Biomedical subjects
Publications and source records attributed to N J Pelc.
We have discussed an approach to the diagnosis of bullous diseases based on available and established methods. We highlighted the clinical features that help distinguish the various diseases. We then outlined a histopathologic pattern approach to the differential diagnosis and extensively discussed the value of immunofluorescence in the diagnosis of bullous diseases.
Drug-induced pemphigus is a heterogenous group of disorders in which a drug induces acantholysis. The majority of patients have immune features of pemphigus and have a course similar to idiopathic pemphigus. Few patients do not have a detectable autoimmune process, and their eruption usually resolves with discontinuation of the associated drug. The mechanism of induction of the autoimmune process and acantholysis is not clear.
Paraneoplastic pemphigus is a newly recognized disease that occurs in some patients with lymphoproliferative neoplasms and occasionally, solid tumors. Patients present with an acute illness of the mucosa and skin that shares clinical and histologic features with erythema multiforme, toxic epidermal necrolysis, and pemphigus vulgaris. These patients have antibodies against a complex of epithelial proteins that are present in desmosomes and hemidesmosomes. The course is usually fatal, except in some patients who undergo total resection of their neoplasm.
Cicatricial pemphigoid presents with oral or ocular inflammation and blisters that are followed by scarring. The differential diagnosis of cicatricial mucositis includes other subepithelial blistering disorders. The disease is usually chronic and can be associated with high morbidity. Treatment of severe cases with immunosuppressive agents is usually helpful.
Alterations in pigmentation of the skin are commonly encountered as a patient's primary reason for seeking medical care. They may be discovered as incidental findings on examination of the skin. The physician should be able to recognize and treat some of the common pigmentary disorders and to make referrals when appropriate. It is important to be aware of associations of pigmentary changes with systemic diseases.
This study evaluated a phase-contrast cine magnetic resonance (MR) imaging technique capable of simultaneously allowing determination of velocity and volume flow rate (VFR) in both carotid arteries and the basilar artery. Forty patients were studied; 24 were neurologically normal, and 16 had intracerebral arteriovenous malformations (AVMs). In the normal group, mean basilar flow was significantly less than mean carotid flow. Mean velocity and VFR showed a significant decline with age in the basilar artery. Carotid artery flow and total cerebral blood flow did not decline with age. In the AVM patients, flow and velocity measurements were significantly elevated in all three arteries. Flow in the carotid artery ipsilateral to the AVM was significantly greater than flow in the contralateral carotid artery. VFR increased in all three arteries with increasing AVM volume. Four patients underwent partial embolization, and a corresponding decrease in flow was observed. Phase-contrast cine MR imaging provides rapid, simultaneous, noninvasive velocity and VFR measurement in the major intracranial arteries.
Brain motion during the cardiac cycle was measured prospectively in 10 healthy volunteers by using a phase-contrast cine magnetic resonance (MR) pulse sequence. The major cerebral lobes, diencephalon, brain stem, cerebellum, cerebellar tonsils, and spinal cord were studied. The overall pattern of brain motion showed caudal motion of the central structures (diencephalon, brain stem, and cerebellar tonsils) shortly after carotid systole, with concurrent cephalic motion of the major cerebral lobes and posterior cerebellar hemisphere. Peak brain displacement was in the range of 0.1-0.5 mm for all the structures except the cerebellar tonsils, which had greater displacement (0.4 mm +/- 0.16 [mean +/- standard error of mean]). Caudal motion of the central structures did not occur simultaneously but progressed in a caudal-to-rostral and posterior-to-anterior sequence, being seen first in the cerebellar tonsils and then later in the diencephalon (hypothalamus). Caudal motion of the low brain stem and cerebellar tonsil was simultaneous with caudal motion of cerebrospinal fluid in the cervical subarachnoid space. Oscillatory flow in the aqueduct was delayed compared with brain stem motion.
