Esophagopericardial fistula in a scleroderma patient with peptic esophagitis.

Esophageal perforation from peptic ulceration is rare. A patient with scleroderma who had an esophagopericardial fistula caused by peptic esophagitis is described. The fistula mimicked an acute myocardial infarction.

Isolation and characterization of relaxin from the sand tiger shark (Odontaspis taurus).

A peptide with relaxin activity in guinea pigs but not in mice has been extracted from the ovaries of pregnant sand tiger sharks (Odontaspis taurus). The structural similarity of this peptide to porcine relaxin includes molecular size approximately 6000 daltons), number of chains, and possibly, disulfide cross-links. The relaxin-type peptide isolated from shark ovaries contains the amino acid residues tyrosine, proline, and histidine, which are absent in the porcine hormone. The amino acid composition of shark relaxin, therefore, resembles that of porcine insulin to a greater extent than does the amino acid composition of porcine relaxin. This finding supports the idea that shark relaxin may be a primitive relaxin that has undergone fewer mutations than porcine relaxin since the putative duplication of the insulin gene. The data presented here suggest that the putative duplication of the insulin gene, which might have given rise to relaxin, has occurred much earlier than the separation of sharks from the general branch of animals that eventually gave rise to mammals.

Differentiation of adrenal masses by magnetic resonance imaging.

Eighty-one adrenal masses in 68 patients were examined with magnetic resonance imaging (MRI). Masses included nonfunctioning adenomas (17), metastases (25), adrenocortical carcinomas (10), and pheochromocytomas (23). T1-weighted pulse sequences depicted the anatomy with a resolution comparable to that of computed tomography (CT). T2-weighted pulse sequences provided some histologic specificity separating nonfunctioning adenomas with low signal-intensity from metastases with intermediate signal-intensity and pheochromocytomas with high signal-intensity. Pheochromocytomas could always be distinguished from other adrenal masses. In 20% of the cases, metastases with low signal-intensity could not be distinguished from nonfunctioning adenomas.

Identification of intrathoracic hemorrhage with Tc-99m sulfur colloid.

Tc-99m sulfur colloid has been shown to be accurate in the detection of intrapulmonary bleeding (1,2). The present example demonstrates the usefulness of Tc-99m sulfur colloid in identifying an unusual manifestation of intrathoracic hemorrhage.

Technetium-99m MDP demonstration of heterotopic ossification in fibrodysplasia ossificans progressiva.

The extensive heterotopic bone formation in patients with fibrodysplasia ossificans progressiva (FOP) has been documented previously with radiographs. A case in which a Tc-99m MDP bone scan showed increased uptake at sites well before ossification could be documented radiographically is described. This finding suggests that bone scans would likely be useful to monitor the extent of involvement with FOP and to detect areas of new activity.

Computed tomography appearance of Golden's "S" sign.

The computed tomography version of Golden's "S" sign is strongly suggestive of a centrally obstructing carcinoma. Although more easily seen in the right lung, the "S" sign can be detected in any lobe on computed tomography. The computed tomography appearance of Golden's "S" sign is described and illustrated.

Professional mammographic quality assessment program for a community hospital.

The evaluation of mammographic interpretations is a difficult challenge for a professional quality assessment program. As most images are read by a single observer and pathologic proof is obtained only if prompted by the report or if clinical symptoms warrant surgical intervention, it is difficult to construct a meaningful quality assessment program. The authors designed a program on the basis of a mammographic coding system that allows both individual physicians and practice groups to be evaluated. The program examines mammographic reports to determine the consistency of reporting by each physician and by the entire group. In addition, the program facilitated periodic evaluation of physicians with use of test cases. The coding system provided an easy method of correlating the mammographic reports with pathology reports from biopsy specimens, allowing a more thorough examination of possible systematic errors in the evaluation of the examinations, as well as enabling calculation of the positive predictive value for the diagnosis of cancer. The professional quality assessment program can be easily implemented in a busy clinical setting to evaluate whether mammograms were read consistently and "correctly" and to provide a method of continuing education for the physicians.

