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PubMed1987

Gallium uptake in myositis ossificans. Potential pitfalls in diagnosis.

Seven cases of gallium uptake in myositis ossificans are described. Gallium scans are done frequently in paraplegics, quadriplegics, and comatose patients to look for occult infection. It is important to be aware of possible gallium uptake in myositis ossificans, particularly in the extremities, which is frequent in these patients. Gallium uptake may be present prior to any abnormalities seen on plain films or CT scans. It is important to correlate roentgenograms with abnormal gallium scans, particularly in the extremities, to avoid potential pitfalls in diagnosis and prevent unnecessary antibiotic treatment. A bone scan should be obtained whenever possible, particularly when roentgenograms are negative, to confirm the diagnosis.

Adult↗
PubMed1990

Scintigraphic pattern of pneumothorax complicating Pneumocystis carinii pneumonia in patients with AIDS.

Spontaneous pneumothorax is a serious though infrequently reported pulmonary complication of AIDS. An unsuspected lung collapse was discovered via gallium scintigraphy for the study of Pneumocystis carinii pneumonia. Neither the pneumonia nor the pneumothorax were apparent on the most recent chest roentgenogram. In evaluating gallium images during the work-up of AIDS patients with associated pulmonary pathology, the possible complication of lung collapse should be considered. If pneumothorax is suspected on gallium imaging, a chest roentgenogram in expiration must be obtained for prompt delineation of this serious, yet correctable, condition.

Acquired Immunodeficiency Syndrome↗
PubMed1975

Biomechanical analysis of clinical stability in the cervical spine.

This study was undertaken because there is a dearth of objective information in the literature on the clinical instability of the cervical spine below C2. To our knowledge, it is the first biomechanical investigation designed to analyze clinical stability. We have carried out a quantitative analysis of the behavior of the spine as a function of the systematic destruction of various anatomic elements. Under controlled conditions designed to maintain the biological integrity of the specimens, 17 motion segments from 8 cervical spines were analyzed. The spines were studied with either flexion or extension simulated using physiologic loads. Some of the more important findings are: (1) In sectioning the ligaments, one observes small increments of change followed without warning by sudden, complete disruption of the spine; (2) Removal of the facets alters the motion segment such that in flexion, there is less angular displacement and more horizontal displacement; (3) The anterior ligaments contribute more to stability in extension than the posterior ligaments and in flexion, the converse is true; (4) The adult cervical spine is unstable, or on the brink of instability, when any of the following conditions are present: a) All the anterior or all the posterior elements are destroyed or unable to function. b) More than 3.5 mm horizontal displacement of one vertebra in relation to an adjacent vertebra measured on lateral roentgenograms (resting or flexion-extension). c) More than 11 degrees of rotation difference to that of either adjacent vertebra measured on a resting lateral or flexion-extension roentgenogram. These findings can be aptly applied to clinical situations and when instability as determined by the above criteria is present, surgical fusion or some other method to achieve stability should be seriously considered. Work is continuing on this problem as we do not consider this to be altogether complete or definitive. Hopefully, this initial study will stimulate further scientific and clinical investigations.

Adult↗
PubMed1992

Increased morbidity with increased pulmonary albumin flux in sepsis-related adult respiratory distress syndrome.

