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Update on digital image management and PACS.

Information technology is becoming a vital component of all health care enterprises, from managed care services to large hospital networks, that provides the basis of electronic patient records and hospital-wide information. The rationale behind such systems is deceptively simple: physicians want to sit down at a single workstation and call up all information, both clinical data and medical images, concerning a given patient. Picture archiving and communication systems (PACS) are responsible for solving the problem of acquiring, transmitting, and displaying radiologic images. The major benefit of PACS resides in its ability to communicate images and reports to referring physicians in a timely and reliable fashion. With the changes in economics and the shift toward managed and capitated care, the teleradiology component of PACS is rapidly gaining momentum. In allowing remote coverage of multiple sites by the same radiologists and remote consultations and expert opinion, teleradiology is in many instances the only option to maintain economically viable radiologic settings. The technical evolution toward more integrated systems and the shift toward Web-based technology is rapidly merging the two concepts of PACS and teleradiology in global image management and communication systems.

Costs and Cost Analysis↗

"Mesorectum": the surgical value of an anatomical approach.

The quality of total extirpation of the "mesorectum" nowadays determines the prognosis of rectal cancer but the planes of surgical dissection which have been proposed and the anatomical restrictions of this "mesorectum" are sometimes contradictory. The aim of this study was to clarify the relationships of the "mesorectum" with the fascias and nerves of the pelvic cavity to harmonize the plane of dissection in its total extirpation. Four pelvises (2 male, 2 female) harvested from embalmed cadavers were studied by dissection and anatomico-imaging correlation. Two pelvises (1 male, 1 female) were injected with copolymer via the internal iliac and inferior mesenteric arteries. They were then frozen and sectioned sagittally into two hemi-pelvises for the dissection. The two other pelvises were initially studied in 5 mm cuts with CT scanning and magnetic resonance scanning in the sagittal and "transverse oblique" planes. They were then frozen and then cut sagittally into two hemi-pelvises. Each hemi-pelvis was then cut into anatomical sections with an electric saw similar to the radiological cuts: sagittal cuts on the right hemi-pelvis, and "transverse oblique" cuts on the left hemi-pelvis. It was noted that the "mesorectum" was carpeted behind and laterally by a postero-lateral fibrous envelope belonging to the pelvic visceral fascia and in front by a recto-genital membrane of variable nature corresponding to the "Denonvilliers fascia". The postero-lateral fibrous envelope splits into two leaves (anterior and posterior) in front of the sacral concavity and constitutes, lateral to the rectum, the armature of the pelvic plexus. These two leaves delineated the avascular retro-rectal space. The results of the correlations were deceptive. Their use was limited by dilatation of the rectum, which flattened the perirectal fat onto the pelvic walls on all the sections. Nonetheless, the description of the "mesorectum" and the demonstration of its enveloping fascias by dissection allowed the development of a dissection plane for its total extirpation.

Aged↗

[Melanocyte tumors. Classical and new diagnostic possibilities].

Melanocytic tumors are one of the major problems in diagnostic dermatopathology as they comprise benign nevi, malignant melanomas and borderline cases. Apart from a proportion of congenital lesions, most benign nevi are acquired tumors that arise during early adulthood and eventually may undergo regressive change. Histologically, they present as so-called common nevi, so-called dysplastic nevi, Spitz's nevi, blue nevi and their variants, and combined nevi. In typical cases, the distinction from a malignant melanoma is not difficult. However, benign simulators of malignancy exist as much as deceptively bland appearing melanomas and in some cases the diagnosis remains dubious despite careful weighting of criteria. Indeed, morphological features may not always suffice to disclose the nature of a melanocytic tumor. Ancillary techniques including immunohistochemistry and measurement of telomerase activity may be of assistance in this respect. One should nevertheless be aware that the biological behavior of certain borderline cases cannot be predicted with certainty.

Diagnosis, Differential↗

Cranial infantile myofibromatosis: report of three cases.

BACKGROUND: Infantile myofibromatosis is a proliferative disorder of infancy and early childhood characterized by the development of single or multiple nodular lesions arising from cutaneous or subcutaneous tissue, muscle, bone or visceral organs. In approximately one-third of cases, this myofibroblastic proliferation involves the head and neck region. CASE REPORT: In this paper we report on three cases of cranial infantile myofibromatosis in infants. The clinical presentation and the deceptive histopathological features can make diagnosis difficult. CONCLUSION: The significance of recognizing this entity is stressed, since its indolent clinical behavior might prevent diagnosis.

Diagnosis, Differential↗

Benign breast lesions in adolescent girls: an overview with a case report.