Quantitative measurements of arterial and venous blood flow were obtained with phase-contrast cine magnetic resonance (MR) imaging and compared with such measurements obtained by means of implanted ultrasound (US) blood flow probes in anesthetized dogs. The US flowmeter was enabled during a portion of each MR imaging sequence to allow virtually simultaneous data acquisition with the two techniques. MR imaging data were gated by means of electrocardiography and divided into 16 phases per cardiac cycle. The rates of portal venous blood flow measured with MR imaging and averaged across the cardiac cycle (710 mL/min +/- 230 [standard deviation]) correlated well with those measured with the flowmeter and averaged in like fashion (751 mL/min +/- 238) (r = .995, slope = 1.053). The correspondence in arterial blood flow was almost as good. No statistically significant difference existed between the paired measurements of blood flow obtained with MR imaging and the implanted probe. It is concluded that, as a noninvasive means of accurate quantification of blood flow, phase-contrast MR imaging may be especially useful in deep blood vessels in humans.
Detection of acute renal failure (ARF) using fast-scan magnetic resonance imaging (MRI) with Gd-DTPA was studied in a dog model. ARF was produced in five dogs by infusion of norepinephrine (0.75 micrograms/kg/min) into the renal arteries for 40 minutes. MRI was performed 1 hour later and compared with baseline (pre-ARF) MRI. There was no significant difference in the ratios of signal intensity-vs.-time curves from 0 to 35 seconds after injection of Gd-DTPA. However, a difference between the outer and inner medulla was significant in the time period of 5 to 20 minutes after Gd-DTPA injection. These later signal intensity differences by fast-scan (gradient-echo) technique may be useful in the evaluation of ARF.
A phase-contrast cine magnetic resonance (MR) imaging technique was used to study normal dynamics of cerebrospinal fluid (CSF) in 10 healthy volunteers and four patients with normal MR images. This pulse sequence yielded 16 quantitative flow-encoded images per cardiac cycle (peripheral gating). Flow encoding depicted craniocaudal flow as high signal intensity and caudo-cranial flow as low signal intensity. Sagittal and axial images of the head, cervical spine, and lumbar spine were obtained, and strategic sites were analyzed for quantitative CSF flow. The onset of CSF systole in the subarachnoid space was synchronous with the onset of systole in the carotid artery. CSF systole and diastole at the foramen of Monro and aqueduct were essentially simultaneous. The systolic and diastolic components were different in the subarachnoid space, where systole occupied approximately 40% and diastole 60% of the cardiac cycle, compared with the ventricular system, where they were equal. This difference results in systole in the intracranial and spinal subarachnoid spaces preceding that in the ventricular system; the same is true for diastole. The fourth ventricle and cisterna magna serve as mixing chambers. The high-velocity flow in the cervical spine and essentially no flow in the distal lumbar sac indicate that a portion of the capacitance necessary in this essentially closed system resides in the distal spinal canal.
Phase contrast cine magnetic resonance imaging (MRI) combines the flow-dependent contrast of phase contrast MRI with the ability of cardiac cine imaging to produce images throughout the cardiac cycle. Two pulse sequence types are used for sensitivity to flow in one direction, whereas four are needed for sensitivity in all directions. Several alternatives for synchronization of the data to the cardiac cycle exist. Retrospectively interpolated methods can image the entire cardiac cycle efficiently. Rapid interleaving of the various sequence types ensures immunity to motion misregistration. The technique produces images in which contrast is related to flow velocity as well as magnitude images such as those of conventional cine MRI. The data can be interpreted qualitatively to demonstrate the presence, magnitude, and direction of flow, and quantitatively to provide estimates of flow velocity, volume flow rate, and displaced volumes. Phase contrast cine MRI is helpful in the diagnosis of aortic dissections, in the study of flow distributions in large vessels such as pulmonary arteries, as well as in smaller vessels such as carotid and basilar arteries, and in the evaluation of complex anatomical variants. Future developments are expected to reduce imaging time and expand the quantitative applications.