OBJECTIVE: To determine the feasibility of utilizing a scintigraphic technique to differentiate patients with adult respiratory distress syndrome due to sepsis syndrome from control volunteers and patients with congestive heart failure. Gamma scintigraphy was compared with chest roentgenograms to predict mortality rate and morbidity in adult respiratory distress syndrome (ARDS) patients. DESIGN: Prospective study. SETTING: University hospital ICUs. PATIENTS: Thirty-five control volunteers, 19 patients with congestive heart failure, 30 patients with a diagnosis of sepsis. MEASUREMENTS AND MAIN RESULTS: All patients were infused iv with technetium 99m-labeled albumin and underwent computerized gamma-scintigraphic analysis with a portable gamma camera. Lung-to-heart ratio of tracer was calculated and expressed as the slope index. Increase in slope index indicated increased pulmonary albumin flux. Slope index was no different in controls compared with congestive heart failure patients, unless the pulmonary artery occlusion pressure (PAOP) was greater than 30 mm Hg. Patients with a diagnosis of sepsis had an overall increased slope index compared with the other groups. A subgroup of patients in the septic group had a normal slope index. Septic patients with an increased slope index had a significantly (p less than .01) longer duration of mechanical ventilation (36 +/- 5 vs. 7 +/- 1 days), spent longer in the ICU (67 +/- 9 vs. 11 +/- 1 days), and had a longer hospital stay (113 +/- 20 vs. 35 +/- 5 days) than septic patients with a normal slope index. CONCLUSIONS: Gamma scintigraphy successfully differentiated between control volunteers and patients with congestive heart failure with PAOP less than 30 mm Hg from patients with sepsis-induced ARDS. Although all of the patients with a clinical diagnosis of septic ARDS had similar impairments in oxygenation and chest roentgenograms, those patients with a significantly increased pulmonary albumin flux (greater than 2 SD above control mean) had a markedly increased morbidity.

Adult↗
PubMedDate not supplied

Roentgenographic study of blood flow redistribution in acute pulmonary edema in dogs.

Acute pulmonary edema was induced in anesthetized vertically suspended dogs by inflating a ballon catheter in the descending thoracic aorta and infusing saline. Indices measured included pulmonary arterial pressure, left ventricle end-diastolic pressure, and cardiac output. Pulmonary blood-flow distribution was determined in frozen tissue after injecting radioactive macroaggregates labelled with 125-I, 131-I, and 99m-Tc. Randomized serial chest roentgenograms were interpreted by three radiologists not taking part in the physiologic studies. When left ventricular end-diastolic pressure was raised initially, roentgenograms usually revealed only interstitial edema. As alveolar edema increased, blood-flow to the lung bases decreased as measured physiologically. The roentgenographic and physiologic data show that in acute experiments on normal lungs, blood-flow redistribution occurs in association with alveolar edema rather than interstitial edema.

Animals↗
PubMed1982

Comparison of double indicator thermodilution measurements of extravascular lung water (EVLW) with radiographic estimation of lung water in trauma patients.

The availability for clinical use of a simple reliable method of determining extravascular lung water (EVLW) provided us with the opportunity to evaluate the accuracy of the plain chest roentgenogram in estimating EVLW in patients with severe trauma. Twelve patients who sustained blunt trauma in motor vehicular accidents were studied. Interval measurements of EVLW were made utilizing the thermal-green dye, double-indicator dilution technique and the results compared in a blind manner to estimation of lung water content on standard chest roentgenograms. The results indicate a significant correlation was present when EVLW was compared to roentgenographic density grade. Considerable overlap existed in quantitative EVLW content between radiographic grades except when extensive consolidation was present on the chest radiograph which was associated with EVLW measurements of greater than 10 ml/kg. The random comparison of a change in measured EVLW with a change in radiographic density indicated that there were opposite changes in 23% of the comparisons. However, in selected patients with progressive improvement (decrease) in EVLW or gradual deterioration (increase) in EVLW over time there was good correlation between improvement or deterioration in the chest radiographic appearance with the decrease or increase in EVLW. There is some ability to ascertain in trauma patients interstitial fluid accumulation from chest radiographs, but attempts at quantitation would be fraught with considerable error.

Body Water↗
PubMed1992

Continuous pulse oximetry and the diagnosis of pulmonary embolism in critically ill trauma patients.

The diagnosis of pulmonary embolism (PE) may be difficult to establish in trauma patients, particularly those who are unresponsive or mechanically ventilated. Based on a prior retrospective study, we hypothesized that patients monitored by continuous pulse oximetry who experienced a 10% or greater sudden sustained drop in arterial oxygen saturation (SaO2) without a change in static lung compliance (Cst) were most likely to have had a PE. We followed SaO2 in 972 patients admitted to our trauma ICU during the 18-month period ending in December 1990. Forty-eight patients (5%) with SaO2 changes, but no Cst changes, were evaluated for suspected PE using pulmonary arteriography (PA). Of these, 21 (44%) had a positive PA study. All patients with a positive PA had either clear chest roentgenograms or no change in underlying pulmonary pathologic processes. Of the remainder, 26 had evidence of a new pathologic entity on chest roentgenograms and only one patient had a SaO2 decrease, no change in Cst, and a negative PA. All mechanically ventilated trauma patients should have SaO2 monitored continuously. Patients with a > 10% drop in Sao2 with no change in Cst and no new roentgenographic chest findings should undergo PA. Based on our experience, this approach would yield a sensitivity, specificity, and predictive value of 100%, 99.9%, and 95%, respectively, for the diagnosis of clinically significant PE.