A wide spectrum of breast disorders occurs in the paediatric and adolescent age groups, but malignant disease is very rare. The relative frequencies of these conditions and their natural history differ substantially from those of adult patients. The gross findings may be very deceptive and mislead the clinician until a histopathological diagnosis is made. We report a case in an adolescent girl that was initially diagnosed and treated as fibroadenoma until a histological assessment proved it to be a phyllodes tumour with malignant potential.

Adolescent↗

Strangulated low Spigelian hernia in children: report of two cases.

Low Spigelian hernia (LSH) in children is considered an extreme surgical rarity. This clinically deceptive hernia is difficult to diagnose preoperatively and has a real risk of strangulation. Strangulated LSH may be misdiagnosed as strangulated inguinal hernia. Early recognition and timely surgical repair are important to avoid strangulation.

Diagnosis, Differential↗

Applications of neural networks to colour recognition.

Colour specification and matching are important tasks used in a number of different industries. However, current methods can employ very complicated, elaborate pieces of laboratory equipment which are not portable, such as spectrophotometers with combinations of calibrated light sources and a large number of narrow band filters. Simpler, portable devices are typically not sophisticated enough to give a high degree of quality control due to the less sophisticated light sources and the necessarily smaller number of filters employed. Lastly, techniques such as the 'match by eye' method can lead to deceptive metameric matches. This paper outlines the beginning of the development of a colour measurement system which is portable, easy to use, and more accurate than other portable devices by virtue of an artificial neural network used to analyze the data. With specialized training of the neural network, it could even be used in applications such as teeth and skin colour measurements.

Color↗

Gastrointestinal stromal tumours: a regular origin in the muscularis propria, but an extremely diverse gross presentation. A review of 200 cases to critically re-evaluate the concept of so-called extra-gastrointestinal stromal tumours.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) are thought to arise from the interstitial cells of Cajal (ICCs). ICCs form a network surrounding the myenteric plexus and between-muscle fibres of the muscularis propria of the tubular GI tract. The cell of origin of so-called extra-gastrointestinal stromal tumours (EGISTs) is not known. AIM AND METHODS: To study the diversity of gross presentation of GISTs and to critically assess the incidence of EGISTs and their relationship to mural GISTs, a total of 200 neoplasms with typical morphologic and immunohistochemical features of GISTs were reviewed, looking for any degree of association with the muscularis propria of the gut wall. RESULTS: There were 130 gastric (65%), 9 duodenal (4.5%), 48 small intestinal (24%), 9 colorectal (4.5%), 1 appendiceal (0.5%) and 3 unclassifiable GISTs (1.5%). Fourteen cases (7%) were initially submitted as EGISTs (four mesenteric, four omental, one pararectal/prostatic, one pelvic/Douglas, one perivesical, one located between root of mesentery and tail of pancreas, one involving the mesentery, omentum and abdominal wall extensively and one located between liver and stomach). After critical re-evaluation of surgical reports and remote clinical history and a careful search for residual muscular tissue from the gut wall in the tumour pseudocapsule (in some cases supported by desmin immunoreactivity), it was possible to reclassify most of these cases (11/14) as either GISTs with extensive extramural growth resulting in loss of contact to the external muscle coat of the gut (8/14) or as metastases from an inoperable GIST (2/14) or from a previously resected deceptively benign tumour (1/14). CONCLUSION: EGISTs are probably rarer than previously reported (1.5% or less in this study). We concluded that most so-called EGISTs represent apparent EGISTs that should have arisen from the outermost muscle coat, but have lost their contact to the point of origin due to extensive extramural growth pattern. From a surgical point of view, it is crucial to document and mark any focal attachment or adhesions to the gut wall noticed during surgery for an apparent EGIST. In contrast to most other neoplasms, GISTs should be defined by virtue of any degree of association with the muscularis propria (no matter how minimal), but not by localisation of the bulk of the tumour.

Aged↗

cAMP signaling cascades and CFTR: is there more to learn?

CFTR is an apically resident ion channel whose activity is regulated by the activation of the cAMP mediated second messenger cascade. As depicted in textbooks, the cAMP mediated signaling cascade appears deceptively simple, yet, our growing understanding of this pathway shows it to be much more complicated and finely tuned than originally thought. The intent of this review is to evaluate our current understanding of the cAMP mediated signaling as it relates to the secretion of mucin and chloride, two compounds whose regulated secretion is altered in cystic fibrosis.

Cyclic AMP↗

The pressing need for better histologic-mammographic correlation of the many variations in normal breast anatomy.

Mammography screening calls for a reevaluation of the working relationship between physicians dealing with the diagnosis and treatment of breast diseases. In this new era, histologic-mammographic correlation needs to be extended to correctly describe the deceptive mammographic findings that correspond to variations in normal breast tissue. Progress in histologic-mammographic correlation can only be made by overcoming the limitations inherent to the traditional histologic technique by examining a histologic specimen of greater length, width, and depth. There are several distinct advantages to using the large-section histology technique in the diagnosis of breast diseases. The subgross (three-dimensional) histology technique serves to bridge the gap that separates the pathologist and radiologist, bringing them to a common ground for a better understanding of breast morphology. These improvements in communication between the members of the diagnostic team will serve to optimize the sensitivity and specificity of breast cancer diagnosis.