Magnetic resonance imaging of the adrenal.

Magnetic resonance imaging (MRI) of the adrenals was performed on 50 subjects: 5 normal volunteers, 6 Cushing patients with bilateral adrenal hyperplasia, 14 patients with adrenal adenomas, 3 with adrenal carcinomas, 15 with pheochromocytomas and 7 with metastatic disease to the adrenal. The normal and hyperplastic adrenal glands were imaged in all cases. Using the signal intensity of the adrenals on a T2 weighted image, various forms of adrenal pathology could be differentiated. A ratio of signal intensity of the adrenal mass to the liver was utilized and allowed the differentiation of adrenal adenomas from adrenal carcinomas, pheochromocytomas and metastases. Using the same ratio, metastases could be distinguished from pheochromocytomas as well. MRI appears to be particularly valuable in distinguishing clinically silent adrenal metastases from nonfunctioning adrenal adenomas.

Oblique chest film: value in routine and selective use.

A retrospective analysis is presented of 308 consecutive cases in which four views of the chest (right and left anterior oblique, posteroanterior, and lateral) were obtained. Most cases (257) were from adult cardiac clinics or thoracic surgery clinics, where the indications were for questionable cardiac abnormality, known cardiac abnormality, or thoracic malignancy. Fewer cases (37) were studied to attempt clarification of possible abnormality on routine films. Of the 257 routine studies, the oblique views yielded no further information in 97.6% of cases, and missed lesions in 1.3%. In the selective group, the oblique views provided information or confirmatory evidence in about 95% of cases when requested by radiologists. The results throw considerable doubt on the value of oblique films in routine studies, but suggest that they may still have a value in delineating possible abnormalities seen on other views or in cases of pleural disease.

Progression of meniscal degenerative changes in college football players: evaluation with MR imaging.

Intrameniscal degenerative changes, presumably due to mild repetitive trauma, have been shown in many college and professional athletes, but it is uncertain over what period of time they can develop or significantly progress. To ascertain this period, the authors used magnetic resonance (MR) imaging to examine one knee in each of 20 players in the starting lineup of a major college football team before and after the season. Only asymptomatic knees (right, n = 10; left, n = 10) were examined; the images were reviewed blindly by one experienced observer without reference to the other examination. A significant progression existed in the grade of signal intensity shown in the menisci over the course of the season (P less than .001). Although this is a small study covering only 1 year, these preliminary results suggest that significant degeneration can occur in the menisci of asymptomatic players over a single season.

Hemodynamics of portal blood flow shown by CT portography. Work in progress.

Computed tomography and arterial portography were combined in 12 patients for studies of the anatomy and hemodynamics of the portal venous system. This technique was found to be more sensitive than conventional venous-phase angiograms of the superior mesenteric and splenic arteries for evaluation of the anatomy of the portal venous system and extent of thrombosis in patients with cavernous transformation and also facilitated recognition of subtle evidence of hepatofugal flow and portosystemic shunts. CT portography can be employed when conventional angiograms fail to show the portal vein adequately.

MR imaging of a ruptured Achilles tendon.

Rupture of the Achilles tendon is an urgent but usually clinically apparent orthopedic problem. Repair must be made promptly for full recovery. A number of methods of radiographic evaluation have been proposed to confirm the diagnosis of Achilles rupture. This report describes a case in which magnetic resonance imaging provided exquisite definition of the injury to the Achilles tendon.

Vascular imaging with MRI: inadequacy in Takayasu's arteritis compared with angiography.