Adolescent↗
PubMed1994

Temporal patterns of radiographic infiltration in severely traumatized patients with and without adult respiratory distress syndrome.

We prospectively evaluated the patterns of pulmonary structural and functional changes in 100 consecutive surgical intensive care unit trauma patients who had (1) emergent major surgery, (2) a pelvic fracture, or (3) two or more major long bone fractures. For each patient, arterial blood gas measurements (ABGs), central venous pressure (CVP), pulmonary capillary occlusion pressure (PAOP), thoracic compliance, arterial oxygen tension/fraction of inspired oxygen (PAO2/FIO2), pulmonary venous admixture (Qs/Qt), and portable chest roentgenograms were sequentially tracked. The senior staff radiologist interpreted all chest roentgenograms. Pulmonary infiltration was quantitated in each of six fields using a scale ranging from 0 to 4, with 0 being no infiltration and 4 being the maximum. Adult respiratory distress syndrome (ARDS) was defined as follows: Qs/Qt > or = 20%, PAO2/FIO2 < 250 or both; dependence on mechanical ventilation for life support for > or = 24 hours; PAOP or CVP or both < 20 mm Hg; and thoracic compliance < 50 mL/cm H2O. Time zero (T0) the time of onset of ARDS, was defined as the time these criteria were met. Eighty-three of 100 study group patients had penetrating injuries, and 17 were admitted with blunt trauma. Fifty-one of 100 patients developed ARDS: 36 of 51 died. Only 4 of 49 (8%) patients without ARDS died. The injured lungs of patients with and without ARDS had similar amounts of infiltration over most measured time intervals. The noninjured lungs of the ARDS patients, however, had significantly greater infiltration than those without ARDS at T0 and over subsequent time intervals.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Isolated avulsion fracture of the lesser tuberosity of the humerus.

Six cases of isolated avulsions of the lesser tuberosity of the humerus were encountered within a short period of time. Although it seldom has been described in the literature, it might be a more common fracture than suspected. Physical examination revealed a painful shoulder with limited function in all six patients. In retrospect, all diagnoses could have been made on the primary plain roentgenograms. However, the fragment of the lesser tuberosity was easily misdiagnosed. An axillary view showed the fragment clearly in all cases. Computed tomography is useful for making an accurate diagnosis because it establishes the size and displacement of the fragment and determines additional injuries, such as a ruptured biceps tendon. Five patients with displacement of the lesser tuberosity were operated on after several weeks or months. The lesser tuberosity was reattached in all cases. After 6 months three patients had slight impairment of elevation and external rotation, and one of them suffered from pain during movements of the arm. The patient with no fracture displacement was treated conservatively with a good result. In conclusion, we recommended an axillary roentgenogram as part of the posttrauma radiologic series of the shoulder. A nondisplaced avulsion fracture of the lesser tuberosity of the humerus can be treated conservatively. We recommend reattachment of displaced fractures.

Accidental Falls↗
PubMed1997

The role of computed tomographic scanning in the management of facial trauma.