Breast↗

Subcutaneous lymphoid hyperplasia arising at site of ethnic scarifications and mimicking subcutaneous panniculitis-like T-cell lymphoma.

The case of a 40-year-old black man, who developed a very unusual tumour-like lymphoid hyperplasia involving primarily the subcutaneous tissue, is reported. The lesion, which arose at a site of tribal scarifications, displayed a deceptive morphology that closely resembled subcutaneous panniculitis-like T-cell lymphoma (SPTCL). An accurate diagnosis could only be made following detailed immunohistochemical and molecular studies. Although SPTCL has been thought to represent a very specific clinicopathologic entity, the present case illustrates that its histological appearance can, however, be closely mimicked by reactive and benign conditions.

Adult↗

A new view of the so-called adenoma malignum of the uterine cervix.

Adenoma malignum of the uterine cervix (mucinous type of minimal deviation adenocarcinoma, mucinous MDA), is a unique neoplasm that is difficult to diagnose owing to the deceptively benign appearance of the tumour cells. The present study was undertaken to explore the phenotypic expression of this tumour compared with those of non-neoplastic cervical tissues and of cervical carcinomas of various types. Ten cases of mucinous MDA, 50 cases with non-neoplastic cervical tissues, 13 of cervical adenocarcinoma including the mucinous (endocervical or intestinal type) and endometrioid types, and 2 of mucoepidermoid carcinoma were examined by various histochemical staining methods, including those for gastric mucins, pepsinogen, lysozyme, chromogranin A and carcinoembryonic antigen. The results revealed that mucinous MDA characteristically exhibited gastric phenotypes. The presence of gastric metaplasia was also demonstrated in 9 cases of mucinous MDA and in 5 of the other cases examined. The 7 endocervical-type adenocarcinomas also included 4 that expressed gastric phenotypes, and 2 of the 3 intestinal-type adenocarcinomas showed the same properties focally. These results indicate the presence of a group of lesions expressing gastric phenotypes in the uterine cervix and suggest a close relationship between these lesions. Cervical adenocarcinomas expressing gastric phenotypes are probably derived from MDA.

Adenocarcinoma, Mucinous↗

Lack of floral nectar reduces self-pollination in a fly-pollinated orchid.

One explanation for the widespread absence of floral nectar in many orchids is that it causes pollinators to visit fewer flowers on a plant, and thus reduces self-pollination. This, in turn, could increase fitness by reducing inbreeding depression in progeny and promoting pollen export. The few previous investigations of this hypothesis have all involved bee-pollinated orchids and some have given contradictory results. We studied the effects of adding artificial nectar (sucrose solution) to the spurs of a non-rewarding long-proboscid fly-pollinated orchid, Disa pulchra. Addition of nectar significantly increased the number of flowers probed by flies (2.6-fold), the time spent on a flower (5.4-fold), the number of pollinia removed per inflorescence (4.8-fold) and the proportion of removed pollen involved in self-pollination (3.5-fold). The level of self-pollination increased dramatically with the number of flowers probed by flies. Experimental self-pollination resulted in fruits with only half as many viable seeds as those arising from cross-pollination. Pollinators were more likely to fly long distances (>40 cm) when departing from non-rewarding inflorescences than when departing from rewarding ones. These findings provide support for the idea that floral deception serves to reduce pollinator-mediated self-pollination.

Animals↗

Syringomatous adenoma of the nipple: report of a case.

We report herein a rare case of syringomatous adenoma (SA) of the nipple. Only 22 cases of SA of the nipple have been documented in the world literature, and to the best of our knowledge this is the first case to be reported in Japan. The patient was a 68-year-old woman who presented with a painful mass in the right subareolar region of over 15 years' duration. Clinical examination including needle biopsy indicated a high possibility of carcinoma; however, the final histopathological diagnosis after mastectomy proved to be SA. SA is a benign locally infiltrating neoplasm of the nipple which shares many clinicopathological features with adenoma of the nipple. Both lesions sometimes show deceptive clinicopathological findings, causing then to be easily confused with carcinomas. However, SA can be distinguished by its unique histological appearance resembling sweat duct, or syringomatous, tumors and locally infiltrating growth, which is probably responsible for its misleading clinical findings and higher rate of recurrence. Surgeons should be aware of the possibility of diagnosing this extremely rare tumor, and the appropriate treatment.

Adenoma↗

Artistic assault: an unusual penetrating head injury reported as a trivial facial trauma.