Magnetic resonance imaging (MRI) and angiography were compared in a prospective and blinded fashion in 10 consecutive patients with Takayasu's arteritis to evaluate the ability of MRI to detect vascular abnormalities in the large arteries of the thorax and abdomen. Only the aorta and its major branches were studied. MRI was performed with a 0.5-T superconducting instrument and a body coil. Overlapping cuts, oblique views, and cardiac gating were used. Using angiography as the gold standard, MRI correctly identified all lesions in three patients, gave false-positive findings in two patients, and gave false-negative findings in five patients. In the latter five patients, MRI missed areas of major pathology in proximal arch vessels. MRI sensitivity was only 38% with a patient-by-patient analysis and 54% with a lesion-by-lesion analysis. The visualization of specific arteries with MRI was compared to visualization with angiography, and was markedly inferior in all vessels except the aorta, the innominate artery, and the common iliac arteries. It appears that with current equipment and technology, MRI is inadequate as a screening examination or for detailed evaluation of arterial disease other than the aorta except in highly selected cases.

CT evaluation of thickened esophageal walls.

A study of 200 consecutive chest computed tomographic (CT) examinations revealed thickened esophageal walls (over 3 mm) in 35%. While this is the earliest finding of carcinoma of the esophagus on CT, only half of the cases of thickened walls were due to esophageal carcinoma. Other mediastinal malignancies as well as benign inflammatory, vascular, and fibrotic conditions such as reflux and monilial esophagitis, esophageal varices, and postirradiation scarring were found to cause thickened esophageal walls. Distension with air and intravenous enhancement aid in the optimal evaluation of the esophagus by CT. The thickened esophageal wall is always abnormal, but it is nonspecific, seen in both malignant and nonmalignant conditions.

The distinctly visible right upper lobe bronchus on the lateral chest: a clue to adolescent cystic fibrosis.

Radiographic differentiation between cystic fibrosis and asthma presenting in teenagers and young adults can be difficult. Many patients with a late presentation of cystic fibrosis display minimal changes on a chest radiograph. However, a large majority (90%) of cystic fibrosis patients with an essentially normal PA chest radiograph will have a distinctly outlined orifice of right upper lobe bronchus on a lateral chest film as opposed to a small number of asthmatics (25%) or normal patients (18%). This observation correlates well with the pathologic finding that the initial pulmonary involvement in cystic fibrosis is typically in the right upper lobe in adolescents. Teenage or young adult patients presenting with a history of repeated respiratory infections, asthma-like symptoms and a distinctly visible right upper lobe bronchus on a lateral chest film should be sweat-tested to exclude cystic fibrosis.

Magnetic resonance assessment of the distribution of lumbar spine disc degenerative changes.

The lumbar spine magnetic resonance (MR) studies in 246 consecutive patients who suffered from persistent back and leg pain were evaluated for the degree of degenerative disc disease and the presence of disc bulging, prolapse, or herniation. No patient had a history of previous back surgery. In those patients, degenerative disc changes increased with age until the fifth decade of life, after which a relatively similar proportion of patients had degenerative disc disease. Significant dehydration and degeneration occurred in less than 5% of the upper two disc spaces while L4/5 and L5/S1 had marked changes in greater than 20%. Prolapse and herniation progressively increased with each lower interspace, where at L5/S1 it was present in nearly one-third of the patients. Although a few patients had disc prolapse or herniation with a nondegenerated disc, there was a relationship between the presence of disc degeneration and prolapse or herniation.

Gaucher disease: sonographic appearance of the spleen.

Ultrasonographic (US) examinations of the upper abdomen were performed in 80 patients with Gaucher disease. Of the 49 patients that had not undergone splenectomy, 47 had splenic enlargement. Sixteen patients had multiple lesions in the spleen. Most patients had discrete hypoechoic lesions that corresponded pathologically to focal homogeneous clusters of Gaucher cells. Several patients had similar lesions that were hyperechoic and were composed of Gaucher cells and fibrosis or infarction. A few patients had a geographic pattern of irregular areas of involvement of Gaucher cells among normal splenic parenchyma. The liver was often enlarged but otherwise sonographically unremarkable. Patients with Gaucher disease often have US examinations of the left upper quadrant for abdominal pain. A variety of US findings in the spleen typical for Gaucher disease should be recognized and not interpreted as acute changes.