OBJECTIVE: To determine how often the management of patients with blunt facial trauma was altered by plain roentgenograms or facial computed tomographic (CT) scans compared with findings from physical examination. METHOD: This is a retrospective review of consecutive patients admitted with blunt facial trauma and evaluated by the Division of Plastic Surgery from 1988 to 1994. Physical findings were correlated with fractures detected by plain roentgenograms or facial CT reports. Treatment plans were reviewed to determine how management was altered by radiographic studies. Hospital charges were determined for the various studies. RESULTS: One hundred thirty-seven records were reviewed. Thirty patients had only lacerations and no fractures. Two hundred forty-three fractures were detected on physical examination among 98 patients (91.5%). One hundred two patients (95.3%) had facial CT scans and 85 patients (79.4%) had facial plain films obtained. Radiographic findings identified a total of 255 fractures among 107 patients (78%). Ninety-four patients (87.9%) required operative interventions for these facial fractures. Only 19 patients (17.8%) had management altered by radiographic findings: CT scan (7 patients) and plain films (12 patients). The management of 88 facial fractures (34.5%) in this series did not appear to be altered by x-ray findings. Computed tomography was most beneficial in the management of orbital fractures (N = 7). Plain films affected mostly the evaluation of mandibular injuries (N = 7). Selective use of CT scan could lead to hospital savings estimated at $11,864 for the diagnosis of facial fractures after blunt trauma. CONCLUSION: Physical examination reliably assessed the facial skeleton for clinically significant fractures in the majority of patients. In an alert and cooperative patient, CT scan is not required before operative repair in all cases. CT scans are expensive, time-consuming, and labor-intensive and in selected cases add little clinical information to that obtained by physical examination and plain films.

Adolescent↗
PubMed1999

Mandibular reconstruction using bone morphogenetic protein 2: long-term follow-up in a canine model.

OBJECTIVE: To determine the degree of bone resorption and stability of 3-cm, full-thickness canine mandibular defects reconstructed with recombinant human bone morphogenetic protein 2 (rhBMP-2) and a bioerodible particle carrier followed for 30 months after reconstruction. STUDY DESIGN: Nine dogs, divided into three groups, underwent reconstruction of surgically created 3-cm, full-thickness defects of the body of the mandible. METHODS: Mandibular reconstruction was performed via a combined intraoral and extraoral approach. Using standard plating techniques, a unilateral full-thickness, 3-cm defect was created in the body of the mandible. After stabilizing the defects with titanium reconstruction plates, test implants composed of rhBMP-2 and poly(lactide-co-glycolide) bioerodible particles were placed in the mandibular defects of six animals. Reconstruction plates were removed from test animals at 10 weeks. Three short-term test animals were sacrificed 3 months after reconstruction. Three long-term test animals were sacrificed 30 months after reconstruction to determine the degree of resorption and long-term stability of the rhBMP-2-induced bone. Control implants (carrier without rhBMP-2) were used in three animals and were sacrificed at 3 months. At 9 months, long-term animals were advanced to a solid diet. Masticatory function and body weight were monitored periodically to assess diet tolerance. Roentgenographic photodensitometry was performed on serial dental roentgenograms of the reconstructed segments to determine bone density and the degree of bone resorption over 30 months. After sacrifice, reconstructed segments were harvested and embedded in plastic for histological analysis and histomorphometry to determine the percentage of the defect replaced by mineralized bone (area density) and degree of resorption from 3 to 30 months after reconstruction. The main outcome measures were bone density and bone height determined from serial roentgenograms and percentage of the reconstructed segment replaced by mineralized bone (area density) determined from histomorphometry. RESULTS: Control animals without rhBMP-2 showed no evidence of bone formation across the defect. Histological examination revealed good bone formation in two of three of the short-term test animals with a mean area density of 41.0%. The long-term test animals treated with rhBMP-2 demonstrated good bone formation that was comparable to that of normal host bone by 3 months. The roentgenographic photodensity measurements stabilized at 5 months without evidence of persistent bone resorption. The height of the reconstructed segment (rhBMP-2-induced bone) initially decreased, then stabilized by 11 months after reconstruction with no indication of resorption or failure. Histological examination of the long-term test animals revealed good bone formation across the mandibular defects. However, there were localized areas of thinning of the cortical bone as compared with the short-term test animals sacrificed at 3 months. Histological examination verified the loss of height of the bone in the reconstructed segments. The area density (mean) of the long-term test animals was 56.5%. Despite the decrease in height of the induced bone, there was an increase in area density of the bone over time. CONCLUSIONS: This study demonstrated that rhBMP-2 in a bioerodible particle carrier induced new host bone formation across critical-size mandibular defects. The newly formed bone successfully integrated with existing host bone creating a stable union capable of withstanding the forces of masticatory function in a canine. There was some evidence of early bone resorption (thinning of the cortical bone and decrease in height) in the rhBMP-2-induced bone. The rhBMP-2-induced bone stabilized by 11 months after reconstruction and no further resorption was noted. The percentage of area of the defect replaced by rhBMP-2-induced bone (area density) increased over 30 months. (ABSTRACT TRUNCATED)

Animals↗
PubMed1981

Use of diagnostic services by physicians in community practice.