The authors report a case of penetrating head injury that presented with a deceptively mild complaint. To our knowledge, it is the first report of a paint brush penetrating the brain. The patient reported being punched in the left eye and presented with a minor headache, swelling around the left orbit, a small cut on the cheek and slightly reduced left eye abduction. After radiological evaluation, a penetrating head injury was diagnosed. Under general anesthesia, through a lateral eyelid incision a 10.5 cm long paint brush, which had penetrated from the left orbit to the right thalamus, was removed. No post-operative infection was seen at six months follow-up. This brief report serves to highlight that penetrating brain injury can occur without neurological deficit and that a minimally invasive surgical approach was successful in avoiding any complications.

Brain Injuries↗

The predictive value of external continuous lumbar drainage, with cerebrospinal fluid outflow controlled by medium pressure valve, in normal pressure hydrocephalus.

BACKGROUND: Although sporadic studies have described temporary external cerebrospinal fluid (CSF) lumbar drainage as a highly accurate test for predicting the outcome after ventricular shunting in normal pressure hydrocephalus (NPH) patients, a more recent study reports that the positive predictive value of external lumbar drainage (ELD) is high but the negative predictive value is deceptively low. Therefore, we conducted a prospective study in order to evaluate the predictive value of a continuous ELD, with CSF outflow controlled by medium pressure valve, in NPH patients. METHOD: Twenty-seven patients with presumed NPH were admitted to our department and CSF drainage was carried out by a temporary (ELD) with CSF outflow controlled by a medium pressure valve for five days. All patients received a ventriculoperitoneal shunt using a medium pressure valve based upon preoperative clinical and radiographic criteria of NPH, regardless of ELD outcome. Clinical evaluation of gait disturbances, urinary incontinence and mental status, and radiological evaluation with brain CT was performed prior to and after ELD test, as well as three months after shunting. FINDINGS: Twenty-two patients were finally shunted and included in this study. In a three-month follow-up, using a previously validated score system, overall improvement after permanent shunting correlated well to improvement after ELD test (Spearman's rho = 0.462, p = 0.03). When considering any degree of improvement as a positive response, ELD test yielded high positive predictive values for all individual parameters (gait disturbances 94%, 95% CI 71%-100%, urinary incontinence 100%, 95% CI 66%-100%, and mental status 100%, 95% CI 66%-100%) but negative predictive values were low (< 50%) except for cognitive impairment (85%, 95% CI 55%-98%). CONCLUSION: This study suggests that a positive ELD-valve system test should be considered a reliable criterion for preoperative selection of shunt-responsive NPH patients. In case of a negative ELD-valve system test, further investigation of the presumed NPH patients with additional tests should be performed.

Adult↗

The rehabilitation of the severely resorbed maxilla by simultaneous placement of autogenous bone grafts and implants: a 10-year evaluation.

The long-term success of Brånemark implants has been previously reported. The success rate of the same implants, when associated with autologous grafts, seemed much less predictable. In the present study it is demonstrated that when these implants are installed in conjunction with an autologous corticocancellous hip graft, either onlay or inlay, the cumulative success rate remains at 95% for individual implants in non-smokers. The short extracorporal time might be an explanation. On the other hand, the same approach in patients with congenital defects or who underwent radiotherapy is deceptive. The use of hyperbaric oxygen may dramatically improve these results.

Adult↗

Human basophils as effectors and immunomodulators of allergic inflammation and innate immunity.

Basophils have often stood in the shadow of their tissue-fixed mast cell counterparts which share some, common features, such as high-affinity IgE receptor expression and the ability to release histamine. That rodent mast cells produce a variety of pro-allergic and inflammatory cytokines has further added to the deception that basophils only play a minor role in allergic inflammation. Surprisingly, in humans, basophils, but not mast cells, appear to be the prime early producers of the Th2-type cytokines IL-4 and IL-13, which perform several crucial functions in initiating and maintaining allergic responses. This putative immunomodulatory role of basophils is supported further by their ability to express CD40 ligand, which, together with IL-4 and IL-13, serve as inductors of B-cell proliferation and class switching to IgE and IgG4. Moreover, human basophils are the main cellular source for rapid IL-4 generation, a mandatory requirement for the development of Th2 responses. Recent specific staining techniques have localised basophils in various tissues affected by allergic diseases and it appears likely, but remains to be proven, that the interaction of basophils, T cells and B cells at these sites propagate pro-allergic immune responses. Additionally, basophil activation is not restricted to antigen-specific IgE crosslinking but can be caused in non-sensitised individuals by parasitic antigens, plant lectins and viral superantigens binding to non-specific IgEs. Finally, the presence of novel IgE-independent receptor targets that cause trafficking and Th2 cytokine release from basophils further underlines their potential role in innate as well as adaptive immunity.

Basophils↗