disruptors inhibit Pur alpha dendritic targeting and allow its mislocalization to axons. Using mouse brain, double-RNA immunoprecipitation places Pur alpha together with Staufen or FMRP on BC1 RNA and specific mRNA species in vivo. These results help define a mechanism by which Pur alpha targets specific mRNA molecules to sites of dendritic translation.

Polyoma virus infection is a prominent risk factor for bladder carcinoma in immunocompetent individuals.

Despite various reports of BK viral (BKV) DNA sequences or proteins in tumors of the urogenital tract, there has been no study statistically linking infection by this polyoma virus (PV) to tumor development. All PV are potential transforming viruses, the large T-antigen of which interacts with tumor suppressor proteins. Here, we have performed a cross-sectional study of 3,782 patients having had urine cytologic analyses, comparing those diagnosed with PV infection with those not so diagnosed. In order to focus on immunocompetent individuals, renal transplant patients, for whom a diagnosis of PV infection followed immunosuppressive therapy, were excluded. Among the 133 immunocompetent patients diagnosed with PV infection, the most frequently occurring neoplasms were bladder carcinoma (15.8%) and prostate carcinoma (3.8%). The incidence of bladder carcinoma was sufficient to statistically establish temporality in a two-sided test, linking a prior diagnosis of PV infection to a subsequent diagnosis of bladder carcinoma (odds ratio = 3.419, P < 0.001).