This study analyzes the use of diagnostic studies by community physicians. Data from billing claims for outpatient visits by Medicaid recipients in three northeastern Pennsylvania counties during a 38-month period were studied, including 55,420 visits to 336 physicians. The use of outpatient laboratory tests and roentgenograms was correlated with the personal characteristics of the prescribing physicians. When case mix was controlled, analysis by specialty showed that internists ordered approximately the same number of procedures as family physicians, and both groups ordered more procedures than general practitioners. The number of years since medical school graduation showed a statistically significant inverse relationship with laboratory and radiology use. Public school graduates ordered more laboratory tests than private school graduates, and foreign medical graduates ordered more roentgenograms than domestic graduates. Other variables, including size and location of practice, and osteopathic or medical training, were not significantly related to patterns of use.

Age Factors↗
PubMed1990

Disseminated histoplasmosis in the acquired immune deficiency syndrome: clinical findings, diagnosis and treatment, and review of the literature.

Histoplasmosis is a serious opportunistic infection in patients with AIDS, often representing the first manifestation of the syndrome. Most infections occurring within the endemic region are caused by exogenous exposure, while those occurring in nonendemic areas may represent endogenous reactivation of latent foci of infection or exogenous exposure to microfoci located within those nonendemic regions. However, prospective investigations are needed to prove the mode of acquisition. The infection usually begins in the lungs even though the chest roentgenogram may be normal. Clinical findings are nonspecific; most patients present with symptoms of fever and weight loss of at least 1 month's duration. When untreated, many cases eventually develop severe clinical manifestations resembling septicemia. Chest roentgenograms, when abnormal, show interstitial or reticulonodular infiltrates. Many cases have been initially misdiagnosed as disseminated mycobacterial infection or Pneumocystis carinii pneumonia. Patients are often concurrently infected with other opportunistic pathogens, supporting the need for a careful search for co-infections. Useful diagnostic tests include serologic tests for anti-H. capsulatum antibodies and HPA, silver stains of tissue sections or body fluids, and cultures using fungal media from blood, bone marrow, bronchoalveolar lavage fluid, and other tissues or body fluids suspected to be infected on clinical grounds. Treatment with amphotericin B is highly effective, reversing the clinical manifestations of infection in at least 80% of cases. However, nearly all patients relapse within 1 year after completing courses of amphotericin B of 35 mg/kg or more, supporting the use of maintenance treatment to prevent recurrence. Relapse rates are lower (9 to 19%) in patients receiving maintenance therapy with amphotericin B given at doses of about 50 mg weekly or biweekly than with ketoconazole (50-60%), but controlled trials comparing different maintenance regimens have not been conducted. Until results of such trials become available, our current approach is to administer an induction phase of 15 mg/kg of amphotericin B given over 4 to 6 weeks, followed by maintenance therapy with 50 to 100 mg of amphotericin B given once or twice weekly, or biweekly. If results of a prospective National Institutes of Allergy and Infectious Disease study of itraconazole maintenance therapy document its effectiveness, alternatives to amphotericin B may be reasonable.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Failure of tracheal aspirate cultures to define the cause of respiratory deteriorations in neonates.