Several aspects of blipped echo-planar imaging (EPI) are treated mathematically. An expression relating the necessary readout gradient strength and sampling time to the spatial resolution and readout duration is derived. It is shown how the net spatial resolution may be limited by the object's T2 characteristics and B0 field homogeneity, irrespective of the number of sampled points. Additionally, off-resonance effects result in a loss of spatial resolution and image distortion to a considerably greater degree than in conventional two-dimensional Fourier transform imaging. The extent of these effects is directly related to the time required to acquire the data matrix, and is therefore amplified when EPI is implemented on a standard commercial whole-body system which because of limited gradient performance uses necessarily longer sampling durations. Specific hardware modifications to a standard commercial imager are considered to allow successful EPI implementation. EPI image characteristics are compared quantitatively with those of conventional methods.
Angiographic displays of cerebral vessels can be generated with single-excitation three-dimensional magnetic resonance imaging. Differentiation of true stenosis from artifactual signal loss, due to dephasing effects from fast or nonconstant blood flow and field inhomogeneities, poses a significant clinical problem that can be largely resolved with the use of very short echo times (TEs). A three-dimensional imaging technique was developed that allows TEs of 3.1 msec without and 4.5 msec with first-order flow compensation gradients. The short TEs were achieved with short asymmetric radio-frequency pulses, gradients of minimal duration, and fractional echoes. Significantly improved images of normal tortuous vessels with fast flow were obtained. With this method, accuracy in depicting the vessel lumen and confidence in the findings were markedly increased.
To assess blood flow rapidly, a limited-flip-angle, gradient recalled pulse sequence was modified to acquire two views at the same phase-encoding step in successive repetitions. One view is obtained with first-moment flow compensation, while the second view is obtained with selectable flow encoding (non-zero first moment) along one direction. Blood flowing along the encoded direction acquires a phase difference between the two views, resulting in signal dependent on both direction and speed of flow. Stationary tissues undergo no phase change. Therefore, the phase shift between the two views produces an image that spatially renders flow direction and velocity. With a 24-msec repetition time, a 256 X 128 matrix, and two excitations, data acquisition is completed in 13 seconds per location (both a magnitude image and a flow image are produced at each location). Images generated with flow phantoms confirmed the accuracy of this method. Preliminary clinical evidence in 23 human subjects suggests that this method is useful in evaluating portal hypertension, distinguishing arterial from venous flow, distinguishing between slow flow and clot, and confirming the presence of clot. This method appears to be a fast, easy way to assess blood flow in large vessels.
A method of subtraction angiography that has an acquisition time of 8 s per slice is described. Flow-compensated and uncompensated measurements are acquired in an interleaved fashion using limited flip angles and gradient refocusing. Magnitude images are reconstructed and subtracted to generate the angiogram. Results were generated in vivo in the imaging of the carotid bifurcation of several human volunteers. Susceptibility and inhomogeneity induced artifacts are prominent in thick slices, but can be greatly reduced by imaging several thin slices and adding them together. Thin slices do not require dephasing gradients to reduce the dynamic range, and there is no signal cancellation in overlapping vessels. The method is ideal for acquiring scout angiograms, and with averaging may produce images of diagnostic quality.
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We present a method for rapid measurement of T1 relaxation times using gradient refocused images at limited flip angles and short repetition times. This "variable nutation" techniques was investigated using a T1 phantom. There was a high correlation between measurements obtained with the variable nutation and partial saturation techniques. The ability of this method to create calculated T1 images is also demonstrated. We conclude that the variable nutation method may allow measurement of T1 relaxation times with a significant reduction in acquisition time compared to partial saturation techniques.
A multichannel biotelemetry system using pulse-width modulation-frequency modulation (PWM-FM) is described in detail for laboratory construction. Its application in a kinematic gait-analysis system is demonstrated, employing minimally encumbering electrogoniometry and foot-contact switches. The triaxial electrogoniometers sense rotational joint motion, and four foot-switches under the sole of each foot provide information on placement and temporal contact. Signals from the multiple sensors are amplified, encoded by pulse-width modulation, and transmitted at an FM radio frequency of 107 MHz. Received data are decoded and then sampled by a minicomputer for analysis. Results from a comparative study of kinematic gait in five normal subjects and five children with cerebral palsy demonstrate system effectiveness in providing quantitative data and various intrasubject and intersubject gait differences. Factors reviewed in the analysis include swing and stance times; cadence; hip-joint motion in sagittal, coronal, and transverse planes; and sequence of foot placement.