The spectrum of organisms responsible for lower respiratory tract infection in chronically ventilated neonates is poorly defined. During an 18-month period 63 infants with a respiratory deterioration defined as an increase in fractional inspired O2 concentration > or = 20% and/or mean airway pressure > or = 3 cm H2O were evaluated for pulmonary infection. These infants were compared with 58 stable control ventilated infants. Tracheal aspirates for culture and Gram stain were taken from both groups and were cultured for bacteria, viruses, Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis. In addition each infant had complete blood counts with differential and chest roentgenograms evaluated. Positive tracheal aspirates defined as a heavy growth of a single or two bacterial organisms, and/or any growth of virus, Chlamydia and U. urealyticum were found in 23 of 63 study patients and 20 of 58 controls (P > 0.05). The most frequent isolate in both groups was U. urealyticum. Chest radiographs were positive (new changes, particularly atelectasis and infiltrates) more frequently in the study group than in controls, but complete blood count and tracheal aspirate Gram-stained smears were not helpful in discerning colonization from infection. We conclude that positive tracheal aspirates occur with equal frequency among infants with a clinical suspicion of lower respiratory tract infection and in "well" controls. Chest roentgenogram may be a useful adjunctive test to discriminate between colonization and lower respiratory tract infection.

Cytodiagnosis↗
PubMed1975

The retrotracheal triangle in pediatric patients.

The retrotracheal triangle is the posterior superior mediastinum and usually is well outlined on the routine lateral chest roentgenogram. It has characteristic features, and careful evaluation of this area on routine roentgenogram will be of assistance in identifying abnormalities producing respiratory or feeding difficulties in infants and children. Anomalies occurring in this area include vascular structures, esophageal lesions, tumor masses, and inflammatory lesions.

Aortic Arch Syndromes↗
PubMed1978

Serum parathormone in the identification and surgical management of hyperparathyroidism.

A prospective series of 200 patients with persistent hypercalcemia had an abbreviated diagnostic work-up consisting of parathormone radioimmunoassay, chest roentgenogram, intravenous pyelography, and serum protein electrophoresis. All patients with hypercalcemia and hyperparathormonism had neck exploration if roentgenograms failed to reveal evidence of ectopic hyperparathyroidism. Serum iPTH proved to be at least 96% accurate in predicting parathyroid disease while at the same time resulting in considerable diagnostic economy. An elevated iPTH was particularly helpful in distinguishing between hypercalcemia due to destruction of bone by malignancy and primary hyperparathyroidism with a coexisting malignancy. Further, measurement of parathormone was useful in evaluation of postoperative hypercalcemia.

Adenoma↗
PubMed1979

Cardiac-pulmonary edema and low pulmonary capillary wedge pressure.

We describe a patient who presented with acute massive pulmonary edema, clinically and on chest roentgenogram. Two hours later the patient became hypotensive and was found to have a low pulmonary capillary wedge pressure (PCWP). The blood pressure returned to normal after administration of fluids. Acute pulmonary edema develops if PCWP rises higher than 25 to 30 mm Hg. In our patient, the elevated PCWP fell to low normal within two hours, when chest roentgenogram and clinical examination still suggested severe pulmonary edema. A phase lag existed between lowering of the pulmonary capillary wedge pressure and clearing of fluid from the alveolar and interstitial spaces in the lungs. At least three different pathogenetic mechanisms in patients with coronary artery disease can produce this phase lag. Transient global ischemia of the left ventricle was thought to be the responsible mechanism in our patient.

Blood Pressure↗
PubMed1981

Detection of recurrent breast cancer.

Most clinicians attempt to identify and treat recurrent breast cancer at the earliest sign of relapse. In an effort to better define the usefulness of commonly used clinical and laboratory tools in evaluating patients after mastectomy, we retrospectively analyzed 120 cases and reviewed the literature. One hundred fifteen sites of metastatic disease were identified in 55 patients, with bone, lung, liver, and skin most common. History and physical examination disclosed 66% of these metastatic events. Of 36 patients with probable bone involvement, 15 were identified by bone scan while asymptomatic. Of 31 patients with evidence of pulmonary metastases, 12 were entirely asymptomatic when identified with a screening chest roentgenogram. In contrast, 36 of 45 hepatic, cutaneous, lymphatic, central nervous system, and ocular metastases were suggested by purely clinical findings. We conclude that basic clinical skills (ie, history-taking and physical examination) are two most important means by which we identify patients with recurrent breast cancer. While chest roentgenogram and bone scan may uncover metastases in asymptomatic patients, liver function tests and radionuclide scans of brain and liver have very low yield in patients clinically free of organ involvement.

Bone Neoplasms↗